Comprehensive Care Plan, Capstone Project Example

Person-centered care programs must reflect the patient’s goals for affirmation and desired outcomes. Person-centered care aims at helping all the involved members in a particular working environment to focus on the management, documentation and assisting clients and their families in making their personal decisions. It entails determining what each client is communicating both verbally and nonverbally, identifying what is important to each client in terms of their daily schedules and preferred activities, thus making sure that the client benefits from the care plan.

T.K is a 77-year-old man who arrived at Holmes Regional Medical Center on 15^th October 2021 to discuss his comprehensive care plan with the facility. T.K’s main concern was his initial visit to Holmes Regional Medical Center was to have a Transcatheter Aortic Valve Replacement (TAVR) procedure which led to a Foley catheter being placed, where it was expected that he would then discharge via gravity to a leg bag. Unfortunately, T.K further had a heart procedure and thus resulted to an extended need in the use of a Foley catheter. This followed from a series of previous admissions at Holmes medical center that had him frustrated. The admissions were due to urological issues, which he wanted to have their charges waived. The client’s concerns were recorded and reviewed with the involvement of a registered nurse and physician leaders, where risk management, quality, and patient relations were included.

Background

The client, T.K, has no previous history of alcohol abuse or smoking. He appears well-nourished and is groomed too. However, the client has a majority of unexpected issues, for example; he is obese, he has got heart disease, suffers hypertension, and prostate issues. At the time of his initial admission to Holmes Regional Medical Center, The client was being monitored by a Cardio-Thoracic Surgeon who performed a Transcatheter Aortic Valve Replacement (TAVR) procedure. This procedure further required the need to put a foley catheter, since the procedure was so long. Due to his previous history of an enlarged prostate, he therefore required a re-insertion of the foley catheter. This foley catheter had previously been removed in the post-Anesthesia recovery area.

T.K portrays a calm nature throughout, although, from his mood, one would tell that T.K has been frustrated by the facility, which is reflected in his behavior history. T.K. is exceptionally charming and inviting. T.K. is self-assured, now and again, but at times he portrays an aggressive nature. T.K. needs to ensure his point is heard before any input is given. His interests were often repeated, which was a way to guarantee him that he was being understood and that the team was apprehending his points.

T.K is more friendly in person compared to the character he had previously portrayed over a voicemail message he had left through the facility’s phone. He has opened up about his care since the initial meeting with the Cardiothoracic surgeon. A cooperative and active conversation with positive patients, for example, T.K, is highly recommendable (Nazif, 2018). T.K continuously remained calm and made positive comments and recommendations throughout the process. Further, he was interactive all through the conversation. He keeps on seeing a heart specialist with whom he has a magnificent relationship, follows with urology month to month for prostate issues, and proceeds with UTIs, which he feels are brought about by delayed Foley use.

Further, he mentions that his wife is also actively involved in the care plan. Additionally, he says that he has lost trust with hospitals but not physicians and hence acknowledges that he has to listen to their recommendations. He receives support from his family and, to some extent, his heart surgeon with whom they share a close relationship. The wife being part of his care plan also shows how supportive and loving she is towards the husband. There is a strong bond between them as the care and support the wife gives to the husband while pursuing care delivery would not go unnoticed.

Assessment

K’s goal was to ensure that the repeated and frequent admissions were permanently over and that he had his bill waived, blaming an early dismissal from the facility as the course. The patients’ goal further was to book regular appointments with the physician, Since he believes that his problem originated from the nursing team not listening to him. After understanding the client and observing his health condition, immediate action to proceed was put into consideration and effected. Incorporating Health system nursing interventions and safety nursing interventions would work best with this case of the given patient. Health system nursing interventions are seen whereby the facility enhances total detailed measures to reduce any risk of infection for the patients while in the hospital. In this case, the nurses and health care providers in Holmes Regional Medical Centre should ensure that the client, T.K, does not get more infections from the blood clots as well as minimize more admission cases. This move would allow them to step in and better the patient’s days in the future.

