NURS FPX4050 Capella University Coordinating Patient Centered Care Essay

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NURS FPX4050 Capella University Coordinating Patient Centered Care Essay

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NURS-FPX-4050 Floyd Carissa Assessment 1-1
Coordinating Patient Centered Care

University
Capella University
Course
Coordinating Patient Centered Care (FPX4050)
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Carissa Floyd
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FINAL CARE COORDINATION PLAN 1
Final Care Coordination Plan
Carissa Floyd
Capella University
NURS-FPX-4050 Coordinating Patient-Centered Care
Cynthia Payne
July 15, 2022
FINAL CARE COORDINATION PLAN 2
Final Care Coordination Plan
Mrs. Simpson is a sixty-seven-year-old African American female who was diagnosed with transverse myelitis 3 years ago. Although she had been mobile prior, the disease process
caused weakness and numbness in her lower extremities. As a result of the loss of strength and
sensation, she developed an infected unstageable left hip pressure injury that led to sepsis. This
wound required debridement ultimately leaving her with a stage 4 pressure injury with exposed
bone. To aid wound healing, Mrs. Simpson also received a diverting colostomy to prevent stool
soilage and contamination. After a long hospital stay for antibiotics and wound care, she is
discharged home in the care of her husband and son. She and her family initially refused home
health services for wound care as well as rehab. A few weeks after her hospital discharge, she
and her husband presented to the community care center for a follow-up visit. They expressed
concerns over caring for her wound. Although Mrs. Simpson is beginning to make a slow
recovery from her transverse myelitis, she remains quite weak and unable to fully care for
herself. Her husband feels he is not doing the best job with wound care and fears he will not
know if the wound worsens. Mrs. Simpson also expresses body image issues regarding her
colostomy. Since Mrs. Simpson has medicare coverage, it should not be difficult to assist her in
obtaining the care she needs.
Goals and Plan
Mrs. Simpson needs proper wound care to assist in healing her wound and preventing
infection. The primary goals of wound care are to prevent infection, prevent further skin
breakdown, relieve pain, and promote wound closure (Kirkland-Kyhn et al., 2018). Currently,
her family agrees with allowing home health services into the home. Home health serves as a
bridge between hospital care and home-based care (Siclovan et al., 2021). A home health nurse
FINAL CARE COORDINATION PLAN 3
will need to visit Mrs. Simpson in her home a few times per week to monitor her wound for signs
and symptoms of infection and teach her and her family how to care for the wound and signs and
symptoms to report. The home health nurse can also assist with teaching about proper use of pain
medications and non-pharmaceutical modalities to aid in reducing the patient’s wound-related
pain. Studies have shown that assessment and management of pain are not well managed in
patients with pressure injuries (Jackson et al., 2017). Nurses are vital in teaching caregivers
about wound care, including basic assessment and treatment (Kirkland-Kyhn et al., 2018). The
roles of home health nurses include assessment, providing treatments, and handling
pharmaceuticals. These tasks are carried out in the patient’s home environment and home health
nurses must be aware and adaptable to the preferences, culture, and habits of the patient and their
family (Andersson et al., 2017). Patients with engaged caregivers who are themselves engaged
are found to have better outcomes, lower morbidity, better chronic condition management, and
fewer hospital readmissions (Lord et al., 2021). Mrs. Simpson’s husband is to practice hands-on
wound care with a home health nurse for the first three visits. The goal is for him to be able to
complete her dressing change with minimal verbal cues from the nurse. Mr. Simpson will be able
to list signs of infection and symptoms to report (European Pressure Ulcer Advisory Panel
[EPUAP] et al., 2019, p.353). Pressure injury is most commonly a chronic condition (Jackson et
al., 2017). As such, Mrs. Simpson will also need a more long-term solution to managing her
wound than home health alone.
