NURS FPX 6610 Assessment 4 Case Presentation
Student Name Capella University NURS-FPX 6610 Introduction to Care Coordination Prof. Name Date Case Presentation Greetings, I am Student Name, and I am pleased to present the case study of a patient, Mrs. Snyder. Importance of Case Study in Healthcare The role of case studies in the healthcare sector is pivotal. These documents succinctly and accurately encapsulate patient medical information. They serve as comprehensive repositories, encompassing details of the patient’s medical condition, diagnoses, potential health concerns, and available treatment options (Hinchliffe et al., 2020). Utilizing real patient scenarios, case studies become invaluable tools for patient tracking and reference (Hinchliffe et al., 2020). In this presentation, the focus will be on transitional patient care, exploring how multidisciplinary teams collaborate to ensure optimal treatment. Transitional Care Plan and Goals of Continuing Care Transitional care, in healthcare settings, revolves around the well-being of patients during their transfer from one healthcare setting to another (Daliri et al., 2019). The goal is to facilitate stress-free and feasible patient transfers. The case under discussion involves Mrs. Snyder, a 56-year-old patient facing a critical health condition, necessitating her transfer between medical centers. Continuing care aims to provide Mrs. Snyder with quality care while respecting her Jewish cultural and religious beliefs. Stakeholder Part in Patient Health and Safety Stakeholders play a crucial role in determining the quality of patient care and well-being (Lianov et al., 2020). The responsibility of stakeholders lies in ensuring the patient’s cooperation without overwhelming them. In the case of Mrs. Snyder, the focus is on a seamless transfer between healthcare facilities, considering her Jewish background. This involves providing Mrs. Snyder with comprehensive care that aligns with her religious and cultural values, including the provision of Kosher food (Lianov et al., 2020). Elements of Continuous Care Continuous care involves identifying patient and family medical records to discern the root cause of health issues, recognizing the hereditary nature of certain conditions (Pervjakova et al., 2022). Accurate patient evaluation serves as a cornerstone for effective treatment. Additionally, emphasis is placed on collecting precise medical health records to facilitate data transmission in healthcare organizations (Asmirajanti et al., 2019). NURS FPX 6610 Assessment 4 Case Presentation Patient Assessment Mrs. Snyder presents several health issues, including ovarian cancer, diabetes, hyperglycemia, weight gain due to stress, and fluctuating blood pressure. Her critical condition necessitates a careful evaluation and consideration of her cultural and religious beliefs. Inter-professional Care Team Effective coordination among thyroid doctors, heart specialists, cancer specialists, and nurses is imperative for Mrs. Snyder’s complex medical issues. This interdisciplinary approach ensures adherence to treatment guidelines and precise care. Factors Affecting Patient Outcomes Various factors, including economic status, lifestyle, social circle, and surroundings, can impact patient care (Chung et al., 2020). Assumption An underlying assumption is Mrs. Snyder’s adherence to Judaism, necessitating consideration of kosher dietary restrictions. Additionally, her family faces economic stress, requiring frequent monitoring and support. Areas of Uncertainties In situations with critically ill patients like Mrs. Snyder, some degree of ambiguity persists, demanding well-trained nursing staff to provide appropriate care (Chung et al., 2020). Determination of Required Resources To address Mrs. Snyder’s needs effectively, various resources, such as frequent monitoring of blood pressure and sugar levels, a healthy diet, proper diabetes treatment, regular exercise, and nursing assistance for daily activities, are essential (Howell et al., 2020). Conclusion Mrs. Snyder’s multiple health issues necessitate her transfer between healthcare centers, emphasizing the importance of a transitional care plan that respects her cultural and religious beliefs. Strategic initiatives, including interdisciplinary collaboration, can enhance patient care quality and reduce mortality rates. It is incumbent upon healthcare providers to address the unique requirements of each patient, ensuring a holistic approach to healthcare. References Ansa, B. E., Zechariah, S., Gates, A. M., Johnson, S. W., Heboyan, V., & De Leo, G. (2020). Attitudes and behavior towards interprofessional collaboration among healthcare professionals in a large academic medical center. Healthcare, 8(3), 323. https://doi.org/10.3390/healthcare8030323 Asmirajanti, M., Hamid, A. Y. S., & Hariyati, Rr. T. S. (2019). Nursing Care Activities Based on Documentation. BMC Nursing, 18(1). https://doi.org/10.1186/s12912-019-0352-0 Chung, G. K.