NURSFPX-4050 Final Care Coordination Plan Essay

NURSFPX-4050 Final Care Coordination Plan Essay

Despite their perceived inferiority, nurses play a critical role in the day-to-day delivery of patient care. As their importance grows daily, the notion that nurses are merely doctors’ accomplices has since been deemed obsolete. Post-acute stroke management, which includes physiotherapy, occupational therapy, speech therapy, and rehabilitation, influences patients’ chances of disability (Powers et al., 2019). Nurses are involved in all phases of care, from acute care to post-discharge care. A final coordination plan for a stroke patient is provided below, outlining patient-centered interventions, ethical issues that arise during care, health policies that influence care coordination and continuum, and the priorities for achieving patient and family-centered care coordination.

Patient-Centered Health Interventions

            Regarding the management of stroke, several health issues must be addressed.  This discussion focuses on the following stroke-related health issues: nutrition and hydration, infection, and bedsores. Patients who have had a stroke have either focal or global dysfunction in cerebral functions, and as a result, they frequently present with loss of consciousness. As a result of their comatose state, or reduced consciousness, they have a decreased cough reflex and are therefore at risk of contracting pneumonia (Kuriakose & Xiao, 2020). Urinary tract infection is also common due to the inability to empty the bladder, which causes stasis and increases the risk of infection. Furthermore, because they are critically ill, stroke patients are at risk of invasive procedures such as peripheral or central venous catheters and urinary catheters, which put them at risk of bloodstream and urinary infections (Kuriakose & Xiao, 2020). Deprivation of nutrition and fluids occurs as a result of decreased or absent oral intake due to the unconscious state; patients are thus at risk of dehydration and hypoglycemia. Furthermore, the unconscious patients are at risk of developing decubitus ulcers over the bony prominences due to their prolonged bed rest.

Patients who can swallow are encouraged to feed and drink orally to avoid dehydration or caloric deprivation. Unconscious patients with no swallowing reflex, on the other hand, have a nasogastric tube in place through which they feed and take their oral medications (Boulanger et al., 2018). Hydration is maintained intravenously for those who do not have a swallowing reflex, while fluid input and output are monitored. To reduce the risk of aspiration pneumonia, airway patency is ensured by suctioning any secretions. Treatment of nausea and vomiting also reduces the risk of aspiration pneumonia (Boulanger et al., 2018). Close monitoring for fever and tachypnea, as well as treatment of any suspected or confirmed infections, are also essential (Boulanger et al., 2018). Furthermore, early ambulation is encouraged in conscious patients to reduce the risk of deep venous thrombosis; however, if the patients are immobile, thromboprophylaxis medications such as Clexane 40 mg are administered once daily as a subcutaneous injection are recommended (Boulanger et al., 2018). Community resources, such as nutrition programs for the elderly, provide widespread nutrition and health education. Infection prevention control measures at home, such as hand washing, reduce the risk of infections, and community physiotherapy centers help reduce the risks of disability and immobility, which would otherwise predispose patients to deep venous thrombosis.

Ethical Decisions in Designing Patient-Centered Interventions

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            Decision-making is one of the most important tasks that caregivers face daily. Decision-making should be ingrained in all healthcare providers. A multidisciplinary team and multiple steps are involved in the process. Mardani et al. (2019) define ethical decision-making as “making decisions following a code of ethics.” Autonomy is an ethical principle that requires patients to be independent and self-determined; this allows them to make decisions that care providers must respect. Non-maleficence requires that care providers do not harm patients in the course of their duties, whereas beneficence requires that care services, interventions, and procedures performed on patients benefit them (Mardani et al., 2019). Justice, which is also an ethical principle, necessitates treating patients fairly and equitably. When all of the principles are considered, a decision is reached that does not violate the patients’ rights and in which the benefits outweigh the risks.

Despite ethically guided decision-making, ethical quandaries arise frequently, raising concerns about the uncertainty of the decisions made. For example, a patient with a stroke and cardiac arrest who requires resuscitation may have a Do Not Resuscitate order. This scenario allows caregivers to apply the non-maleficence ethical principle, avoiding harm to the patient and assisting him in achieving a more peaceful and natural death (Huang et al., 2018). Others, however, may view the doctor as having failed because it is his responsibility to ensure the patients’ health preservation and maintenance, an incident that raises concerns about the uncertainties of ethically guided decision-making.