One objective of Healthy People 2030 is reducing the rate of pressure ulcer related
hospitalizations among older adults (Health People 2030, n.d.). Mrs. Simpson would also benefit
from a consultation and ongoing care from an outpatient wound clinic. The local outpatient
wound clinic utilizes wound care certified nurses to assess and administer patient care. Research
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FINAL CARE COORDINATION PLAN 4
has shown that patients receiving nurse-led care for chronic wounds experience better outcomes
(Dhar et al., 2020). This clinic also utilizes two wound care and sharps debridement certified
nurse practitioners full-time and two general surgeons part-time. Mrs. Simpson can have her
wound assessed on a regular basis to adjust her treatment to facilitate healing. Mrs. Simpson
should present to the outpatient wound clinic every other week (EPUAP et al., 2019, p. 252). Her
goals are for her wound to be free of signs and symptoms of infection such as larger size or
depth, foul odor, necrotic tissue, increased pain, increased exudate, or change in nature of
exudate (EPUAP et al., 2019, p. 252). Clinical staff can continue educating the family on proper
wound care in the home. Conservative debridement can also be done in the clinic when needed,
eliminating the need for hospital-based surgery in some cases. The clinicians can monitor for
signs and symptoms of infection and prescribe appropriate antibiotics. Studies demonstrate that
outpatient management of medically stable wound patients through multispecialty wound care
clinics frequently resulted in wound resolution and reduced hospitalization (Lundeen et al.,
2017). Medical transport for appointments is scheduled via the wound clinic and is covered by
Medicare.
Another important factor in wound healing is proper nutrition. NPUAP recommends
thirty to thirty-five calories per pound of body weight per day for patients with pressure injuries.
In addition, NPUAP recommends one gram of protein per kilogram of body weight per day for
these patients (EPUAP et al., 2019). Another objective of Healthy People 2030 is improving
health by promoting healthy eating and making nutritious foods available. The Community
Preventative Services Taskforce (CPSTF) recommends home delivery of meals to adults sixty
and older to reduce malnutrition after their studies found that home delivered meals increased
energy intake and improved quality of life and well-being as well as reduced malnutrition by
FINAL CARE COORDINATION PLAN 5
15% (The Community Guide, n.d.). Mrs. Simpson will receive meals daily five days per week
delivered to her home by the local Meals on Wheels program. These meals follow nutritional
guidelines and may follow cultural or health related needs (The Community Guide, n.d.).
Mrs. Simpson has also suffered a loss of strength and decreased ability to mobilize
herself. She did receive some physical and occupational therapy while inpatient and some of her
strength was restored but admits she has been mostly chair bound since her discharge. She is now
able to transfer in and out of her wheelchair. Although she is slowly regaining her strength, she
remains at high risk for falls. Mrs. Simpson would greatly benefit from outpatient rehab services.
Physical therapy (PT) is a rehabilitation modality aimed at preserving, enhancing, and restoring
movement and physical function damaged by disease, injury, or disability. PT uses exercise,
assistive devices, and patient training to help patients become stronger and adapt (Fonzo et al.,
2020). PT is an important tool in managing neuromuscular diseases with strong evidence of
effectiveness (Quinn et al., 2017). The hospital from which she was discharged has an outpatient
physical therapy clinic that provides wheelchair-accessible transportation to and from therapy
sessions free of charge to patients. Restoring Mrs. Simpson’s mobility will increase her
confidence and independence. In addition
Mrs. Simpson has also expressed body image issues related to her colostomy. She states
she is embarrassed by wearing a pouch to contain stool. She says that she doesn’t know anyone
who has had a similar issue and that no one understands what she is experiencing. There is a
United Ostomy Associations of America, Inc affiliated support group in Columbia, SC that meets
monthly (United Ostomy Associations of America, n.d.). This support group is led by an ostomy-
certified RN. Meetings include informative presentations, the introduction of new products,
assistance with ostomy issues, and fellowship for individuals with ostomies. This group would
FINAL CARE COORDINATION PLAN 6
give Mrs. Simpson a chance to connect with others in a similar situation. This will give her a
sense of support and belonging that she is lacking at this time.
The ultimate goals for Mrs. Simpson are to help her regain some of her independence and
manage the care of her wound. Her first short-term goal is to attend her PT sessions as
prescribed, typically three times per week initially (Quinn et al., 2017). Additional, more focused
goals will be set for her during her time in therapy. The second set of short-term goals for her
and her caregiver are to learn proper wound care methods and complete dressing changes as
prescribed. She will also need to attend wound clinic appointments as scheduled.