-K., Dong, D., Wong, S. Y.-S., Wong, H., & Chung, R. Y.-N. (2020). Perceived poverty and health, and their roles in the poverty-health vicious cycle: A qualitative study of major stakeholders in the healthcare setting in Hong Kong. International Journal for Equity in Health, 19(1). https://doi.org/10.1186/s12939-020-1127-7 NURS FPX 6610 Assessment 4 Case Presentation Daliri, S., Hugtenburg, J. G., ter Riet, G., van den Bemt, B. J. F., Buurman, B. M., Scholte op Reimer, W. J. M., van Buul-Gast, M.-C., & Karapinar-Çarkit, F. (2019). The effect of a pharmacy-led transitional care program on medication-related problems post-discharge: A before—after prospective study. Plos One, 14(3), 0213593. https://doi.org/10.1371/journal.pone.0213593
NURS FPX 6610 Assessment 3 Transitional Care Plan
Student Name Capella University NURS-FPX 6610 Introduction to Care Coordination Prof. Name Date Transitional Care Plan Patient safety and quality of care are heavily reliant on transitional care, aiming to offer advanced facilities and services during the transfer of patients between treatment phases. Particularly crucial in chronic illnesses, continuous monitoring across treatment phases is imperative to prevent mortality, a task accomplished by a transitional care plan. This assessment explores the case of Mrs. Snyder, a 56-year-old patient with diabetes admitted to Villa Hospital for an infected toe. The focus is on discussing the transitional care plan for Mrs. Snyder and examining communication barriers that may impact the overall transitional plan (Korytkowski et al., 2022). Key Elements & Information Needed for High-Quality Treatment Patient care and safety improvements hinge on strict adherence to guidelines ensuring precision in diagnosis and effective tracking of patient medical records (Watts et al., 2020). Collecting Mrs. Snyder’s medical records is crucial for addressing her health issues comprehensively. These records not only aid in diagnosing specific health problems but also uncover other issues affecting overall health, such as depression, high blood pressure, and heart conditions (Chen et al., 2018). In addition to medical records, understanding Mrs. Snyder’s medication list is vital for ensuring the appropriateness of her treatment. Medication reconciliation is necessary to determine the efficacy of her current medication and explore potential substitutes (Fernandes et al., 2020). Obtaining information about emergency and advance directives is essential for providing patient-centered care. It helps in accommodating religious beliefs and understanding the patient’s treatment history from previous healthcare providers, minimizing potential conflicts (Dowling et al., 2020). Patient feedback serves as a crucial element, offering insights into medical personnel behavior and the treatment process. Addressing patient concerns enhances the effectiveness of care and minimizes the risk of readmissions (Moghaddam et al., 2019). Plan of Care and Education Healthcare professionals play a pivotal role in tailoring care plans to meet individual patient requirements. This involves providing community-based healthcare services and facilitating rapid information exchange among healthcare professionals (Dyer, 2021). Access to community and healthcare resources is vital for preventing adverse outcomes like hospital readmissions and mortality rates. These resources include mobility options, social support, health education, and outpatient treatment (Yue et al., 2019). An insightful assessment of Mrs. Snyder’s needs requires comprehensive information such as medical test results, post-discharge prescriptions, time spent in the previous hospital, counseling documents, follow-up plans, social assistance and insurance coverage documents, current health condition, safety risk assessments, and detailed treatment and drug history related to chronic diseases (Humphries et al., 2020). Importance of Key Elements of a Transitional Care Plan Each key element in the transitional care plan is integral to improving patient care. Advance directive information aids in preparing for potential issues during treatment, while community and healthcare resources directly address patient concerns and needs (Schultz