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(NURBN 3033) Nursing assignment on the importance of self-management and SMART Goals


Task: You are the Clinical Nurse Consultant at the RCH, and you have been referred Jamie’s case for your nursing assignment. You are required to identify the current health priorities for Jamie and develop a Self-Management Plan for the next three (3) months with her recovery, rehabilitation, and ongoing management of her condition.


1. Introduction and SMART Goals for the nursing assignment
“Self-management or self-care” refers to management techniques for acute,”chronic illness” that adversely affect patients' health conditions (Araújo-Soares et al., 2018). It helps to “empower patients” to manage their health conditions effectively by undertaking effective measures related to physical condition, emotional condition, social consequence and lifestyle factors. Further, self-management helps patients with chronic illnesses to improve their health conditions while preventing further deterioration leading to a challenging lifestyle (Pérez et al., 2019). It is found in the nursing assignmentthat self-management of chronic diseases is essential as medical assistants cannot accompany the patients to places such as educational institutions, social events and workplaces (Obro et al., 2021). Moreover, as patients suffering from chronic illnesses are prone to severity, it is necessary for them to be thorough with self-management techniques in order to treat severe health conditions with preliminary medications.

In addition, self-management is effective in helping patients regulate their behaviour in social situations while controlling emotions and ensuring physical stability (Anekwe&Rahkovsky, 2018). The given scenario in the nursing assignmentpresents the situation of an 8 year old girl named Jamie who suffers from cystic fibrosis, which is a chronic illness. It has been presented in the case scenario for the nursing assignmentthat the young girl suffers from pancreatic insufficiency and frequent pneumonia, for which she needs medical assistance often. Considering her young age and the jovial nature of Jamie as presented in the case scenario for the nursing assignment, it can be understood that helping her with the self-management of her chronic illness can improve not only her physical condition but also her social life. The nursing assignmentelaborates on the SMART goals that can effectively improve Jamies’ condition in terms of physical aspects as well as social aspects. Further, the importance of self-management has been discussed in the study. The effectiveness of self-management for Jamie has been discussed in the nursing assignmentto understand ways self-management can improve health conditions and independence.






Time frame

To improve Jamie’s perspective about morning coughs

Through regular interactive sessions

By conveying through the nursing assignmentthat adverse health conditions can be common

In order to make her feel comfortable among other students

For 3 months

To prevent the deterioration of Jamie's health conditions

Through the timely intake of medicines

By making her understand the importance of medication

In order to help her live a healthy life

For 3 months

To improve Jamie’s social life

Through socialisation with friends

by improving her health conditions

Using regular medicines

For 3 months


Table 1: SMART Goals
(Source: Self-created)

2. Discuss and Critically Analyse Consumer Directed Care/Self-Management Importance
Consumer-directed self-management for chronic illness emphasises patients' autonomy while undergoing treatment lifestyle (Pérez et al., 2019). Patient autonomy refers to the “patient’s wish” to accept or refuse treatment. Further, it prioritises patients’ emotional and psychological aspects while undergoing treatment. It is found in this nursing assignmentthat self-management of chronic illness helps patients to be independent and self-dependent in terms of medical assistance. Further, self-management for chronic illnesses is essential in order to maintain positive health conditions and prevent the deterioration of chronic health illness (Araújo-Soares et al., 2018). It is important for patients suffering from chronic illnesses to be aware of self-management techniques in order to deal with severe health conditions in emergency situations. Moreover, patients with chronic illness need to be mentally prepared for severe health conditions and take effective medication or measures as preliminary treatment.

It has been stated in the nursing assignmentthat patients with chronic illness often face emotional and psychological challenges in addition to their adverse physical conditions (Obro et al., 2021). Further, they face challenges in socialising and participating in social events. It has been observed in the nursing assignmentthat patients with chronic illness feel uncomfortable among others in educational institutions and workplaces due to their different health aspects. Care planning and self-management of patients are important in order to help them cope with the surrounding environment (Mitchell et al., 2020). As presented in the given scenario for the nursing assignment, Jemmie, the young girl, felt uncomfortable among her friends due to recurrent coughing and breathing trouble that she often experienced. Further, it has been observed in the nursing assignmentthat the girl made efforts to prevent her coughing in order to feel the same as others in her age group.

