NURS-FPX4050 Assessment 1 Preliminary Care Coordination Plan SOLVED

NURS-FPX4050 Assessment 1 Preliminary Care Coordination Plan SOLVED

Preliminary Care Coordination Plan

Taking the role of care coordination as an RN in the community care center, it is essential to acknowledge age-related and elder care health issues. Aging encompasses numerous physical, psychosocial, and cultural issues, which together make it very demanding and, therefore, require a multi-faceted approach to achieve optimum health for our elderly citizens. This initial plan for care coordination has HF as the focus when it comes to elderly patients in a community care context.

The staff shortage in the dedicated care management area prompts the development of a different approach, where the functions of the nurses predominate in care coordination. The plan below encompasses physical, psychosocial, and cultural considerations for elderly patients with HF, as well as community resources that can provide a safe and effective continuum of care.

Analysis of Health Concerns and Best Practices

Heart failure (HF) is a chronic condition that results from the weakening of the heart’s pumping function; thus, the blood flow becomes insufficient throughout the body. It becomes more common with age, making it a significant problem in older adults (Hajouli & Ludhwani, 2022). The established guidelines for managing HF connotes drug adherence, lifestyle changes, and patient education.

Examples of drug treatment include diuretics, angiotensin-converting enzyme (ACE) inhibitors, and beta-blockers (Hajouli & Ludhwani, 2022). Lifestyle modifications aim at advancing a healthy diet, weight management, regular physical activity, and quitting smoking. Education for patients is one of the main pillars that enable HF patients to competently manage their conditions, among them identification of the symptoms associated with deterioration of heart failure (Allida et al., 2020).

While the introduction of these best practices for elderly patients into a community setting has some distinctive challenges, they provide significant advantages. The elderly frequently experience polypharmacy, where multiple drugs are used, thereby complicating the task of medication adherence (Unlu et al., 2020). Moreover, age-related cognitive decline, a frequently occurring occurrence in older persons, can interfere with the mastery of educational materials and the application of self-management approaches (Yang et al., 2022).

Specific Goals

The following specific goals are intended to address the issues experienced by older individuals with HF in a community care setting:

1. Increase drug adherence by 80% within three months. Implement medication reminders, educate patients on the purpose of medications, and simplify prescription regimens to improve adherence.
2. Increase participation in an appropriate exercise program by 70% within two months. Collaborate with physical therapists and provide transportation to encourage older people to participate in personalized exercise regimens.
3. Increase patient education by 60% in one month: Use more straightforward materials, include family members in education sessions, and provide educational resources in preferred languages to improve good comprehension and self-management of HF.
4. Reduce hospital readmission rates by 50% in 6 months: Focus on early detection of increasing symptoms and prompt communication with healthcare providers to avoid unnecessary hospitalizations.

Physical Considerations

Physical limitations, such as fatigue, shortness of breath, and low exercise tolerance, are highly prevalent among elderly patients with heart failure. Such restrictions may prohibit everyday activities, and they could make falling more likely or increase crash skills. The care coordination plan addresses these needs through:

• Working together with physical therapists to formulate proper and safe exercise regimens aimed at increasing mobility and muscle strength.
• Assessment for devices, such as crutches and walkers that support the body’s strength and take away the risk of slipping.
• Nutritional counseling to ensure a well-balanced diet enriched in weight management that lowers cardiovascular risk factors.

Psychosocial Considerations

Social isolation and depression are recurring problems for the elderly suffering from HF (Go