NURS-FPX 4050 Preliminary Care Coordination Plan

Sample Answer for NURS-FPX 4050 Preliminary Care Coordination Plan Included After Question

Develop a 3-4 page preliminary care coordination plan for a selected health care problem. Include physical, psychosocial, and cultural considerations for this health care problem. Identify and list available community resources for a safe and effective continuum of care.

Complete the following:

Identify a health concern as the focus of your care coordination plan. In your plan, please include physical, psychosocial, and cultural needs. Possible health concerns may include, but are not limited to:

• Stroke.

 

• Heart disease (high blood pressure, stroke, or heart failure).

• Home safety.

• Pulmonary disease (COPD or fibrotic lung disease).

• Orthopedic concerns (hip replacement or knee replacement).

• Cognitive impairment (Alzheimer’s disease or dementia).

• Pain management.

• Mental health.

• Trauma.

• Identify available community resources for a safe and effective continuum of care.

 

A Sample Answer For the Assignment: NURS-FPX 4050 Preliminary Care Coordination Plan

Title: NURS-FPX 4050 Preliminary Care Coordination Plan

Chronic obstructive pulmonary disease (COPD) is a respiratory condition characterized by airflow limitation. It is caused by an inflammatory response to inhaled toxins, often cigarette smoke. COPD is characterized by chronic bronchitis with airflow obstruction. The two main causes of COPD include smoking and genetic factors. Cigarette smoking is the primary causative factor for COPD in >90% of patients (Rossaki et al., 2021). Environmental factors like air pollution also contribute to the development of COPD. The purpose of this paper is to discuss the related best practices for health improvement in COPD, outline goals to address the problem, and community resources.

Health Concern

A large proportion of patients with COPD cannot enjoy life to the fullest due to dyspnea, physical limitations, and inactivity caused by the disease. As the condition progresses, patients encounter more challenges in performing their normal daily activities, usually due to breathlessness. Anxiety and fear connected with shortness of breath and feelings of breathlessness often decrease a patient’s ability to engage in a full life. Consequently, their occupational, social, and sexual roles are usually affected (Franssen et al., 2018). Besides, patients with COPD tend to have comorbid conditions like heart disease, lung cancer, musculoskeletal disorders, osteoporosis, depression, and anxiety.

COPD affects a person’s social life. Most individuals report having reduced socialization with friends and family members, avoiding them due to the constant coughs leading to feelings of isolation. Besides, COPD negatively affects an individual’s economic status due to changes in income from reduced occupational functioning and health insurance coverage (Franssen et al., 2018). Patients with severe COPD often require role changes which negatively affect their self-image. Drugs like metered doses and dry powder inhalers are usually expensive, which creates a significant financial burden in addition to regular medical treatments.

Associated Best Practices for Health Improvement

Best practices for COPD aim at improving patients’ quality of life by reducing the severity of symptoms and exacerbations. Pulmonary rehabilitation is one of the best practices aimed at improving the health of COPD patients. It comprises a range of therapeutic interventions tailored to enhance patients’ quality of life by minimizing airflow limitation, relieving respiratory symptoms, and preventing secondary COPD complications (Wouters et al., 2018). Pulmonary rehabilitation is associated with improved health status, well-being, and quality of life. It is provided through a multidisciplinary approach with a team that includes a physician, nurse, pharmacist, dietitian, exercise physiologist, physical, respiratory, occupational, and recreational therapists, cardiorespiratory technician, and psychosocial professionals.

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The multidisciplinary approach focuses on: Medical management; Smoking cessation; Patient and family education; Respiratory and chest physiotherapy; Psychosocial support; Physical therapy with exercise, bronchopulmonary hygiene, and vocational rehabilitation. Pulmonary rehabilitation can include a number of these components and must be tailored to the patient’s unique needs. The educational component is crucial since it prepares the patient and the family to actively engage in providing care, thus promoting collaborative self-management (Zhang et al., 2022). Physical therapy is mandatory in COPD care and includes aerobic lower and upper extremities endurance exercises. The exercises improve patients’ performance of ADLs, reduce dyspnea, and enable individuals to engage in more activities (Zhang et al., 2022). Furthermore, respiratory and chest physiotherapy improves a patient’s ventilatory pattern and prevents airway compression.