et al., 2021). Medication reconciliation ensures accurate and safe administration of medications, reducing the risk of errors and adverse events (Borulkar et al., 2022). Patient feedback enhances the understanding of individual patient needs, contributing to more effective and patient-centered care (Fiorillo et al., 2020). Healthcare professional training is essential for collaborative and culturally sensitive care. Education for patients like Mrs. Snyder is crucial for promoting self-management strategies and adopting a healthier lifestyle (Kaper et al., 2019). Potential Effects of Incomplete or Inaccurate Information on Care Transferring incomplete or inaccurate patient information can lead to treatment delays, complications, and adverse outcomes. Inaccurate medication information, for instance, may result in errors and increased mortality rates (Zirpe et al., 2020). Importance of Effective Communication Effective communication with healthcare agencies is vital for understanding patients’ detailed medical history and fostering positive patient-staff interactions. It plays a crucial role in decision-making for patient well-being (Garcia-Jorda et al., 2022). Potential Effects of Ineffective Communications Ineffective communication can result in delays in timely treatment, health disparities, increased treatment costs, and reduced patient satisfaction. These factors negatively impact patient outcomes and the quality of care (Raeisi et al., 2019). Barriers to the Transfer of Accurate Patient Information Barriers include insufficient staff, incomplete medical histories, and a lack of knowledge about Electronic Health Records (EHR) technology. Overburdened staff may compromise information accuracy, while incomplete medical records and EHR knowledge gaps can hinder seamless information transfer (Ilardo & Speciale, 2020; Tsai et al., 2020). Strategy to Establish Absolute Understanding of Continued Care Effective planning, accurate information transfer, and follow-up sessions are crucial strategies to ensure continued care. Collaboration with destination healthcare providers, complete discharge instructions, and understanding patient perspectives contribute to successful transitional care plans (Spencer & Singh Punia, 2020). Conclusion The transitional care plan is indispensable for transferring patients between healthcare sectors, preventing complications, and improving overall patient care. Strategic planning, effective communication, and comprehensive information transfer contribute to successful transitional care, ensuring the well-being of patients like Mrs. Snyder. References Moghaddam, M. A.A., Zarei, E., Bagherzadeh, R., Dargahi, H., & Farrokhi, P. (2019). Evaluation of service quality from patients’ viewpoint. BMC Health Services Research, 19(1). https://doi.org/10.1186/s12913-019-3998-0 Blackwood, D. H., Walker, D., Mythen, M. G., Taylor, R. M., & Vindrola-Padros, C. (2019). Barriers to advance care planning with patients as perceived by nurses and other healthcare professionals: A systematic review. Journal of Clinical Nursing, 28(23-24), 4276–4297. https://doi.org/10.1111/jocn.15049 Borulkar, R., Dhande, P., & Dhande, P. (2022). Medication Reconciliation: A beneficial tool in patient safety 1 1. Bharati Vidyapeeth Medical Journal (BVMJ), 2(3). https://bvmj.in/journal/borulkar_2022.pdf Chen, Y., Ding, S., Xu, Z., Zheng, H., & Yang, S. (2018). Blockchain-based medical records secure storage and medical service framework. Journal of Medical Systems, 43(1). https://doi.org/10.1007/s10916-018-1121-4 Cullati, S., Bochatay, N., Maître, F., Laroche, T., Muller-Juge, V., Blondon, K. S., Junod Perron, N., Bajwa, N. M., Viet Vu, N., Kim, S., Savoldelli, G. L., Hudelson, P., Chopard, P., & Nendaz, M. R. (2019). When team conflicts threaten the quality of care: A study of health care professionals’ experiences and perceptions. Mayo Clinic Proceedings: Innovations, Quality & Outcomes, 3(1), 43–51. https://doi.org/10.1016/j.mayocpiqo.2018.11.003 NURS FPX 6610 Assessment 3 Transitional Care Plan Dowling, T., Kennedy, S., & Foran, S. (2020). Implementing advance directives—An international
NURS FPX 6610 Assessment 2 Patient Care Plan
