| Course | NR 601 Primary Care of the Maturing and Aged Family Practicum |
|---|---|
| Week | 6 |
| Paper type | Care plan |
| Length | About 950 words, 5 pages |
| Format | APA 7 student paper |
| School | Chamberlain University |
| Program | MSN, Family Nurse Practitioner (FNP) |
| Updated | October 2026 |
Free sample paper for NR 601 Week 6
Care Plan: R.D.'s Three Goals in R.D.'s Own Words, Every Action With a Named Owner, and a Review at Six Weeks
Student Name
College of Nursing, Chamberlain University
NR 601: Primary Care of the Maturing and Aged Family Practicum
Instructor Name
Month Day, Year
Care Plan: R.D.'s Three Goals in R.D.'s Own Words, Every Action With a Named Owner, and a Review at Six Weeks
Problems in the Order They Threaten
1. Falls at night, three in seven months, with sedating medicines, urgency, neuropathy and the home all contributing.
2. Medicine management, with mild cognitive impairment and two medicines being stopped in sequence.
3. Weight loss of 3 kilograms over six months, linked to shopping once a week.
4. Blood pressure, now managed for standing pressure rather than seated.
5. Diabetes, kidney disease and knee pain, stable.
What R.D. Wants, Written Down
Asked what matters most over the next few months, R.D. said: "Not falling. Staying in my house. Sunday lunch at my daughter's." Asked what R.D. would give up to stay at home, R.D. said, "Not my house. Maybe the upstairs." Tinetti et al. (2016) describe care organized around the outcomes a patient most wants, rather than around each disease separately, as the better fit for people with several chronic conditions. This plan is built that way.
Goals R.D. Would Recognize
Goal 1: Make the night walk from bed to toilet without reaching for furniture and without falling, within six weeks.
Measure: no falls on the calendar; the physical therapist observes the night route without support at week 6.
Goal 2: Walk to the mailbox and back, about 60 meters, without stopping, within six weeks.
Measure: R.D. records it on the calendar; Timed Up and Go under 13 seconds at the therapist's week 6 visit.
Goal 3: Keep Sunday lunch at the daughter's house, including the four steps at the front door, every week.
Measure: the daughter notes each Sunday whether R.D. went and managed the steps.
Every Action Has an Owner
For Goal 1:
- Stop diphenhydramine then oxybutynin, in sequence. Owner: the nurse practitioner, with the clinic nurse calling at week 1 and week 3.
- Timed voiding and less fluid after 19:00. Owner: R.D., with a reminder card on the refrigerator.
- Motion-sensor night light, threshold tape, bedside commode. Owner: the home health physical therapist, who checks installation.
- Sit on the bed edge for one minute before standing. Owner: R.D.; the therapist practices it.
For Goal 2:
- Strength and balance exercises twice weekly with the therapist and daily at home. Owners: the physical therapist and R.D.
- New glasses. Owner: the daughter, who will drive R.D. to the optometry appointment on the 14th.
For Goal 3:
- Practice steps with a rail during therapy. Owner: the physical therapist.
- A second handrail at the daughter's front steps. Owner: the daughter.
For medicine management:
- Fill the weekly pill organizer each Sunday after lunch, updated for each medicine change. Owner: the daughter.
- Ask the pharmacy for blister packs from next month. Owner: the clinic nurse.
For weight:
- A second grocery delivery midweek, using the store's service. Owner: the daughter sets it up; R.D. receives it.
- Weight at each clinic visit. Owner: the clinic nurse.
Exercise programs that include balance training reduce falls in older adults living at home (Sherrington et al., 2019), which is why the therapist's program is the main action for Goals 1 and 2.
Why These Three Goals
Each goal comes from something R.D. said and each has a different threat behind it. The night walk is where all three falls happened. The mailbox walk is the daily trip that keeps R.D. outside and moving. Sunday lunch is the week's main social contact and the reason R.D. gives for wanting to stay well. A plan aimed at blood pressure targets and A1c alone would not have touched any of them. The falls guidance recommends that prevention plans be built around the person's own goals and circumstances (Montero-Odasso et al., 2022).
How Progress Will Be Recorded
R.D. keeps the calendar on the kitchen wall, marking falls, near falls, the mailbox walk and how many times up at night. The daughter checks it on Sundays. The physical therapist adds a weekly line. The calendar comes to every clinic visit and is the main record of whether the plan is working.
What Happens if the Daughter Cannot Help
The plan leans on the daughter for shopping, the pill organizer and Sunday lunch. If the daughter becomes unavailable, the clinic nurse will contact the area agency on aging about a home care aide for medication reminders, and the pharmacy blister packs, already requested, will reduce the organizer's role.
Constraints
R.D. lives alone. The daughter works weekdays and can help on evenings and weekends. Home health physical therapy is covered for a limited number of visits under Medicare Part B; the therapist estimates eight. R.D. does not drive. A bedroom on the ground floor is not available; the bathroom is upstairs, beside the bedroom, which is why the night route matters most.
What the Plan Does Not Include
A medical alert pendant was offered and declined: "I'm not wearing that." It will be offered again at the review. Moving the bedroom downstairs is not possible in the current house.
Review Point
The review is set for a date the daughter can attend, after work.
Six weeks from today, in clinic, with the calendar, the therapist's report and the daughter. At the review: if R.D. has fallen again, the alert pendant and a home safety assessment by an occupational therapist come next; if goals are met, the review moves to omeprazole and aspirin.