Self-management is important in order to help patients to regulate their behaviour, emotions and psychological aspects. It is essential to regulate the behaviour and emotions of patients suffering from chronic illnesses in order to help them live better social life (Anekwe&Rahkovsky, 2018). Self-management is significant in helping patients to behave in accordance with the social environment without making them feel uncomfortable as a result of their different health conditions. Further, self-management is important to improve the psychological aspects of patients suffering from chronic illnesses (Anekwe&Rahkovsky, 2018). It has been stated in the nursing assignmentthat patients often hesitate to socialise. Further, they perceive that their health conditions would be humiliating when exposed in public. Self-management effectively helps patients with chronic illnesses to overcome psychological weaknesses and improve their mental stability. It is important for such patients to adopt self-management techniques in order to prevent adverse conditions in social events, educational institutions and workplaces.

Effectiveness of care planning
A care plan is a document that is created for a person who has chronic long term health issues and healthcare provides a personal care plan. The care plan is applied predominantly by care professionals, healthcare experts, nurses, and other medical stakeholders by involving in the management and delivery of the individual’s care (Dineen-Griffin et al., 2019). The care plan in the nursing assignmentmentions why that person needs care after assessing his/her health needs, their medical history, personal details, expected outcomes and care schedule to deliver to the individual, when, how and by whom. Care plan creates an assessment of the individual’s care needs by assessing health risks in the near future and advocates for the family members (Nelson et al., 2020).

Care plan information helps the individual and family members to learn about treatment plans and its effectiveness to control the effect of long term chronic diseases. The care plan in the nursing assignmentis consulted by pharmacists, doctors, nurses to gain information on an individual to assist with the healthcare (Saxby et al., 2019). The primary function of a care plan is to deliver social and health care services. Based on a care plan the individual can analyse on how to practise healthy habits that gives significant impact on their physical and mental health. Care planning and self-management can effectively help Jamie to improve her social life beyond the periphery of her home. It has been stated in the nursing assignmentthat the psychological aspects of patients are an integral part of self-management (Allegrante, Wells& Peterson, 2019).

Self-management can be effective in improving the mental health conditions of patients suffering from chronic illnesses. It can be stated that Jemmie can adopt self-management strategies by regulating her behaviour and emotions in social situations.

Further, she can be beneficial in developing a positive perspective about her illness and its consequences. It has been stated in the nursing assignmentthat patients with chronic illnesses need to be ensured that their health conditions are not socially criticised and they are accepted without criticism (Schulman-Green et al., 2021). It can be stated in the nursing assignmentthat inculcating the notion that Jemmie’s health conditions are not socially criticised can help her to feel comfortable among others of her age. Moreover, suppressing her coughs would only deteriorate her health conditions leading to respiratory issues. It is essential to guide patients in self-care planning and management in order to help them improve their well-being (Aasmul et al., 2018).Self-management can be effective in helping her live a life that supports her health conditions by avoiding the suppression of coughs. Thus, it can be understood that self-management can effectively improve Jemmie’s health conditions, including physical, emotional, psychological and behavioural aspects.

3.Designing a Self-management plan for the nursing assignment

Student to fill out Goals and corresponding intervention under each goal







Intervention 1 and Rationales

Jamie as per the nursing assignmentneeds to drink more water and sleep in a humidifier room. Jamie needs to sleep at night with the head slightly elevated (Calthorpe et al., 2020). Caregivers structure a schedule by mentioning time to drink water and intake food (Cree et al., 2018).

Jamie needs “chest physical therapy” that includes pounding back and chest to assist Jamie cough up accumulated mucus in lungs (Schmid Mohler et al., 2019). This therapy needs to follow up times and mechanical devices are applied to help the process.

The caregivers make social connections with Jamie’s school friends and neighbours. Caregivers motivate Jamie to share her thoughts and regular experience via telephone or video calls. This intervention mentioned in the nursing assignmenthelps Jamie to motivate to increase social connection.


Intervention 2 and Rationales






To reduce morning cough the caregiver needs to identify allergen items that trigger the cause of morning cough. After detecting the allergen product the caregiver limiting and avoiding exposure to these triggers can be helpful (Calthorpe et al., 2020). The doctor also needs to prescribe an inhaler for severe asthma attacks to reduce inflammation in the airway.

