NURS FPX 4900 Assessment 4 Patient Family or Population Health Problem Solution


NURS FPX 4900 Assessment 4 Patient Family or Population Health Problem Solution

NURS FPX 4900 Assessment 4 Patient Family or Population Health Problem Solution


Capella university

NURS-FPX 4900 Capstone project for Nursing

Prof. Name


Summary of Patient’s Health Problem 

This capstone project is focused on an in-depth analysis of my mother’s type 2 diabetes, which was recently diagnosed at Alhambra Hospital Medical Center, where I also work as a registered nurse. My mother is 60 years old and has been experiencing excessive thirst, unintentional weight loss, and tingling sensation in her toes and fingers. Upon laboratory investigation, her fasting blood glucose test of 280 mg/dL confirmed type-2 diabetes mellitus. Her past medical history revealed she was a hypertensive patient, which was under control due to consistent medication adherence. Delving into the lifestyle and personal history, it was found that my mother had been living a sedentary lifestyle with no adequate physical activity, frequent alcohol consumption, and intake of an unhealthy diet. 

I selected this problem as the focus of my project because it is a global health issue, and half of the individuals with diabetes are older (Bellary et al., 2021). Moreover, this healthcare issue is particularly relevant to me both professionally and personally, as a large number of patients admitted to my hospital have chronic diseases, including diabetes. Diabetes kills 1.6 million people globally and is considered the top ten causes of death universally (Oguntibeju, 2019).  Additionally, this healthcare problem holds significant value as the patient, in this case, is my mother, and I want to deliver the best nursing practices to treat her diabetes. Therefore, I will strive to create the best solution tailored to her preferences and health needs. 

Role of Leadership and Change Management in Treating Diabetes 

Diabetes mellitus can be well treated healthcare professionals such as physicians and doctors exhibit leadership in providing patient-centered care treatments. This involves considering patients’ preferences and healthcare needs while devising care plans and interventions. Moreover, healthcare professionals such as nurses can take leadership roles such as diabetes educator roles in providing patient education on diabetes management such as guiding on lifestyle changes, including diet and physical activity, and supporting these changes (Mercer et al., 2019).

Likewise, change in management is essential to treat diabetes, such as integrating technologies to facilitate diabetes care in terms of improving medication adherence and lifestyle changes. Furthermore, organizational changes such as fostering a culture of interdisciplinary collaboration, enhanced communication, and educating healthcare professionals on patient empowerment to promote diabetes self-care are essential roles of change management in diabetes (Barbosa et al., 2021). 

NURS FPX 4900 Assessment 4 Patient Family or Population Health Problem Solution

The proposed intervention developed for my mother includes remote monitoring of diabetes and the provision of Diabetes Self-Management Education and Support (DSMES) through telehealth. Leadership strategies such as transformational leadership influenced the development of this intervention as it directed nurses in making decisions considering patients’ health needs and preferences and led to delivering patient-centered care through the devised intervention plan (Mushtaq et al., 2021). The change management strategies, such as changes in lifestyle modification for diabetes management, informed me about providing DSMES for my mother (Kloss et al., 2022).

Nursing ethics, such as beneficence and non-maleficence, also influenced the development of this intervention. Beneficence is related to a patient’s well-being and improved health through safe and effective care treatments. Non-maleficence directs healthcare providers not to cause deliberate patient harm and to be vigilant in delivering care treatments (Jokinen et al., 2020). These nursing ethics also guided me in preparing an intervention plan that promotes the well-being of my mother and improves her diabetes without causing her any harm (Jokinen et al., 2020). 

Strategies for Communicating and Collaborating with Patients

Chronic healthcare issues like diabetes require a vast patient engagement in regular glycemic control and to improve health outcomes by preventing diabetes-associated comorbidities (Hong et al., 2020). Therefore, healthcare professionals must devise strategies that promote communication with patients and enhance their buy-in to promote adherence to the proposed treatment plan. These strategies include actively listening to patients about their health concerns to build a bond of trust and rapport, which will further improve their collaboration.

Furthermore, healthcare professionals must use plain and simple language to communicate with patients and make medical terms easily understandable by patients (Hong et al., 2020). This will educate patients about their disease and enhance their comprehension of the role of the proposed intervention in improving health outcomes for their diabetes (Ndjaboue et al., 2020). Additionally, shared decision-making enables patients to collaborate with healthcare professionals in promoting patient-centered care as their preferences on treatment options are valued along with their health needs (Lambrinou et al., 2019). 

