This document presents an interdisciplinary care plan for a patient named McKay Johnson who has been diagnosed with diabetes and heart disease. It provides background information on Johnson's medical history and current condition. The care plan involves monitoring Johnson's glucose levels, blood pressure, physical activity, and medication regimen. The goal is to control his diabetes and heart disease by maintaining normal levels for glucose, BMI, hemoglobin A1C, and other lab results. The care will be provided by an interdisciplinary team to effectively treat both of Johnson's conditions.

1. INTERDISCIPLINARY CARE PLAN 7
Class: NUR3400
Professor: Maikel Y. Portal APRN, FNP-BC
Miami Regional University
Abstract
Patient care has received much attention in today’s healthcare
system. It enhances the treatment plan by involving different
health specialists in caring for the patient. Interdisciplinary
approach involves elements such as leadership, teamwork,
patient-centered practice, and through communications. The
care providers ensure effective assessment of the condition thus
meeting patient’s desires and needs. The team pools their
knowledge and expertise together towards the recovery of the

2. patients not just the treatment of the disease. Ideally, effective
patient outcomes can be achieved through a collaborative
approach to the treatment plan. This reduces readmission rates
and avoids duplication of duties during the treatment process.
The future of health care delivery depends on how effectively
the health providers implement the interdisciplinary approach.
In this paper, the interdisciplinary care plan will be drafted for
McKay Johnson, a patient diagnosed with diabetes and heart
disease.
Keywords: interdisciplinary, therapy, diabetes, heart disease.
Background Information
Patient Name:?
Age: ?
Sex: ?
Demographics: ?
Condition: (Diabetes and Heart Disease) or any other PMH
Situation: Patient is forgetful and lives alone
Medical History
Johnson was diagnosed with type 2 diabetes in 2013, but he
reports he had symptoms one year before the diagnosis. The
medical record shows that he had fasting blood glucose records
showing values of 118-127 mg/dl, which categorized his
condition as “borderline diabetes.” In 2016, he was diagnosed
with heart problem. Johnson has been controlling diabetes until
last year when his family physician referred him to our hospital
for special treatment of the disease. His wife reports that her

3. husband began to experience abnormal heartbeats, difficulties in
breathing, and high blood pressure. The diagnosis shows that
Johnson recorded a pulse of 115 per minute while the systolic
blood pressure was 180 mm/Hg. He had bulging neck veins,
swelling in the legs, and fluids in the lungs. He had been on
glyburide (2.5 g every morning), Gymnema Sylvester, and
chromium picolinate to control diabetes. Johnson was also given
Angiotensin II receptor blockers and Statins to control heart
disease.
Johnson’s physical examination results show a BMI of 33.4
kg/m2, Pulse of 85 bpm, fasting glucose of 164 mg/dl, blood
pressure of 160/96 mmHg, JVP of 7 cm H2O, and 20
respirations per minute. He has lung crackles, no retinopathy,
swelling legs, non-palpable thyroid, no carotid bruits, and
diminishing vibratory sense to the forefoot. He reports regular
wheezing and dizziness throughout the day. The lab results
presented by the nurse show that Johnson has cholesterol-to-
HDL ratio of 4 (normal < 5.0), HDL cholesterol of 46 mg/dl
(normal < 40 mg/dl), triglycerides of 180 mg/dl (normal < 155
mg/dl), AIC of 7.5 % (normal 4-6 %), sodium of 137 mg/dl
(normal 136-146 mg/dl), potassium of 4.0 mg/dl (3.5-4.3
mg/dl), blood urea nitrogen 34 mg/dl (normal 6.1-30 mg/dl) and
Urine microalbumin of 42 mg (normal < 30 mg).
Medical Assessment
Based on Johnson’s medical history, physical examination, and
lab tests, it is evident he has uncontrollable type 2 diabetes and
heart disease. His hemoglobin level (7.5%) is slightly more than
the normal indicators (4-7%). He has a BMI of 32. 4 kg/m2 and
it is way above the BMI of a normal person. When an individual
exceeds a BMI of 30, he is termed as obese (Pop-Busui et al.,
2017). Johnson has elevated urine microalbumin and blood urea
nitrogen. These are the indicators of heart problem and diabetes.
Swelling legs, lung crackles, and regular wheezing are also the
signs of heart disease.
Care Plan
Johnson presents uncontrollable type 2 diabetes and heart