The caregiver needed to provide pulmonary rehabilitation training that helped Jamie to practise healthy habits to reduce impact of cystic fibrosis (Schmid Mohler et al., 2019). The pulmonary rehabilitation includes nutrition instruction, exercise, and techniques to control breathing, counselling and education about cystic fibrosis.

The caregiver motivates Jamie to stay active. In this context of the nursing assignment caregivers structure a workout plan and regular exercise have a significant impact on mental health and relieve stress, emotional health, improve memory and help to sleep better.


Intervention 3 and Rationales

Caregiver need to focus on the source of inflammation like to avoid indirect smoking and prescribe medicines to reduce inflammation and swelling.

Caregiver creates a workout plan and provides instruction to Jamie that in the early morning she practises yoga for one hour. During yoga time Jamie follows the yoga teacher’s instruction property and drinks water adequately (Rodriguez-Ayllon et al., 2019).

Jamie needs to visit a mental health support group. In this group Jamie can share her thoughts and interact with people to analyse on how to practise healthy habits (Dineen-Griffin et al., 2019). In the support group mentioned in the nursing assignmentthe counsellor arranges a storytelling session and members share their experiences and book review to develop knowledge and skills.


Intervention 4 and Rationales







The caregiver changes routine, for example to consume fewer acidic food items and eat at least three hours before going to sleep (Dineen-Griffin et al., 2019). Jamie needs to keep the head slightly elevated during sleeping time and needs to use “over the counter antacids” (Dineen-Griffin et al., 2019).

Jamie needs to wash hands properly before taking food that helps to reduce the percentage of other diseases. Jamie needs to wash hand after touching surfaces in public places. It is advised in the nursing assignmentthat she needs to take vaccines properly based on schedule.

Caregiver inspires Jamie to note down daily experience by which she can identify her needs and how to improve her lifestyle to stay healthy. The caregiver reads the diary and analyses her mental state that gives a significant impact on her physical health.


Intervention 5 and Rationales








The caregiver practises exercises in the morning which help Jamie to control breathing practices. On the other hand, the caregiver consults with doctors to know medications to help to open airways.

To provide mental health support, caregivers need to connect with community members and she shares her thoughts with same aged peer groups.


The caregiver practises mindfulness, yoga, deep breathing and meditation that help Jamie for mental relaxation. It is found in the nursing assignmentthat Jamie practises mindfulness for at least 30 hours and thinks positive ideas (Saxby et al., 2019).


Intervention 6 and Rationales





Jamie needs to eat a balanced diet and in a diet plan the caregiver mentions fruits, whole grains, vegetables, protein, full fat dairy products and healthy fats (Saxby et al., 2019).

Jamie needs talk therapy by which she expresses her mental pain and feel free to analyse her health issues.

Foods that support mood include fatty fish rich in Omega-3S, nuts, avocados, leafy greens, beans and fresh fruits (Saxby et al., 2019). It is found in the nursing assignmentthat the caregiver structures a diet plan by mentioning nutritional values by which Jamie can understand the importance of following a diet.


Intervention 7 and Rationales



For severe cases, the caregiver provides oxygen therapy based on the situation mentioned in the nursing assignmentand provides breathing treatment therapies. It also prevents pulmonary hypertension that affects the heart and lung (Saxby et al., 2019).

Support groups help Jamie the opportunity to interact with other people who have experienced similar symptoms and experiences (Dineen-Griffin et al., 2019). It is found in the nursing assignmentthat the support group gets ideas on how to take care of themselves and also support group members during critical phases.

Sleep is an essential thing that helps a human’s body rejuvenates. For this reason, the caregiver provides instructions to Jamie for at least 8 hours of sleep everyday at night (Dineen-Griffin et al., 2019).

Self management is appalled in relation to long term chronic health conditions while self care used to acute illness. In this nursing assignmentJamie suffers from cystic fibrosis that gives a negative impact on her physical as well as mental health. By structuring a self care plan Jamie can improve her health and manage practical and emotional issues. In this nursing assignmentcontext Jamie needs to know about her treatment plan and also needs to know how treatment gives an impact on her health. Jamie needs to follow a routine by which she can practise healthy habits to reduce disease complications.

