Preliminary Care Coordination Infographic

SPECIFIC Reduce A1c Level by 1% in 3 months (ADA)

MEASUREABLE Track daily blood sugar readings ( CDC)

ATTAINABLE This SMART goal is feasible if you have access to the necessary resources and a diabetes management plan.

RELEVANT/TIME BOUND GCM allows for daily monitoring. Patients to log cards and physical activity in the GCM app. The patient will come to the next visit in 3 months for a review.

SMARTGOALSGOALS FOR DIABETES

TYPE-1TYPE-1

Include description of condition and/or relevant starting patient information here

YOUR PARAGRAPH TEXTYOUR PARAGRAPH TEXTYOU

List of Resources Would go here.

Best Practice

Frequent testing helps maintain optimal levels.

Administering insulin as prescribed by a healthcare provider.

Focus on whole grains, lean proteins, fruits, and vegetables.

 Regular exercise improves insulin sensitivity.

Blood Sugar Monitoring

Insulin Therapy

Diet

Physical Activity

Type 1 Diabetes

Disease Description

CDC

ADA

NIDDK

Clinical Diabetes Journal

Citation

Citation

Citation

Citation

Sentinel City® Student Report

Luis Gonzalez AutoGen_03699f5a-148f-4957- bb09- 5786d8398102_17@SentinelU.com

Capella University-2147311862

7/19/2026

7/23/2026

Name:

ID:

First Access:

Last Access:

Email:

Tenant:

10 hrs 58 mins10 hrs 53 mins5 mins

Total Time SpentTime in AssessmentsTime in City

CARE PLAN FAMILY SUPPORT ASSESSMENT

100%Progress: Time Spent: 2 hrs 52 mins

RelationshipName

selfCandice

RelationshipName

3Fair

Total Household Occupants (Include Client)Ability to Pay Other Monthly Bills

FairRent

Ability to Pay Rent / MortgageRent / Own

YesGovernment aid

Child SupportOther Sources of Income

9,984Employed

Total Annual Income from EmployerEmployment Status

High School Grad

Highest Level of Education Completed

EnglishUnknown

Primary Language Spoken At HomeReligious Preference

Single26White / Non-Hispanic

Marital StatusAgeRace/Ethnicity

Candice Conway

Client Full Name

07/21/2026Luis Gonzalez

DateInterviewer Completing this Assessment

ADULTS IN THE HOME

FINANCIAL

GENERAL FAMILY INFORMATION

Page 1 of 9Thursday, July 23, 2026

Sentinel City® Student Report

Luis Gonzalez AutoGen_03699f5a-148f-4957- bb09- 5786d8398102_17@SentinelU.com

Capella University-2147311862

7/19/2026

7/23/2026

Name:

ID:

First Access:

Last Access:

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Tenant:

10 hrs 58 mins10 hrs 53 mins5 mins

Total Time SpentTime in AssessmentsTime in City

Brandi's fatherJessi

RelationshipName

Page 2 of 9Thursday, July 23, 2026

Sentinel City® Student Report

Luis Gonzalez AutoGen_03699f5a-148f-4957- bb09- 5786d8398102_17@SentinelU.com

Capella University-2147311862

7/19/2026

7/23/2026

Name:

ID:

First Access:

Last Access:

Email:

Tenant:

10 hrs 58 mins10 hrs 53 mins5 mins

Total Time SpentTime in AssessmentsTime in City

Lot of conserns about Jessi. Canice doesn't want to leave her kids with hime anymore because of his short temper. Lack of support from newborn father

General Childcare Arrangements / Concerns

Child Support

Jessi won't probably be involved in child's careBottle feed

Information about child's fatherPlans to breastfeed or bottle feed

Noabout 24

Prenatal care?How many weeks?

Yes

Is client currently pregnant?

Female2Brandi

GenderAgeChild

NoYes

Are there medical issues with this child?Are Immunizations up to date for this child?

Jessi works at his dad's liquor store in Industrial Heights.He has short temper and consumes drugs and alcohol

Information about child's father

Child Support

Child Support

His father is Randy. He was locked up for domestic abuse for a couple of years. Candice thinks he's out now on work-release, but he must be in a different city

Information about child's father

YesYes

Are there medical issues with this child?Are Immunizations up to date for this child?

Male8Brayden

GenderAgeChild

CHILDREN IN THE HOME

Page 3 of 9Thursday, July 23, 2026

Sentinel City® Student Report

Luis Gonzalez AutoGen_03699f5a-148f-4957- bb09- 5786d8398102_17@SentinelU.com

Capella University-2147311862

7/19/2026

7/23/2026

Name:

ID:

First Access:

Last Access:

Email:

Tenant:

10 hrs 58 mins10 hrs 53 mins5 mins

Total Time SpentTime in AssessmentsTime in City

Uncertain when she goes back to work

Newborn care

Page 4 of 9Thursday, July 23, 2026

Sentinel City® Student Report

Luis Gonzalez AutoGen_03699f5a-148f-4957- bb09- 5786d8398102_17@SentinelU.com

Capella University-2147311862

7/19/2026

7/23/2026

Name:

ID:

First Access:

Last Access:

Email:

Tenant:

10 hrs 58 mins10 hrs 53 mins5 mins

Total Time SpentTime in AssessmentsTime in City

Other environmental, health, and safety hazard identified on the scenario also impact the life quality of this family

Other Notes

Excessive sodium, high added sugar, lack of fiber and micronutrients like essential vitamins as well as unhealthy fat and additives from frozen food and sodas

Frozen food. Milk and cereal for children

At Joe's Grocery across the street

Nutrition ConcernsFoodGrocery

Yes

Concerns about physical, emotional, or behavioral problems with any of the children?