Relevant Health Policy Implications for Coordination and Continuum of Care

            In the United States, the Affordable Care Act (ACA) provides the most solid foundation for health reforms and the long-term viability of the health industry for the first time in health policy history. The ACA expanded insurance coverage for US citizens, particularly the low and middle socioeconomic populations, thereby increasing access and utilization of care services among that group (Collins & Saylor, 2018). Prior-to implementation, healthcare costs were exorbitant, and President Obama’s dream was to establish a health reform that would significantly reduce healthcare costs while also improving access to care services, which has been accomplished. Furthermore, the elderly who are retired and have no sources of income benefited greatly from the expansion of Medicare services, which paid for their healthcare costs. This strategy was accomplished through Medicare’s various payment options, including payment for hospital stays, reimbursement for doctor’s consultation fees, and reimbursement for prescription medications (Collins & Saylor, 2018). Finally, improved care coordination improved the healthcare outcomes of vulnerable populations (low-income populations, the elderly), increasing their life expectancy (Collins & Saylor, 2018). The introduction of new care delivery models compatible with the ACA, such as electronic health records and remote patient monitoring technologies, ensured continuity of care even after patients were discharged.

Priorities for Patient and Family Members’ Inclusion in the Care Coordination

Patient-centered care and family-centered care are two distinct models of care delivery that are currently overemphasized compared to clinician-centered care. Individualized patient care must be provided while keeping the patient’s needs and preferences in mind. A family, on the other hand, is now viewed as a client, and a comprehensive analysis of the interconnectedness and relationships among family members provides a foundation for care (Poku et al., 2019). As a result, it is beneficial for the caregiver to employ the four critical pillars of collaborative practice: communication, respect, partnership, and negotiation (Poku et al., 2019). For example, when educating the patient on medication adherence, it must be delivered in the most unadorned prose (simple, effective language) while also considering the patient’s views and perspectives (respect), and the education must be provided when the patient or family members are comfortable or free (negotiation), and everyone must be considered partners. A patient whose cardioembolic stroke is caused by heart failure must be aware of the change, such as the fact that they will be on heart failure medication for the rest of their life.

Aligning Teaching Sessions to Healthy People 2030 Document

            The Healthy People 2030 framework envisions creating a society in which people can reach their full potential for health and well-being throughout their lives. Furthermore, as part of its mission, the Healthy People 2030 framework aims to strengthen, promote, and evaluate the nation’s efforts to improve the health of its citizens (U.S. Department of Health and Human Services., 2020). The teaching sessions align with the overarching goals of the Healthy People 2030 framework, including the definition of the health issue (stroke), its epidemiology, stroke health-related problems, and collaborative practice with patients and family members. Some of the Healthy People 2030 goals include being free of preventable diseases, injury, and disability, eliminating health disparities, creating a social, physical, and economically safe environment that promotes healthy lives, and engaging leaders to take action and design policies that improve people’s health. When aligned with the Healthy People 2030 goals, the knowledge gained and lessons learned from the topic can be used to address current public health priorities.


            With the prevalence of cardiovascular-related conditions on the rise, countries at all levels, whether government, state, or county, are attempting to develop interventions to reduce the incidence of these diseases. Stroke has long been a source of consternation in the healthcare system, as it is one of the conditions with the highest morbidity and mortality rates worldwide. As a result, interventions have taken center stage in line with the Healthy People 2030 framework, which outlines the goals for reducing preventable diseases. In addition to the ACA, which improved access to care and increased screening for diseases such as diabetes and hypertension, a slight decrease in stroke morbidity and mortality has been reported. Regardless of the government’s efforts to control diseases, an individual’s efforts determine the success and magnitude of interventions.




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Preliminary Care Coordination Plan