Reference List
Aasmul, I., Husebo, B. S., Sampson, E. L., & Flo, E. (2018). Advance care planning in nursing homes–improving the communication among patient, family, and staff: results from a cluster randomized controlled trial (COSMOS). Frontiers in psychology, 9,
Allegrante, J. P., Wells, M. T., & Peterson, J. C. (2019).Interventions to support behavioral self-management of chronic diseases.Annual review of public health, 40, 127.
Anekwe, T. D., &Rahkovsky, I. (2018). Self-management: a comprehensive approach to management of chronic conditions. American Journal of Public Health, 108(S6), S430-S436.
Araújo-Soares, V., Hankonen, N., Presseau, J., Rodrigues, A., &Sniehotta, F. F. (2018).Developing behaviour change interventions for self-management in chronic illness.European Psychologist.
Calthorpe, R. J., Smith, S., Gathercole, K., & Smyth, A. R. (2020). Using digital technology for home monitoring, adherence and self-management in cystic fibrosis: a state-of-the-art review.Thorax, 75(1), 72-77.
Cree, R. A., Bitsko, R. H., Robinson, L. R., Holbrook, J. R., Danielson, M. L., Smith, C., ... & Peacock, G. (2018). Health care, family, and community factors associated with mental, behavioral, and developmental disorders and poverty among children aged 2–8 years—United States, 2016. Morbidity and Mortality Weekly Report, 67(50), 1377. Dineen-Griffin, S., Garcia-Cardenas, V., Williams, K., &Benrimoj, S. I. (2019). Helping patients help
themselves: a systematic review of self-management support strategies in primary health care practice. PloS one, 14(8), e0220116.
Mitchell, S. L., Volandes, A. E., Gutman, R., Gozalo, P. L., Ogarek, J. A., Loomer, L., ... &Mor, V. (2020). Advance care planning video intervention among long-stay nursing home residents: a pragmatic cluster randomized clinical trial. JAMA internal medicine, 180(8), 1070-1078.
Nelson, C. A., Bhutta, Z. A., Harris, N. B., Danese, A., & Samara, M. (2020). Adversity in childhood is linked to mental and physical health throughout life. bmj, 371.
Obro, L. F., Heiselberg, K., Krogh, P. G., Handberg, C., Ammentorp, J., Pihl, G. T., &Osther, P. J. S. (2021). Combining mHealth and health-coaching for improving self-management in chronic care.A scoping review.Patient Education and Counseling, 104(4), 680-688. 6F37FB50418383F9F23D432EAA77C0CDEDC7A57340E9D645B1DE3FFD1A0147AB&originRegion=eu-west-1&originCreation=20221025130956
Pérez, Y. I. V., Medlow, S., Ho, J., & Steinbeck, K. (2019). Mobile and web-based apps that support self-management and transition in young people with chronic illness: systematic review. Journal of medical Internet research, 21(11), e13579. Rodriguez-Ayllon, M., Cadenas-Sánchez, C., Estévez-López, F., Muñoz, N. E., Mora-Gonzalez, J., Migueles, J. H., ...& Esteban-Cornejo, I. (2019). Role of physical activity and sedentary behavior in the mental health of preschoolers, children and adolescents: a systematic review and meta-analysis. Sports medicine, 49(9), 1383-1410.

Saxby, N., Beggs, S., Battersby, M., & Lawn, S. (2019). What are the components of effective chronic condition self-management education interventions for children with asthma, cystic fibrosis, and diabetes? A systematic review.Patient education and counseling, 102(4), 607-622. _review/links/5ccbd6d792851c3c2f81913b/What-are-the-components-of-effective-chronic-condition-self-management-education-interventions-for-children-with-asthma-cystic-fibrosis-and-diabetes-A-systematic-review.pdf
Schmid Mohler, G., Caress, A. L., Spirig, R., Benden, C., &Yorke, J. (2019). “Thrust out of normality”—How adults living with cystic fibrosis experience pulmonary exacerbations: A qualitative study. Journal of clinical nursing, 28(1-2), 190-200.
Schulman-Green, D., Feder, S. L., Dionne-Odom, J. N., Batten, J., En Long, V. J., Harris, Y., ...&Whittemore, R. (2021). Family caregiver support of patient self-management during chronic, life-limiting illness: a qualitative metasynthesis. Journal of family nursing, 27(1), 55-72.


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