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FINAL CARE COORDINATION PLAN 7
References
Andersson, H., Lindholm, M., Pettersson, M., & Jonasson, L.-L. (2017). Nurses’ competencies in
home healthcare: An interview study. BMC Nursing, 16(1).
https://doi.org/10.1186/s12912-017-0264-9
Dhar, A., Needham, J., Gibb, M., & Coyne, E. (2020). The outcomes and experience of people
receiving community based nurse led wound care: A systematic review. ‐ ‐ Journal of
Clinical Nursing, 29(15-16), 2820–2833. https://doi.org/10.1111/jocn.15278
European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, & Pan
Pacific Pressure Injury Alliance. (2019). Prevention and treatment of pressure ulcers/
injuries: Clinical practice guidelines (3rd ed.). EPUAP, NPIAP, PPPIA.
Falls prevention in community-dwelling older adults: interventions. (n.d.).
uspreventiveservicestaskforce.org. Retrieved July 11, 2022, from
https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/falls-prevention-
in-older-adults-interventions
Fonzo, M., Sirico, F., & Corrado, B. (2020). Evidence-based physical therapy for individuals
with rett syndrome: A systematic review. Brain Sciences, 10(7), 410.
https://doi.org/10.3390/brainsci10070410
Health People 2030. (n.d.). health.gov. Retrieved July 11, 2022, from
https://health.gov/healthypeople/objectives-and-data/browse-objectives/older-
adults/reduce-rate-pressure-ulcer-related-hospital-admissions-among-older-adults-oa-04
Jackson, D., Durrant, L., Bishop, E., Walthall, H., Betteridge, R., Gardner, S., Coulton, W.,
Hutchinson, M., Neville, S., Davidson, P. M., & Usher, K. (2017). Pain associated with
FINAL CARE COORDINATION PLAN 8
pressure injury: A qualitative study of community-based, home-dwelling individuals.
Journal of Advanced Nursing, 73(12), 3061–3069. https://doi.org/10.1111/jan.13370
Kirkland-Kyhn, H., Generao, S., Teleten, O., & Young, H. M. (2018). Teaching wound care to
family caregivers. AJN, American Journal of Nursing, 118(3), 63–67.
https://doi.org/10.1097/01.naj.0000530941.11737.1c
Lord, J., Borkowski, N., & Weech-Maldonado, R. (2021). Patient engagement in home health:
The role of health literacy and “ask me three®”. Home Health Care Management &
Practice, 33(3), 202–209. https://doi.org/10.1177/1084822321996623
Lundeen, G., Diefenbach, C., Smith-Gagen, J., Whitlow, S., White, L., Sidorski, A., & Johnson,
M. (2017). Outpatient surgical management of patients with complex wounds through a
multispecialty wound care clinic. Foot & Ankle Orthopaedics, 2(3), 2473011417S0002.
https://doi.org/10.1177/2473011417s000270
Nutrition: home-delivered and congregate meal services for older adults. (n.d.). health.gov.
Retrieved July 11, 2022, from https://health.gov/healthypeople/tools-action/browse-
evidence-based-resources/nutrition-home-delivered-and-congregate-meal-services-older-
adults
Quinn, L., Busse, M., Carrier, J., Fritz, N., Harden, J., Hartel, L., Kegelmeyer, D., Kloos, A., &
Rao, A. (2017). Physical therapy and exercise interventions in huntington’s disease: A
mixed methods systematic review protocol. JBI Database of Systematic Reviews and
Implementation Reports, 15(7), 1783–1799. https://doi.org/10.11124/jbisrir-2016-003274
Quinn, L., Kegelmeyer, D., Kloos, A., Rao, A. K., Busse, M., & Fritz, N. E. (2020). Clinical
recommendations to guide physical therapy practice for huntington disease. Neurology,
94(5), 217–228. https://doi.org/10.1212/wnl.0000000000008887
FINAL CARE COORDINATION PLAN 9
Siclovan, D. M., Bang, J. T., Yakusheva, O., Hamilton, M., Bobay, K. L., Costa, L. L., Hughes,
R. G., Miles, J., Bahr, S. J., & Weiss, M. E. (2021). Effectiveness of home health care in
reducing return to hospital: Evidence from a multi-hospital study in the us. International
Journal of Nursing Studies, 119, 103946. https://doi.org/10.1016/j.ijnurstu.2021.103946
The community guide. (n.d.). thecommunityguide.org. Retrieved July 11, 2022, from
https://www.thecommunityguide.org/content/cpstf-recommends-home-delivered-and-
congregate-meal-services-older-adults
United Ostomy Associations of America. (n.d.). www.ostomy.org.
http://www.ostomy.org/support-group-finder/
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NURS FPX4050 Capella University Coordinating Patient Centered Care Essay