Yes

Does the client have concerns about harming their children?

Yes

Does the client have concerns about someone threatening or physically hurting them?

Yes

Does the client need to get away from an abusive relationship or harmful situation?

Yes

Is client currently a victim of domestic violence?

Yes

Has client ever been a victim of domestic violence?

NoYes

Abuse of Prescription MedicationsAlcohol Use

YesYes

Use of Illegal SubstancesSmoker

OTHER

SUBSTANCES

Page 5 of 9Thursday, July 23, 2026

Sentinel City® Student Report

Luis Gonzalez AutoGen_03699f5a-148f-4957- bb09- 5786d8398102_17@SentinelU.com

Capella University-2147311862

7/19/2026

7/23/2026

Name:

ID:

First Access:

Last Access:

Email:

Tenant:

10 hrs 58 mins10 hrs 53 mins5 mins

Total Time SpentTime in AssessmentsTime in City

APARTMENT ASSESSMENT 1 hr 9 minsTime Spent:100%Progress:

Care PlanRationaleNameCategory

Educate the patient and residents on strictly moving all smoking activities outdoor to eliminate active secondhand smoke accumulation. Instruct the patient to open windows and utilize exhaust fans to clear airborne toxins while explaining that ventilation alone does not fully remove third-hand residue. Recommend washing hard surfaces with detergent and hot water to break down embedded tar and resinated chemicals.

Indoor smoking represents not only an immediate health but also an environmental and safety risk. Resinated chemicals permanently embed into surfaces and ventilation networks maintaining high pollution levels. Toxins trigger acute respiratory distress, cardiovascular strain, and long term cancer risk for all residents. Besides, dropped embers present a constant fire hazard while tar physically degrades the structure and assests

Smoking cigarattes

Environmental

Instruct the patient to discard expired leftovers and store all remaining food items in airtags, sealed plastic or glass containers. Guide the patient to wipe down kitchen counters daily, clean up spills immediately and remove garbage from living space every evening. Assist the patient in contacting landlord services or a professional exterminator to address the roach infestation safely

May cause intestinal disease transmission as well as respiratory and psychological issues due to unsanitary living space. They may also cause stain and property damage

Leftovers and roaches

Environmental

Page 6 of 9Thursday, July 23, 2026

Sentinel City® Student Report

Luis Gonzalez AutoGen_03699f5a-148f-4957- bb09- 5786d8398102_17@SentinelU.com

Capella University-2147311862

7/19/2026

7/23/2026

Name:

ID:

First Access:

Last Access:

Email:

Tenant:

10 hrs 58 mins10 hrs 53 mins5 mins

Total Time SpentTime in AssessmentsTime in City

See above

Indoor smoking represents not only an immediate health but also an environmental and safety risk. Resinated chemicals permanently embed into surfaces and ventilation networks maintaining high pollution levels. Toxins trigger acute respiratory distress, cardiovascular strain, and long term cancer risk for all residents. Besides, dropped embers present a constant fire hazard while tar physically degrades the structure and assests

Smoking cigarattes

Health

Educate the resident on how standing, unattended organic garbage acts as breeding ground for harmful bacteria, mold spores, and airborne foul odors. Explain the direct correlation between left-out trash bags and attracting disease-carrying insects or rodents into the living space. Help the resident to set up a structured household routine, such as taking trash to the main dumpster or outside bin every evening before bed

Trash bag left unattended can create foul odors, attrackt pests, and create breeding grounds for harmful bacterias

Trash bag left unattended

Health

Intruct the caregiver to empty the bucket of water immediately to eliminate the active, proximal drowning hazard. Establish a household rule requiring all cleaning bucket or large open containers to be stored inverted (upside down) in a locked closet or high shelf immediately after use

An unattended bucket of water puts the kids on a risk of drowning. The kids high levels of gravity and large heads make them prone to losing their balance and toppling headfirst into containers

Drowning hazardSafety

Direct immediate removal of all glass bottles from the floor area to clear walkways and prevent immediate lacerations or falls. Discuss how fragile glass can shatter easily which present severe cutting hazards for adults and children. Assist the patient in designating a safe area to store the glass bottles.