Student Name Capella University NURS-FPX 6610 Introduction to Care Coordination Prof. Name Date Patient Identifier: #6700891 Patient Medical Diagnosis: Anxiety Issues, Ovarian Cancer, uncontrolled diabetes, obesity and hyperglycemia Nursing DiagnosisAssessment Data Goals and Outcomes Nursing Interventions Rationale Outcome Evaluationand Re-planning Include 3–5 pieces of data (subjective, objective, or a combination) that led to a nursing diagnosis. Write two goal statements for each nursing diagnosis. Goals must be patient- and family-focused, measurable, attainable, reasonable, and time-specific. List at least three nursing or collaborative interventions and provide the rationale for each goal and outcome. Explain why each intervention is indicated or therapeutic; cite applicable references that support each intervention. Were the goals met? How would you revise the plan of care according to the patient’s response to the current plan of care? Support your conclusions with outcome measures and professional standards. Nursing diagnosis First Diagnosis: Anxiety IssuesLack of Rest due to excessive household duties, from meal prep, to cleaning to looking out for her mother. Regardless of her health, she often takes on duties that are bigger than her physical health limits because she feels that her husband is happy with her (attention seeking behavior). The majority of the verbatim of Mrs. Snyder, and his family was associated with her being the sole caretaker of many people around her, which reflected a lot of duties for her and made her feel fatigued and tired most of the time. constant anxiety of not fulfilling the homemaker role perfectly and constant in stress of taking care of another dependent person excessive use of medication due to stress factors First goal: The underlying issue is that Mrs. Snyder is facing a problem related to her mental health, especially in the lines of compassion fatigue since she herself is taking care of her mother, who has dementia, and over top of that, she is managing her house with her health complications. . The first goal is to introduce counseling and anxiety management through CBT and behavioral activation. Outcome: The outcome is to help Rebacca manage her expressed emotions while helping her to control her anxiety. The goal will help in managing the anxiety as well as to help her regulate her emotions and be able to accept the change of roles in the family such as giving away some of their responsibilities. she will have better mood, while being able to move through the transitional phase smoothly First intervention Refer the patient to the psychologist for psychological intervention and family therapy to help the patient adjust to her new role where she prioritizes her health and family therapy to help the family understand her needs and ways to support her. providing a regulated amount of anxiolytics to ensure the client does not overdose on the medication. The rationale for referring her to the psychologist is that the majority of the stress factors for Mrs. Snyder are associated with her overcompensating behavior and taking care of her mother and her family. Somehow, it can be associated with the fact that providing care is the only way she receives attention and validation; thus, not being able to fulfill her role is making her anxious. This suggests that Mrs Synder is currently facing issues in adjusting to the new reality of life and is unable to transition into the new life situations. Therefore, it is important to offer psychological intervention and to involve family to reduce the psychological stress and help the family to provide support in the way that is needed by her. Similarly, studies have highlighted that psychological interventions play a significant role in providing results and reducing anxieties without major harm (Colizzi et al., 2020). These goals and treatment options are proposed, but none of them are being implemented currently. Thus, to provide a better picture of outcomes and to plan how to move forward, it is important to address the weekly assessments. Second Diagnosis: Ovarian CancerThe patient has been recently diagnosed with ovarian cancer and has undergone radiation and chemotherapy.She misses her chemotherapy appointments as she often feels nauseous afterwards and often reports that her mother requires her help; therefore, she misses her appointments.She expressed her dislike for the post therapy symptoms and how difficult it is to work after it. Second Goal:The goal is to help her become regular to chemotherapy and medication adherence, as with her condition, it is inevitable to miss appointments. Suggesting other care facilities for her mother to help her focus on her health OutcomeThe aim is to bring acceptance, help her understand the importance of chemotherapy, and motivate her to be better. thus, gaol will help her to accept and become punctual to the therapy session Second Intervention suggesting strategies to keep track of the appointments and reminders. involving other