Goals That Should Be Established to Address COPD

            The first goal in addressing COPD is to achieve complete smoking cessation within six months. Smoking causes changes in the airways that limit airflow. Therefore, smoking cessation will be a key goal in addressing COPD. The second goal is to create an environment free of COPD symptom triggers within four weeks. Despite patients adhering to medication management, environmental triggers like smoke, dust, and pollutants can cause COPD exacerbations (Ambrosino & Bertella, 2018). In addition, the patient will be engaged in moderate aerobic exercises for at least 150 hours a week within two weeks. Physical exercises improve a patient’s lung function, activity intolerance, maintain a healthy weight, and lower anxiety and depression levels (Ambrosino & Bertella, 2018). Another goal is to engage the patient in creating a healthy COPD-friendly diet with high-calorie, high-protein foods within one week. An appropriate diet helps to prevent weight loss and improves overall health status. The other goal is to have an absent anxiety state in the COPD patient within four weeks. Anxiety is associated with dyspnea and comorbid psychiatric conditions.

Available Community Resources for A Safe and Effective Continuum of Care

Community resources include assistance programs and support groups. Elderly patients with COPD can be linked with assistance programs like Meals on Wheels, a national network of community-based, non-profit programs committed to supporting older adults in the communities to enable them to remain in their homes. The support includes quick safety checks, nutritious meals, and friendly visits. Patients can also be linked to support groups, like Better Breather clubs, which are sponsored by the American Lung Association (Rossaki et al., 2021). These are in-person support groups for persons with chronic lung disease like COPD, asthma, and lung cancer and their caregivers. Another resource is smoking support programs to help patients wishing to quit smoking. In addition, disability benefits through Social Security insurance plans can help COPD patients ease their financial burden (Rossaki et al., 2021). Thus, the primary care provider should coordinate with the case manager or social worker to help the patient access these community resources.

Conclusion

COPD symptoms limit patients’ quality of life and level of functioning. It affects not only their physical health but also their social and financial aspects. The best practices for health improvement in COPD include pulmonary rehabilitation, patient education, smoking cessation, physiotherapy, and physical exercises. They are associated with reduced respiratory symptoms, improved exercise tolerance and functional activities, decreased anxiety and depression, and increased feelings of control and self-esteem in patients. Available community resources include social support groups, assistance groups, and social insurance plans.

References

Ambrosino, N., & Bertella, E. (2018). Lifestyle interventions in prevention and comprehensive management of COPD. Breathe (Sheffield, England)14(3), 186–194. https://doi.org/10.1183/20734735.018618

Franssen, F. M., Smid, D. E., Deeg, D. J., Huisman, M., Poppelaars, J., Wouters, E. F., & Spruit, M. A. (2018). The physical, mental, and social impact of COPD in a population-based sample: results from the Longitudinal Aging Study Amsterdam. NPJ primary care respiratory medicine28(1), 1-6. https://doi.org/10.1038/s41533-018-0097-3

Rossaki, F. M., Hurst, J. R., van Gemert, F., Kirenga, B. J., Williams, S., Khoo, E. M., … & van Boven, J. F. (2021). Strategies for the prevention, diagnosis, and treatment of COPD in low-and middle-income countries: the importance of primary care. Expert review of respiratory medicine15(12), 1563-1577. https://doi.org/10.1080/17476348.2021.1985762

Wouters, E. F., Wouters, B. B., Augustin, I. M., Houben-Wilke, S., Vanfleteren, L. E., & Franssen, F. M. (2018). Personalized pulmonary rehabilitation in COPD. European Respiratory Review27(147).DOI: 10.1183/16000617.0125-2017

Zhang, H., Hu, D., Xu, Y., Wu, L., & Lou, L. (2022). Effect of pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis of randomized controlled trials. Annals of medicine54(1), 262–273. https://doi.org/10.1080/07853890.2021.1999494