NURS FPX 4900 Assessment 4 Patient Family or Population Health Problem Solution

The interdisciplinary teams, such as physicians, pharmacists, nurses, fitness experts, and nutritionists, will all play their roles in providing patient-centered care. Nurses will undermine patients’ health status and provide care treatments as per patients’ health demands and desires (Hong et al., 2020). A nutritionist will delve into the patient’s dietary preferences and tailor meal plans that include healthy nutrients and are palatable to the patient. Fitness experts will guide patients on weight management and exercises to maintain regular weight. Physicians and pharmacists will collaboratively plan a pharmacological plan for patients to manage diabetes (Hong et al., 2020).  

These strategies will improve my mother’s collaboration when she is heard attentively and knows her diabetes and its treatment by communicating in simple language. This is necessary as my mother’s input in medication adherence and lifestyle modification must be obtained in achieving the desired outcomes of well-managed diabetes and prevention of diabetes complications such as peripheral neuropathy, blindness, and foot infections. The benefits of my mother’s input will lead to better glycemic control when a patient-centered care plan is developed per her preferences. Shared decision-making and patient-centered care will increase the chances of adherence to the treatment plan, leading to an enhanced probability of improving diabetes health outcomes (Kim et al., 2019). 

State Board Nursing Practice Standards and/or Governmental or Organizational Policies on Guiding the Development of Proposed Intervention

The California Board of Registered Nursing has provided the Nursing Practice Act (NPA) for nurses to provide high-quality care treatment to patients and deliver best nursing practices. These policies on medication management through care coordination and educational programs have guided me in developing the proposed intervention for my mother’s diabetes. These policies effectively improve diabetes management as Mikhael et al. (2020) have shown that diabetes is better managed when patients are educated about their condition and supportive care is provided. the DSMES program will enhance her knowledge of diabetes self-management, leading to improved health as a result of high-quality care treatments Additionally, I will be able to evaluate the glycemic control of my mother when I am away from her and monitor her medication adherence with remote monitoring. (California Board of Registered Nursing, 2019). 

The American Diabetes Association has provided guidelines for diabetes management in elderly people, including self-management education and support from healthcare providers (ADA, n.d.). These guidelines further directed me to consider DSMES as a primary intervention for her effective management of diabetes. The DSMES has resulted in better glycemic control by improving healthy diet intake and changing a sedentary lifestyle to active for patients with diabetes (Mikhael et al., 2020). 

The Health Information Technology for Economic and Clinical Health (HITECH) act of 2009 has a policy that encourages healthcare organizations to utilize Healthcare Information Technologies (HIT) to enhance patient recovery and facilitate care for them (HIPAA Journal, 2023). This policy has guided me in developing an intervention for my mother using remote monitoring, as she lives far from the city and requires consistent monitoring. This policy’s effectiveness can be evaluated from a pool of evidence-based resources where HIT improves patient’s health outcomes. According to Kang et al. (2021), remote diabetes monitoring has improved patients’ self-management and compliance while preventing weight gain during COVID-19. Remote diabetes monitoring in my mother will enable ongoing evaluation of treatment plans and patient adherence.

 Role of Proposed Intervention in Improving Quality of Care, Enhancing Patient Safety, and Reducing Costs

The proposed intervention of remote monitoring and DSMES programs through telehealth can improve the standard of medical services and enhance patient safety. In remote monitoring, the healthcare providers, such as nurses, will monitor my mother’s health condition daily, including her medication adherence and compliance with the treatment plan. Remote monitoring will allow healthcare providers to continuously track the blood glucose levels and her symptoms, which can lead to timely interventions (Amante et al., 2021). This will result in enhanced quality of care and patient safety as complications related to diabetes are prevented, and hospital readmission rates will be reduced (Amante et al., 2021). 

Moreover, DSMES through telehealth will educate my mother on self-management behaviors and implementation through continuous support at home through reminders and notifications. This will lead to better adherence to medication and treatment plans, enhancing its effectiveness. Ultimately, the quality of care delivered will be improved, and the patient’s glycemic levels will be under control. This results in enhanced patient safety (Drobycki & Roseman, 2021). 

NURS FPX 4900 Assessment 4 Patient Family or Population Health Problem Solution

Providing the DSMES program through telehealth will also reduce costs to the organization and the patient. As the healthcare providers will deliver diabetes care through telehealth and remote services, the organization’s resources, such as the emergency department, laboratories, and hospital beds, will be available for treating other patients (Nkhoma et al., 2021). This will lead to better allocation of resources and elimination of costs needed for physical infrastructure expansion. Furthermore, the administrative costs will be alleviated as the appointment scheduling and medical record management through paper will be streamlined through telehealth (Nkhoma et al., 2021). 

