Running head: INDIVIDUALIZED PLAN OF CARE: PAUL MARTIN 1

Individualized Plan of Care: Paul Martin

Ashley Selby

Delaware Technical Community College

April 24, 2019

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Introduction

Mr. Martin is a healthy 34 year-old male with no significant medical history. He reports

having ankle surgery and dental work many years ago and denies any other surgeries. He

currently is employed as a Texas State Trooper where he rides bicycles at an average 20-30 miles

daily. His health history assessment revealed that he is a former smoker and that there is an

extensive cardiac history in his family including his mother, father, maternal grandfather, and

paternal grandfather. Using Mosby’s Guide to Nursing Diagnosis 5th edition (2017), a care plan

was developed for Mr. Martin to identify at risk medical problems as well as to encourage

prevention for disease processes that were revealed in his family history.

Assessment & Plan of Care

At Risk for Stress & Safety

During his health assessment, Mr. Martin denied any job related stress regarding his job

as a law enforcement officer and stated “I’m sure it’s just as stressful and typical as the nine to

five.” Mr. Martin also denied any safety concerns as a law officer and having to patrol downtown

Austin. Mr. Martin stated that with the few days that he is allowed off, which are “few and far

between”, he likes to race cars and play guitars. Mr. Martin’s current job as a law enforcement

officer is listed as one of the most stressful jobs in America (Renzulli, 2019). While there is no

signs of evident stress at this time Mr. Martin can still be considered at risk given his current job

title and daily duties it entails. During his assessment Mr. Martin mentioned that he was taking

preventative measures to alleviate potential stress with his hobbies of playing guitar and racing

cars. However, his hobby of racing cars could also be considered a possible element for

developing stress since it is an activity that requires great focus and can become a safety concern
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if not performed correctly. Additional information regarding techniques to alleviate stress such

as goal setting, deep breathing, and low stress inducing activities such as yoga was given to Mr.

Martin. A referral to a local yoga studio, Wanderlust Yoga, was also provided. In addition, a list

of rules and regulations from a vintage racing group he participates in was also discussed in

regards to his safety and the equipment he uses while racing cars.

Sleep

During his health assessment Mr. Martin mentioned that he is unable to obtain an

adequate amount of sleep at night due to his mind “not settling”. He denied any direct thoughts

that would lead him to his inability to sleep and denied any major stress. Mr. Martin mentioned

that he has tried to speak with professionals in the past regarding his inability to sleep and his

thoughts at night, but stated that he did not believe that the prior interventions helped him. It was

discussed with Mr. Martin different techniques to help him fall asleep at night which included

decreased caffeine intake, cooler room temperatures, and the 4-7-8 breathing technique (Semeco,

2017). He was also given information to a local sleep clinic for further evaluation.

At Risk for Heart Disease

During his health assessment Mr. Martin disclosed that his mother, father, paternal

grandfather, and maternal grandfather all suffered from heart disease. Mr. Martin also stated that

he is a former smoker. He takes preventive measures against developing cardiac disease as he

has not smoked for several years and has quit eating red meat. Since there is a genetic correlation

with heart disease and his family, Mr. Martin was given information regarding additional

preventive measures he can take such as eating a heart healthy diet, managing his stress, the
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continuance of not smoking, regular blood pressure screenings, as well as information for a local

cardiologist and how to set up an appointment for a general wellness check.

Conclusion

As proven by his actions such as abstaining from smoking, no longer eating red meat, and

partaking in stress relieving hobbies, Mr. Martin is very proactive in his wellbeing. While

conducting his health assessment it was very noticeable that he is educated on health problems

that he may be at risk for. Mr. Martin was very grateful for the information provided to him

regarding additional resources and preventive measures he may like to take regarding the health

problems he is at risk for. He plans to continue to follow his current regiment of healthy habits as

well as partake in some of the suggested activities in his care plan.

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Resources

Best ways to manage stress. (2015, January). Harvard Health Letter. Retrieved from

https://www.health.harvard.edu/mind-and-mood/best-ways-to-manage-stress

Heart disease prevention: strategies to keep your heart healthy. (2019, January 9). Mayo Clinic.

Retrieved from https://www.mayoclinic.org/diseases-conditions/heart-disease/in-

depth/heart-disease-prevention/art-20046502

Ladwig, G.B., Ackley, B.J., Makic, M.B.F., (2017) Mosby’s guide to nursing diagnosis (5th ed.).

St. Louis, Missouri: Elsevier Inc.

Renzulli, K.A. (2019, March 7) The most stressful job in america pays $26,802—here are the

other 9. Retrieved from https://www.cnbc.com/2019/03/07/the-most-stressful-jobs-in-

america.html

RMVR - rules. (2019, April). Rocky Mountain Vintage Racing. Retrieved from

http://rmvr.com/rules/allrules.pdf

Semeco, A. (2017, October 30). 20 simple tips that help you fall asleep quickly. Healthline.

Retrieved from https://www.healthline.com/nutrition/ways-to-fall-asleep