Can cause cutting injuries to adult and children if shuttered. Risk for slips, trips, and falls

Glass bottles on floor

Safety

Page 7 of 9Thursday, July 23, 2026

Sentinel City® Student Report

Luis Gonzalez AutoGen_03699f5a-148f-4957- bb09- 5786d8398102_17@SentinelU.com

Capella University-2147311862

7/19/2026

7/23/2026

Name:

ID:

First Access:

Last Access:

Email:

Tenant:

10 hrs 58 mins10 hrs 53 mins5 mins

Total Time SpentTime in AssessmentsTime in City

NURSING DIAGNOSIS 6 hrs 52 minsTime Spent:100%Progress:

Evidence - Based Rationale(s)Nursing Actions

1- Maternal Outcome: The patient will remain free of preventable pregnancy-related complications (e.g. severe preeclampsia, injury from falls, or unchecked infections) throughout the gestational period.�Fetal Outcome: The fetus will maintain a reassuring status as evidenced by normal feta heart rate (FHR) patterns (HR 110-160 bpm) and a healthy reactive non-stress test (NST) by week 28. 2- Immediate Safety Outcome: The patient will formulate a comprehensive, actionable safety plan and identify a secure emergency shelter location within 24 hours. Short-Term Outcome: The patient will disclose immediate dangers and escalation of violence to the healthcare team and accept referrals to local IPV advocates and social services within 48 hours. Long-Term Outcome: By the time of delivery, the patient and infant will reside in a safe environment (either via secure shelter, independent housing, or monitored family placement) free from violence with active links to substance rehabilitation and economic aid.

Expected Outcome

Statement: 1- Risk for Maternal and Fetal Injury among pregnant community residents related to innadequate regional prenatal care accessibility, environmental hazard exposure, and/or socioeconomic stressors. 2- Dysfuntional Family Processes within the community setting related to substance use disorder, financial deprivation, and intimate partner violence, as evidenced by chronic domestic conflict, physical safety hazards to the pregnant patient/fetus and fractured support systems.

Community Health Nursing Diagnosis

Dysfunctional Family Processes

Risk for Maternal and Fetal Injury

Nursing Diagnosis

1- The nurse will evaluate goal achievement by reviewing fetal kick counts, blood pressure trends, serial ultrasound metrics, and lab data (such as urine protein and blood glucose) at each regular prenatal visit. 2- The community nurse will evaluate safety metrics through unannounced or carefully coordinated home visits (when safe), private face-to-face interviews away from the partner and collaboration with case managers, victim advocates, and law enforcement if necessary.

How will the nurse evaluate if goals/outcomes are achieved?

ANALYSIS

PLANNING

IMPLEMENTATION

Page 8 of 9Thursday, July 23, 2026

Sentinel City® Student Report

Luis Gonzalez AutoGen_03699f5a-148f-4957- bb09- 5786d8398102_17@SentinelU.com

Capella University-2147311862

7/19/2026

7/23/2026

Name:

ID:

First Access:

Last Access:

Email:

Tenant:

10 hrs 58 mins10 hrs 53 mins5 mins

Total Time SpentTime in AssessmentsTime in City

1- Early detection of hypertension and proteinuria is critical for managing preeclampsia, which directly threatens placental perfusion and maternal safety.2 - A drop in fetal movement or a non-reactive NST can point to placental insufficiency or fetal hypoxia, signaling a need for immediate intervention.3- Hormonal changes induce joint laxity, shifting the maternal center of gravity and raising the risk of falls and physical injury. Excessive physical strain after mid-pregnancy is statiscally linked to an increase in preterm birth risks. 4- Screening in the presence of the perpetrator significantly increases the risk of immediate retaliation and severe harm to the patient. 5- Having a pre-established, hidden safety strategy reduces panic and reduces response time when a crisis escalate, increasing likelihood of a successful escape. 6- Addressing substance dependency requires specialized care that accounts for IPV-related trauma; alleviating economic strain reduces a major trigger for household stress and removes barriers to leaving an abusive.

1- Check blood pressure and screen for protein in the urine at each check-up.2- Teach the mother to perform daily fetal kick counts and schedule clinical NSTs as indicated for high-risk profiles. 3- Instruct the patient on safe body mechanics, modifying physical tasks over 20 weeks, avoiding strenuous lifting, and minimizing enviromental risks. 4- Conduct private screening and universal IPV assessments at every encounter and only when she is entirely alone.5- Collaboratively develop a personal safety plan.6- Initiate multidisciplinary referrals for substance use and financial aid.

EVALUATION

Goal met: The patient demonstrated a stable blood pressure below 140/90 mmHg, urine test remained negative for protein, and fetus maintained a reactive NST with normal growth tracking. Goal met (Safety component): The patient successfully completed a personalized safety plan, memorized a domestic violence hotline number, and safely hid an emergency bag at a trusted neighbor's home. Goal met (Systemic component): The family unit remains highly unstable. The partner refused substance use rehabilitation, but the patient has completed intake paperwork for emergency maternal housing and transitional financial assistance. Continued close monitoring by community health systems is required.

Page 9 of 9Thursday, July 23, 2026