Capella University
February 2022

Preliminary Care Coordination Plan
Lifestyle factors are important in disease etiology. Changes in lifestyle behaviors have recently been blamed for an increase in cardiovascular disease cases. Unhealthy eating habits, cigarette smoking, alcohol consumption, and physical inactivity are all examples of risk factors for cardiovascular disease. Roth et al. (2020) believe that combining lifestyle changes with pharmacological therapies for various diseases yields the best results. Stroke is an example of a cardiovascular-related event characterized by a high-risk lifestyle. Here below, find a discussion about the health concern of stroke, best practices for health improvement, management, and prevention goals, and community resources for a safe and effective continuum of care.
Analysis of Stroke, Best Practices for Improvement
Over the years, the definition of a stroke has evolved. Many scholars now define it as a rapidly developing episode of focal or, at times, global loss of cerebral function that lasts more than 24 hours (Roth et al., 2020). According to the World Health Organization, the global burden of stroke is estimated to be 15 million cases per year, with an estimated 5.8 million deaths per year (Tarvonen-Schröder et al., 2019). The majority of cases, roughly two-thirds, occur in developing countries, with a decreasing incidence reported in developed countries. The literature has extensively discussed two types of stroke: ischemic, which is the most common, and hemorrhagic. The pathophysiologic processes are based on a clot that causes Vaso occlusion in ischemic stroke and, hemorrhage into the cerebral tissue in hemorrhagic stroke (Tarvonen-Schröder et al., 2019). There are numerous risk factors for stroke, which can be classified as non-modifiable (such as advanced age, Black race, male sex, and previous history of stroke) or modifiable (such as hypertension, Diabetes Mellitus, cardiac diseases, tobacco use, alcohol use, HIV, and oral contraceptives (Tarvonen-Schröder et al., 2019). Among the factors listed, hypertension and diabetes are the most common modifiable risk factors, affecting 80% and 34% of stroke patients, respectively.
Physical, psychosocial, and cultural strategies can be used to improve health and prevent the occurrence, treatment, or recurrence of stroke. Physical primary prevention strategies include screening for and treating risk conditions such as hypertension, diabetes, hyperlipidemia, and obesity, as well as reducing behavioral risk factors such as quitting smoking and limiting or stopping alcohol consumption (Tarvonen-Schröder et al., 2019). Secondary strategies aim to reduce the risk of disability by preventing recurrent strokes, preventing brain tissue damage, and reducing disability risk. One of the strategies is to use an antiaggregant such as aspirin. Blood pressure control, behavioral risk reduction (smoking cessation and alcohol consumption limitation), a healthy diet, and physical activity are all recommended (Tarvonen-Schröder et al., 2019). Stroke may have neuropsychiatric consequences because of (1) direct damage to cerebral tissues and (2) the stigma and debilitation that accompany stroke (Nemani & Gurin, 2021). As a result, psychological support, such as providing information to patients and caregivers, assessing dependency and providing assistance in daily activities, being present and communicating with them, and reminding patients to take their medications, is provided (Nemani & Gurin, 2021). In terms of cultural influence on stroke, some communities still believe in spiritual explanations for the condition; however, this belief is fading as a result of the increased awareness created by social media (Sanuade, 2018). As a result, many communities now believe that early detection and treatment of diseases is the way to go. Furthermore, because stroke is perceived as more disabling than other conditions, communities move quickly to help stroke patients access the nearest available health center.
Goals Established to address Stroke
Specific objectives guide stroke management and prevention. The first goal in dealing with stroke is to prevent its occurrence. This goal is attained through a variety of strategies, some of which have already been discussed. A patient with high stroke risk factors, such as a hypertensive individual, will benefit greatly from taking antihypertensive medications, lowering the risk of stroke occurrence. Patients who have no obvious risk factors but have a positive family history of cardiovascular disease, should be screened for the risk diseases, begin early treatment, avoid risky behaviors such as alcohol consumption, and be physically active as much as possible (Pandian et al., 2018). The second goal is to prevent stroke recurrence and disability associated with stroke. This is accomplished through the use of antiaggregant (Aspirin), antihypertensives, the cessation of risk behaviors, healthy eating, and physical activity (Pandian et al., 2018). Furthermore, physiotherapy is an important intervention in stroke management to prevent disability; speech therapy is also important to prevent speech difficulties. Moreover, frequent turning in bed, the use of supportive items such as pillows and foam pads, and keeping the skin dry and clean aid in the prevention of decubitus ulcers. Finally, the other goal of management is to address stroke comorbidities. Patients are given thromboprophylaxis to prevent deep venous thrombosis, as well as antibiotic prophylaxis to prevent pneumonia and urinary tract infections, both of which are common in stroke patients.
Community Resources
There are several community resources available to help with stroke prevention. Warmline, for example, connects stroke survivors and their families with a person, usually a health professional, who can offer support or a listening ear. If there is a problem with medications, a recurrence problem, or any other psychosocial sequelae, the patient or family members can reach out using the contact information provided (Erlebach et al., 2021). Aside from that, community physiotherapy is available to assist stroke patients in their recovery and to reduce the incidences of stroke-related disabilities (Erlebach et al., 2021). The physiotherapy sessions are conducted by qualified physiotherapists, for example, twice a week or as needed based on the patients’ condition. Community skilled rehab facilities are plentiful, and they help patients recover well while also living a safe and secure life.
To summarize, stroke is a cardiovascular disease with significant morbidity and mortality. There are numerous risk factors for stroke, both non-modifiable and modifiable, the two most important of which are hypertension and diabetes. Stroke incidences will be significantly reduced if risk diseases are identified and treated early. Lifestyle changes, which have recently been prominent in the etiology and risk for various cardiovascular conditions, add to the risk. As a result of this discovery, interventions that target lifestyle changes have been shown to be beneficial in stroke management. Even as pharmacology plays an important role in stroke treatment, community resources such as physiotherapy, skilled rehab facilities, and stroke organizations help to speed up the recovery process.

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Tarvonen-Schröder, S., Hurme, S., & Laimi, K. (2019). The World Health Organization Disability Assessment Schedule (WHODAS 2.0) and the WHO Minimal Generic Set of domains of functioning and health versus conventional instruments in subacute stroke. Journal of Rehabilitation Medicine: Official Journal of the UEMS European Board of Physical and Rehabilitation Medicine, 51(9), 675–682.

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