Similarly, the DSMES, through telehealth and remote monitoring, saves patient’s traveling costs as patients seek care in the comfort of their homes. Moreover, the costs associated with future complications will be reduced by consistently monitoring and balancing glycemic levels through these interventions (Chen et al., 2022). The source of benchmark data on evaluating the health outcomes of diabetes is the American Diabetes Association, where standard glycemic levels are established along with standards of diabetes care. These standards must be used to benchmark the performance of the current proposed intervention for patients with diabetes (ADA, 2022). 

 Role of Technology, Care Coordination, and Utilization of Community Resources in Diabetes

HIT plays an enormous role in improving patient health outcomes in diabetes. For instance, telehealth consultations and remote monitoring are adequate substitutes for physical face-to-face care for chronic disease patients like diabetes. Long-term diabetes management at the hospital can be complex for patients and healthcare providers (Kang et al., 2021). For this purpose, telehealth and remote monitoring serve the same purpose without needing patients to travel to the hospital and acquire the same quality of care at home.

This will include using patient portals, apps, or social media platforms where healthcare professionals can conduct an online meeting on current health status (Graetz et al., 2020). This is followed by regular evaluation of patient’s health through these apps, where patients can notify healthcare providers of their daily blood glucose levels, symptoms, severity, and medication adherence behavior. Healthcare providers can track these factors anywhere by logging into the synced accounts and apps connected to their patients. This remote diabetes care enhanced the quality of care, patient safety, and patient satisfaction (Kim et al., 2019). 

Care coordination in diabetes also contributes to effective diabetes care with interdisciplinary team collaboration and safe care treatments without errors. Patient-centered care is encouraged when healthcare providers such as physicians, pharmacists, nurses, nurses, dieticians, and fitness experts collaborate and coordinate care plans. This leads to better adherence and compliance with care treatments and improved glycemia control in diabetes patients (McLendon et al., 2019). Furthermore, community resources can be practically used, such as diabetes management toll-free helplines and community support groups such as Diabetes Sisters and Diabetes Daily Forum, where patients with diabetes share their struggles and wins (Mukpalkar et al., 2020). This will motivate others to cope with their diabetes and improve self-care, such as diet and maintaining a healthy weight. This will improve patient’s health outcomes in managing their diabetes citation (Mukpalkar et al., 2020). 


This analysis of intervention includes multiple factors that influenced and guided in developing the specific intervention plan for my mother, who is facing type 2 diabetes mellitus. The proposed intervention plan consists of providing a DSMES program through telehealth and remote diabetes monitoring. Transformational leadership and change management in lifestyle influenced the creation of the proposed plan. Furthermore, communication and collaboration strategies like active listening, shared decision-making, and clear and plain language are essential to obtain patient input and improve diabetes health outcomes. Further, policies, including NPA by the California Board of Nursing Practice, HITECH Act, and ADA, guided me in making interventions for my mother. The proposed plan improves the quality of care, enhances patient health standards, and diminishes expenses for patients and healthcare organizations. Lastly, the use of tools, collaborative care, and community resources is highlighted, which plays a huge role in managing diabetes. 


ADA. (2022). American diabetes association releases 2023 standards of care in diabetes to guide prevention, diagnosis, and treatment for people living with diabetes | ADA 

Amante, D. J., Harlan, D. M., Lemon, S. C., McManus, D. D., Olaitan, O. O., Pagoto, S. L., Gerber, B. S., & Thompson, M. J. (2021). Evaluation of a diabetes remote monitoring program facilitated by connected glucose meters for patients with poorly controlled type 2 diabetes: Randomized crossover trial. JMIR Diabetes6(1), e25574. 

Bellary, S., Kyrou, I., Brown, J. E., & Bailey, C. J. (2021). Type 2 diabetes mellitus in older adults: Clinical considerations and management. Nature Reviews Endocrinology17(17). 

Barbosa, H. C., Oliveira, J. A. de Q., da Costa, J. M., de Melo Santos, R. P., Miranda, L. G., Torres, H. de C., Pagano, A. S., & Martins, M. A. P. (2021). Empowerment-oriented strategies to identify behavior change in patients with chronic diseases: An integrative review of the literature. Patient Education and Counseling104(4), 689–702. 

California Board of Registered Nursing. (2019). Nursing practice act

NURS FPX 4900 Assessment 4 Patient Family or Population Health Problem Solution

Chen, F., Jasik, C. B., Dall, T. M., & Siego, C. V. (2022). Impact of a digitally enhanced diabetes self-management program on glycemia and medical costs. The Science of Diabetes Self-Management and Care48(4), 263501062211007. 

