care cord. PPT1
Care Coordination
- Provider Care: Focus on intertwining patient care involving the health care team and patients.
- Main Facilitators: Caitlin Campbell MSN, RN leads Care Team Coordination.
Learning Objectives
1. Develop and implement a patient-centered plan of care related to stress and coping and care coordination.
2. Prioritize the care of a patient with alterations in stress and coping and care coordination.
3. Implement strategies that minimize the risk for a patient with alterations in stress and coping and care coordination.
4. Analyze the concept of stress and coping, and care coordination, as it relates to death and dying, discharge planning, including admission and transfer of the client.
5. Identify nursing considerations when implementing pharmacologic and non-pharmacologic interventions for comfort in clients receiving palliative or end-of-life care.
6. Identify ethical considerations related to palliative care and end-of-life.
Definition of Care Coordination
- Definition: "The deliberate organization of and communication about patient care activities between two or more members of the health care team (including the patient) to facilitate appropriate and continuous health care to meet that patient’s needs across care transitions." (Ignatavicius, pg.1)
- Communication Among Team Members: Essential for effective care coordination.
- Safe Transitions: Ensures the patient's smooth transition between care settings.
- Think-Pair-Share Activity: Reflect on instances where poor communication impacted patient care in a clinical setting.
Importance of Care Coordination
- Reduces Hospital Readmissions: Enhances overall efficiency and effectiveness of care.
- Improves Patient Outcomes: Directly impacts the health and recovery of patients.
- Enhances Patient Satisfaction: Contributes to overall patient experience in healthcare settings.
- Supports Continuity of Care: Ensures unbroken and continuous patient support throughout their care journey.
SBAR Communication Tool
- Purpose: Structured communication among healthcare providers.
- Components:
- Situation: Describe what is currently happening that necessitates communication.
- Background: Relevant background information concerning the situation.
- Assessment: Analysis of the problem or patient need based on assessment data.
- Recommendation/Request: Stating the desired outcome or needs.
- Nurse Usage Context: Specific scenarios where nurses should apply SBAR.
Admission Process
- Starting Point of Care Coordination: Care coordination begins during the admission process.
- Comprehensive Patient Assessment: Key component that includes:
- Medical History: Review existing health conditions and past medical interventions.
- Medication List: Document current medications used by the patient.
- Social Determinants: Assess support systems, housing, finances influencing care.
- Advanced Directive/Code Status: Understanding patient wishes regarding treatment.
- Risk Assessment: Identify any risks that could impact patient care.
- Discharge Needs: Early identification to inform later planning.
- Interdisciplinary Collaboration: Initiation of teamwork to address patient needs.
Discharge Planning
- Timeline: Begins during the admission phase; consideration of patient discharge starts immediately.
- Components of Discharge Instructions:
- Diagnosis: Explanation of medical condition.
- Prognosis: Expectations regarding condition outcomes.
- Follow-up Instructions: Steps for patient follow-up care if complications arise.
- Improving the Discharge Process: Enhancements can be made by:
- Providing written discharge instructions.
- Incorporating health education and promotion moments.
- Collaborating with healthcare teams on discharge plans.
Patient Transfer
- Transfer Definition: Movement of a patient to another unit or facility.
- Nurse Responsibilities Pre-Transfer: Ensure necessary information sharing and preparation for continuity of care.
Phases and Layers of Care
- Palliative Care: Managing life-limiting illnesses and associated symptoms. Includes:
- Symptom Management: Ongoing treatment of pain and discomfort.
- Psychosocial Support: Emotional and mental health support for patient/family.
- Ongoing Medical Treatments: Treating conditions appropriately as needed.
- Hospice Care: Specialized care for non-curative conditions.
- End-of-Life Care: Focuses on comfort during the final days of life.
- Support for Loved Ones: Emotional and practical support for the family.
Definitions of Care Types
- Palliative Care Definition: "A philosophy of care for people with life-threatening disease that helps patients and families identify their outcomes for care, assists them with informed decision-making, and facilitates high-quality symptom management." (Ignatavicius, pg.144)
- Hospice Care Definition: "Model for high-quality, compassionate care for people facing life-limiting illness or injury. It includes a team-oriented approach providing expert medical care, pain management, emotional and spiritual support tailored to individual needs." (Ignatavicius, pg.142)
Case Study: Maria Lopez
- Patient Profile: 58 years old female with metastatic breast cancer; treatment history includes chemotherapy and radiation therapy.
- Current Status: Progressed to palliative care for symptom management.
- Symptoms Experienced: Severe fatigue, chronic pain (rated 8/10), nausea, decreased appetite, emotional distress.
Quiz Questions on Palliative and Hospice Care
- Understanding Statements: Assess comprehension of palliative care and hospice care through specific examples of patient statements.
- Identifying Readiness for Hospice: Evaluate statements to determine when a patient is ready for hospice care based on conditions worsening.
Nursing Responsibilities During Hospice Care
- Care After Admission: Assess Maria’s needs when admitted to the hospice facility and respond appropriately.
- Medication Requests: Determine the correct medications to request based on patient needs, such as for restlessness or delirium.
- Morphine Infusion: Understand the assessment criteria for adjusting morphine dosages for pain management.
- Implementing Comfort Measures: Identify interventions to enhance patient comfort for Maria as requested by the family.
- Recognizing End of Life Signs: Assess for physiological indicators suggesting nearing death.
Post-Mortem Care Considerations
- Nursing Interventions Post-Death: Understand the required steps for post-mortem care, such as proper identification and cultural sensitivity regarding family involvement.
- Professional Conduct: Correct actions necessary by a new nurse in performing post-mortem care to ensure compliance with protocols and patient dignity.
Family Involvement in Post-Mortem Care
- Encouraging Family Participation: Assess the best approaches for families who wish to engage in post-mortem care while maintaining professional standards.