family members to come to therapy to support herconstant the oncologist to help her manage her post-chemotherapy session symptoms and to help her feel better The rationale here is to help the patient accept her condition while contacting social support services to help her find better caring alternatives for her mother. Studies have highlighted that chemotherapy holds a significant place in cancer management, and with the progressive stage, chemo can help increase life expectancy (Amjad, & Kasi, 2020). The aim is to help the patient become regular and to provide as much palliative care as possible. as with progressive stages, the palliative care provides a cushion that helps reduce cancer related pain and help the patient live better life (World Health Organization, 2020) These goals and treatment options are proposed, but none of them are being implemented currently. Thus, to provide a better picture of outcomes and to plan how to move forward, it is important to address the weekly assessments. Third Diagnosis: Uncontrolled Diabetes Lack of awareness for the disease management excessive house stress and lack of regulation of diet and medication adherence irregular blood sugar levels that may seem dangerous, as she might be facing more health complications. obesity due to excessive stress eating and other associated health factors. Third Goal: Being a cancer patient, it is imperative to manage the patient’s blood sugar levels, as
NURS FPX 6610 Assessment 1 Comprehensive Needs Assessment
Student Name Capella University NURS-FPX 6610 Introduction to Care Coordination Prof. Name Date Comprehensive Needs Assessment Conducting a comprehensive needs assessment is imperative for healthcare professionals to utilize diverse resources that enhance patient care. This assessment is crafted to identify gaps in patient care and address them through effective care coordination. It also facilitates the recognition of patients’ needs and the development of strategies to assess and meet those needs. The importance of care coordination in patient care is emphasized, and various strategies to enhance patient care are explored. The assessment also delves into interdisciplinary team collaboration in the context of care coordination. Current Gaps in Patient Care A case study involving a 79-year-old diabetic patient, Mr. Decker, illustrates existing gaps in patient care. Factors such as Mr. Decker’s low-income status, insufficient communication about post-discharge care, and lack of post-discharge evaluation contribute to gaps in his care. Utilizing the Patient-Centered Assessment Method, the assessment tool emphasizes an effort-based approach to address not only Mr. Decker’s physiological needs but also his social, religious, and psychological requirements (Perazzo et al., 2020). Informational Needs for Optimal Patient Care To assess the current level of care, essential patient information includes medical records (e.g., age, weight, allergies), emotional behavior, desires, medical schedule, and religious beliefs. Gathering additional necessary data involves conducting preliminary discussions and interviewing Mr. Decker’s family members, considering factors such as his interests, diet, and social connections. Electronic health records, patient registration documents, and routine follow-up procedures are also employed, ensuring adherence to HIPAA compliance (Shah & Khan, 2020). Societal, Economic, and Interdisciplinary Factors Impacting Patient Care Factors such as financial crisis, aging, and insufficient social support significantly impact patient care. Aging, in particular, poses additional risks for complications in chronic patients like Mr. Decker. Economic determinants, such as Mr. Decker’s low income, affect his access to recommended therapies. Limited social support from family members further complicates post-discharge procedures, potentially leading to serious complications (Ko et al., 2019; Palileo-Villanueva et al., 2022). Professional Standards and Care Coordination Outcomes Organizations like the National Quality Forum and the Agency for Healthcare Research and Quality play crucial roles in establishing standards for safety, care coordination outcomes, and evaluation benchmarks. Models such as the Care Coordination and Transition Management Logic Model and evidence-based practices contribute to effective care coordination, focusing on patient-centered care and multidisciplinary collaboration (Hofmann & Erben, 2020; Artiga et al., 2020). Evidence-Based Practices for Patient Care Coordination Evidence-based strategies like GENESIS, routine evaluation