References
Montero-Odasso, M., van der Velde, N., Martin, F. C., Petrovic, M., Tan, M. P., Ryg, J., Aguilar-Navarro, S., Alexander, N. B., Becker, C., Blain, H., Bourke, R., Cameron, I. D., Camicioli, R., Clemson, L., Close, J., Delbaere, K., Duan, L., Duque, G., Dyer, S. M., ... Masud, T. (2022). World guidelines for falls prevention and management for older adults: A global initiative. Age and Ageing, 51(9), afac205. https://doi.org/10.1093/ageing/afac205
Sherrington, C., Fairhall, N. J., Wallbank, G. K., Tiedemann, A., Michaleff, Z. A., Howard, K., Clemson, L., Hopewell, S., & Lamb, S. E. (2019). Exercise for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews, 2019(1), CD012424. https://doi.org/10.1002/14651858.CD012424.pub2
Tinetti, M. E., Naik, A. D., & Dodson, J. A. (2016). Moving from disease-centered to patient goals-directed care for patients with multiple chronic conditions: Patient value-based care. JAMA Cardiology, 1(1), 9-10. https://doi.org/10.1001/jamacardio.2015.0248
NR 601 Week 6 instructions, in plain terms
The Week 6 plan should read as though someone asked the patient what they hoped to get back. Write goals in the patient's terms and make them measurable in the same sentence: getting to the bathroom at night without holding furniture, walking to the mailbox and back, keeping Sunday lunch. Under each goal, list interventions, and give each one an owner. Record what the patient wants in their own words. State constraints and set a review point. Most rubrics mark down a goal nobody could fail, interventions with no owner and goals written for a chart rather than for a life. Build each goal from something the patient said.
How this NR 601 Week 6 example is built
The sample orders five problems by threat, with night falls first. R.D.'s priorities are quoted: not falling, staying in the house, Sunday lunch. Three goals follow, each with a six-week measure, such as the therapist observing the night route without support. Every action has an owner: the nurse practitioner for the medicine changes, R.D. for timed voiding, the therapist for the night light, the daughter for the organizer, glasses and a second handrail. A section explains why these goals were chosen. The calendar is the record, a fallback covers the daughter's absence, constraints are stated and a review at six weeks sets next steps. Margin notes show where the patient's words and the named owners earn credit.
NR 601 Week 6 rubric: what full points look like
The heaviest loss is a goal nobody could fail, such as improve mobility; each goal here has a number, a date and a way for R.D. to know it was reached. Interventions with no owner are where home plans collapse, and every action here names a person. Goals written for the chart cost a row, while these come from R.D.'s own words. Ignoring constraints loses marks, and living alone, limited therapy visits and the upstairs bathroom are named. A review point with next steps for each outcome earns the final criterion, and planning for the main helper's absence shows foresight. Planning for the daughter's absence shows the plan has considered what could make it fail.
Common NR 601 Week 6 mistakes, and how to avoid them
Weak NR 601 Week 6 care plans set goals like improve mobility or optimize blood pressure. Others list interventions with no one responsible. Many never record what the patient wants. Constraints such as living alone or limited coverage are often ignored. Review dates are frequently missing. Ask the patient what matters most, write two or three goals in their words with a measure and a date and put a person's name beside every action, including family. Then set the review. If your patient differs, send their priorities and circumstances, and a matching sample plan can be drafted. Plan what happens if the main helper cannot continue.
Get a NR 601 Week 6 example written to your instructions
Send the Week 6 template your classroom uses and the case you were given, and a custom care plan is written into that template and returned inside 24 to 48 hours, free the first time. Every intervention in it will have an owner, a frequency and a way of telling whether it worked.
More NR 601 papers and FNP samples
- NR 601 Week 1: Atypical Presentation Post
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- NR 601 Week 3: Chronic Care Note
- NR 601 Week 4: Falls Case Analysis
- NR 601 Week 5: Deprescribing Write-Up
- NR 601 Week 7: Complex Case Analysis
- NR 601 Week 8: Reflection
- NR 566 Week 6: Geriatric Medication Review
- NR 511 Week 6: Chronic Care Note, Diabetes Reopened
NR 601 Week 6 questions, answered
Where do goals of care belong in the plan?
Among the goals, not in a paragraph at the end. What a patient is willing to trade, what they want protected and what they would refuse all change which interventions belong in the document at all. Written late, they read as a box being ticked. Written early, they explain why an aggressive target was set aside and make the whole plan defensible.
How specific should a functional goal be?
Specific enough that two people would agree on whether it happened. Walking to the corner and back without stopping is a goal. Improving endurance is not. In this course function is an outcome in its own right, so a plan that moves a laboratory value while the patient stops leaving the house has not achieved what it set out to.
What if the caregiver cannot do what the plan asks?
Then the plan changes, and the write-up says so. Caregiver capacity is a clinical variable here, and a document that assigns a daughter four tasks a day without asking whether she works full time will fail in the first week. Record what was actually agreed, name the tasks that need another solution, and price the gap honestly.
Where can I find a free NR 601 Week 6 sample paper?
The full care plan for R.D., with three goals in the patient's words and an owner for every action, is published on this page.
What are R.D.'s goals in the NR 601 Week 6 plan?
Walking from bed to toilet at night without holding furniture, walking to the mailbox and back without stopping and keeping Sunday lunch at the daughter's house.