4. disease, which require a coordinated treatment process from all
nurses across the concerned disciplines. The first step of the
interdisciplinary team is to select the most pressing health issue
and prioritize his medical care in order to formulate an effective
treatment plan. The team has to follow the care plan for the two
diseases.
Nursing Intervention
Rationale
Assess the signs of hyperglycemia
A patient who uses insulin to treat type 2 diabetes is at risk of
developing hyperglycemia. Signs of hyperglycemia include
headache, fatigue, tachycardia, dizziness, and visual changes.
Assess glucose level before and after the meals
The glucose level should be between 140 mmHg and 180
mmHg. Non-intensive care patients should be maintained at less
than 140 mmHg (American Diabetes Association, 2019).
Monitor patient’s hemoglobin level
A level of 4-7% is desirable and shows the progress of the
treatment process.
Monitor blood pressure, apical pulse and peripheral pulse
Increased blood pressure is a sign of diabetes/heart disease.
Low pulse is a sign of decreasing tissue perfusion.
Do not take an axillary temperature
Elderly persons have poor peripheral circulation which
contributes to the formation of pocket airs in axillary areas
(Touhy, Jett, Boscart, & McCleary, 2018). This gives inaccurate
results.
Assess feet for temperature, and swellings. Monitor the color of
the skin
This will help to monitor peripheral perfusion. Pale skin color
is an indicator of decreased tissue perfusion.
Assess the pattern of physical activity
Regular physical activities assist in lowering the glucose level
(Naik, Dave, Stephens, & Davies, 2015). These activities
prevent further complications of diabetes and cardiac disease.
Administer basal insulin

5. Adhering to the prescribed medical regimens promotes tissue
perfusion. This will keep glucose at a normal level.
Report BP of more than 155 mmHg (systolic)
Hypertension is a common condition for diabetes and heart
disease. Controlling blood pressure can prevent further
complications such as stroke and retinopathy.
Monitor urine output as well as urine albumin
Urine albumin is a sign of diabetes while urine output shows the
control of both diabetes and heart disease.
Encourage Active ROM
ROM prevents venous pooling and promotes tissue perfusion.
Encourage bedrest with the head of the bed elevated at 45
degrees
This position prevents blood from returning to the heart thus
increasing oxygenation and decreasing dyspnea responsible for
cardiac attack (American Diabetes Association,2015).
Evaluate patient’s understanding of the medical conditions and
treatment plan
This reduces medication errors. Non-adherence to the prescribed
medication can lead to more complications such as
hypoglycemia and stroke.
Administer and monitor medication regimen
Proper administration of prescribed diabetic and heart disease
medication is important in stabilizing glucose level, hemoglobin
level, and blood pressure.
Review the patients current diet and nutritional needs
Proper diet helps maintain the normal level of glucose level
thus sustain the smooth flow of blood.
Treatment Goal
At the end of the treatment, Johnson should have blood glucose
level of less than 180 mmHg, BMI of less than 30.0 kg /m2,
Hemoglobin AIC level of less than 7%, blood urea nitrogen less
than 30 mg/dl, and Urine microalbumin of less than 30 mg/dl.
These results will be an indication of the successful treatment
plan.

6. Running head: CARE PLAN 1
CARE PLAN 6
References
American Diabetes Association. (2015). Cardiovascular disease
and risk management. Diabetes Care, 38(Suppl. 1), 49-57.
Retrieved from https://doi:10.2337/dc15-S011
American Diabetes Association. (2019). Cardiovascular disease
and risk management: Standards of medical care in diabetes-
2019. Diabetes Care, 42(Suppl. 1), 103–123. Retrieved from
https://doi.org/10.2337/dc19S010
Pop-Busui, R., Boulton, A., Feldman, E., Bril, V., Freeman, R.,
Malik, R. A. … Ziegler, D. (2017). Diabetic neuropathy: A
position statement by the American Diabetes Association.
Diabetes Care, 40(1) 136-154. Retrieved from
https://doi:10.2337/dc16-2042
Naik, V., Dave, R., Stephens, J. W., & Davies, J. S. (2015).
Evidence based prevention of type 2 diabetes: Role of lifestyle
intervention as compared to pharmacological agents.
International Journal of Diabetes and Clinical Research, 2(6).
49-56. Retrieved from
https://clinmedjournals.org/articles/ijdcr/international -journal-
of-diabetes-and-clinical-research-ijdcr-2-049.pdf
Touhy, T., Jett., K., Boscart, V., & McCleary, L. (2018).
Ebersole and Hess' gerontological nursing and healthy aging
(5th ed.). New York, NY: Elsevier - Health Sciences Division.