of older patients, and the sepsis six bundles are recommended for managing elderly patients with infection. These practices aim to identify and address infection outbreaks, monitor essential signs, and provide timely interventions to reduce mortality rates associated with sepsis (Kregel et al., 2022; LeRoith et al., 2019; Bleakley & Cole, 2020). Benefits of a Multidisciplinary Approach to Patient Care A multidisciplinary approach in healthcare enhances patient care by considering various aspects of a patient’s health simultaneously. This approach minimizes errors, particularly those related to socioeconomics and age-related variables. Mr. Decker’s care gaps, influenced by social, economic, and interprofessional factors, could have been mitigated through a multidisciplinary team. Research suggests that a multidisciplinary approach can reduce readmissions and provide more thorough care to patients (Ni et al., 2019). Conclusion In conclusion, care coordination is integral for improving overall patient care quality. Identifying and addressing gaps in patient care, particularly those influenced by socioeconomic, age-related, and interdisciplinary factors, requires a comprehensive needs assessment. This assessment, coupled with evidence-based practices and adherence to professional standards, contributes to enhanced patient care. The incorporation of a multidisciplinary approach further strengthens patient care outcomes. References Artiga, S., Orgera, K., & Pham, O. (2020). Issue brief disparities in health and health care: Five key questions and answers. Deancare.com. https://deancare.com/getmedia/e00c9856-28d0-4c63-b2c0-9bf68cadcebb/Disparities-in-Health-and-Health-Care-Five-Key-Questions-and-Answers.pdf Bleakley, G., & Cole, M. (2020). Recognition and management of sepsis: The nurse’s role. British Journal of Nursing, 29(21), 1248–1251. https://doi.org/10.12968/bjon.2020.29.21.1248 Hofmann, F., & Erben, M. J. (2020). Organizational transition management of circular business model innovations. Business Strategy and the Environment, 29(6), 2770–2788. https://doi.org/10.1002/bse.2542 Ko, H., Park, Y.-H., Cho, B., Lim, K.-C., Chang, S. J., Yi, Y. M., Noh, E.-Y., & Ryu, S.-I. (2019). Gender differences in health status, quality of life, and community service needs of older adults living alone. Archives of Gerontology and Geriatrics, 83, 239–245. https://doi.org/10.1016/j.archger.2019.05.009 Kregel, H. R., Murphy, P. B., Attia, M., Meyer, D. E., Morris, R. S., Onyema, E. C., Adams, S. D., Wade, C. E., Harvin, J. A., Kao, L. S., & Puzio, T. J. (2022). The geriatric nutritional risk index as a predictor of complications in geriatric trauma patients. Journal of Trauma and Acute Care Surgery, 93(2), 195–199. https://doi.org/10.1097/TA.0000000000003588 LeRoith, D., Biessels, G. J., Braithwaite, S. S., Casanueva, F. F., Draznin, B., Halter, J. B., Hirsch, I. B., McDonnell, M. E., Molitch, M. E., Murad, M. H., & Sinclair, A. J. (2019). Treatment of diabetes in older adults: An endocrine society* clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 104(5), 1520–1574. https://doi.org/10.1210/jc.2019-00198 NURS FPX 6610 Assessment 1 Comprehensive Needs Assessment Liu, X., Xu, Y., An, M., & Zeng, Q. (2019). The risk factors for diabetic peripheral neuropathy: A meta-analysis. Plos one, 14(2), 0212574. https://doi.org/10.1371/journal.pone.0212574 Mertens, F., Debrulle, Z., Lindskog, E., Deliens, L., Deveugele, M., & Pype, P. (2020). Healthcare professionals’ experiences of inter-professional collaboration during patient’s transfers between care settings in palliative care: A focus group study. Palliative Medicine, 35(2), 026921632096874. https://doi.org/10.1177/0269216320968741 Milgrom, J., Hirshler, Y., Reece, J., Holt, C., & Gemmill, A. W. (2019). Social support—A protective factor for depressed perinatal women? International Journal of Environmental Research and Public Health, 16(8). https://doi.org/10.3390/ijerph16081426 Namburi, N., & Lee, L. S. (2022). National quality forum.Europepmc.org https://europepmc.org/article/med/31751044 Ni, Y., Liu, S., Li, J., Dong, T., Tao, L., Yuan, L., & Yang, M. (2019). The effects of nurse-led multidisciplinary team management on glycosylated hemoglobin, quality of life, hospitalization, and help-seeking behavior of people with diabetes mellitus. Journal of Diabetes Research, 2019, 1–9. https://doi.org/10.1155/2019/9325146 NURS FPX 6610 Assessment 1 Comprehensive Needs Assessment Villanueva, L. M.P., Palafox, B., Amit, A. M. L., Pepito, V. C. F., Ab-Majid, F., Ariffin, F., Balabanova, D., Isa, M.-R., Mat-Nasir,