Drobycki, N., & Roseman, D. (2021). Navigating diabetes care and education through telehealth services. ADCES in Practice10(1), 8–15.×211060764 

Graetz, I., Huang, J., Muelly, E. R., Fireman, B., Hsu, J., & Reed, M. E. (2020). Association of mobile patient portal access with diabetes medication adherence and glycemic levels among adults with diabetes. JAMA Network Open3(2), e1921429. 

Hong, Y.-R., Jo, A., Cardel, M., Huo, J., & Mainous, A. G. (2020). Patient-provider communication with teach-back, patient-centered diabetes care, and diabetes care education. Patient Education and Counseling103(12). 

Jokinen, A., Stolt, M., & Suhonen, R. (2020). Ethical issues related to eHealth: An integrative review. Nursing Ethics28(2), 096973302094576. 

Kang, J., Chen, Y., Zhao, Y., & Zhang, C. (2021). Effect of remote management on comprehensive management of diabetes mellitus during the COVID-19 epidemic. Primary Care Diabetes15(3). 

Kim, E. K., Kwak, S. H., Jung, H. S., Koo, B. K., Moon, M. K., Lim, S., Jang, H. C., Park, K. S., & Cho, Y. M. (2019). The effect of a smartphone-based, patient-centered diabetes care system in patients with type 2 diabetes: A randomized, controlled trial for 24 weeks. Diabetes Care42(1), 3–9. 

Kloss, K. A., Funnell, M. M., & Nwankwo, R. (2022). Going beyond education: A practical framework for diabetes self-management and decision-making. ADCES in Practice10(5), 2633559X2211148.×221114871 

NURS FPX 4900 Assessment 4 Patient Family or Population Health Problem Solution

Lambrinou, E., Hansen, T. B., & Beulens, J. W. (2019). Lifestyle factors, self-management and patient empowerment in diabetes care. European Journal of Preventive Cardiology26(2), 55–63. 

McLendon, S. F., Wood, F. G., & Stanley, N. (2019). Enhancing diabetes care through care coordination, telemedicine, and education: Evaluation of a rural pilot program. Public Health Nursing36(3), 310–320. 

Mercer, T., Chang, A. C., Fischer, L., Gardner, A., Kerubo, I., Tran, D. N., Laktabai, J., & Pastakia, S. (2019). Mitigating the burden of diabetes in sub-saharan Africa through an integrated diagonal health systems approach. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy12, 2261–2272. 

Mikhael, E. M., Hassali, M. A., & Hussain, S. A. (2020). Effectiveness of diabetes self-management educational programs for type 2 diabetes mellitus patients in middle east countries: A systematic review. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy13(13), 117–138. 

Mukpalkar, S., Gilbert, C., Murthy, G., Gudlavalleti, A. G., Batchu, T., Edla, S., Hebrew, V., Vemulapalli, L., Janagama, H., Shukla, R., Bala, V. M. S., Yamarthi, P., Pendyala, S., & Puppala, A. (2020). 1800 121 2096 Diabeteshelp – A toll free helpline for people with diabetes. Indian Journal of Ophthalmology68(1), S100–S102. 

Mushtaq, K., Hussain, M., Parveen, K., Afzal, M., Khan, S., & Gilani, S. A. (2021). Impact of transformational leadership intervention on head nurses working in government hospital. Pakistan Journal of Medical and Health Sciences15(9), 2417–2421. 

Ndjaboue, R., Chipenda Dansokho, S., Boudreault, B., Tremblay, M.-C., Dogba, M. J., Price, R., Delgado, P., McComber, A. M., Drescher, O., McGavock, J., & Witteman, H. (2020). Patients’ perspectives on how to improve diabetes care and self-management: Qualitative study. BMJ Open10(4), e032762. 

NURS FPX 4900 Assessment 4 Patient Family or Population Health Problem Solution

Nkhoma, D. E., Soko, C. J., Banda, K. J., Greenfield, D., Li, Y.-C. (Jack), & Iqbal, U. (2021). Impact of DSMES app interventions on medication adherence in type 2 diabetes mellitus: Systematic review and meta-analysis. BMJ Health & Care Informatics28(1). 

Oguntibeju, O. O. (2019). Type 2 diabetes mellitus, oxidative stress and inflammation: Examining the links. International Journal of Physiology, Pathophysiology and Pharmacology11(3), 45–63. 

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