A prevention practice that would be beneficial to the patient would be improvement and enhancement of better communication strategies amongst the client and the healthcare workers, who in this case are the nurses resulting in a better relationship with the client. The client would have spent more time under the care of the nurses, had he been admitted a little longer. This would have seen the nurses having to cross-examine the client further, which would probably result in a smooth recovery process for the patient. From the evidence-based practice, communication between a health advisor and the patient is recommended and expected to be positive and friendly. (Sibiya, 2018) This way, the health care provider can get the most out of the patient, hence delivering detailed diagnosis and care.

A health caring intervention practice seen during the hands-on practice work that benefitted the client is Congestive Heart Failure best practices, like everyday weight and liquid admission following and tracking. This helped in that the client was able to observe the progress of his recovery. This care practice further developed the well-being of T.K by being alarmed when ailments disintegrated or worsened. CHF patients are discouraged from putting on weight rapidly to keep away from unexpected issues. CHF patients are additionally expected to record their everyday loads, which are utilized while deciding suitable treatment plans. Recognizing weight changes decreased the client’s readmissions and guaranteed that patients got appropriate treatment to forestall the decay of his medical issues. Therefore, the adherence to the consideration practice that was seen in Holmes Regional Medical Center, diminished readmission paces of the client, and other patients experiencing intense and constant circumstances. Family nursing interventions too worked for the family. This is where the healthcare providers at Holmes Regional Medical Center encouraged T. K’s family to continuously support him during the care plan process.

The patterns and models of shared decision-making are essential in the care planning process as they are of significant impact. Examples include recognizing and admitting that a decision has to be made, or instead, a determination is needed. The committee recognized that the facility had failed and therefore had to put in place abrupt measures to come up with a decision, which would lead to an action in favor of the client. Another example is having to incorporate the patient’s values, together with his preferences, in the decision-making process. This way, the patient is part of the process. In this case, the decision-making process greatly impacted T.K’s outcomes. This was seen where; T.K and his wife took part in the decision-making process, and it helped them where they felt included, and hence felt satisfied by the entire recovery process. Further, having the wife provide consent before the care process was delivered played an essential role in the process.

The aspect of setting up, inviting, acquiring knowledge, empathizing, summarizing, and strategizing by the committee and the facility was used in the care plan and it pioneered during the entire care plan process and saw its success (De Kruiff et al., 2018). The first step was setting up a platform for the client to have a conversation about the way forward in the care plan process. The client was then invited to the venue where the discussions and decisions were made. At this platform, the panel acquires the necessary knowledge, which in this case was the grievances and complaints from T.K and how he felt about the service at Holmes Regional Medical Center. After empathizing with the client, there was a summary of the issues and strategies that saw the way forward for the care plan. The evidence-based care plan advocates for the client being in a position to present their grievances in a committee in the event of dissatisfaction. It is the same evidence based care plan, which supported the entire care plan process in that, it acted as the basis for the whole plan step by step and saw the plan a success.

Recommendations and Plan

The resource referrals that would benefit the client includes; an home visit nurse, referral to a pharmaceutical, and a further referral to the family care, which is supposed to act as primary care. The client needed a home visit nurse that would visit often to check that the client was being managed rightfully. Further, referral to a pharmaceutical would help the client with the daily and minor inquiries about drug administration and in the rightful dosage to see the success of the recovery process. Finally, the client needed the family, as part of the primary care, with the knowledge on management of the catheter. For example, keeping the catheter clean and neat should be a top priority to avoid cases of infections. The client needed to learn the procedure of cleaning the catheter and also the urethra, that is, where the catheter comes out through. Keeping it neat helped lower the risk factors of further infections. Second, the client needed to know how to take care of the leg bag especially while involving in physical activity like walking or standing so as to ensure that it stays in place. Further, the client needed to know the position of the drainage bag while sleeping should be below the bladder and off the floor always to prevent chances of infections. Finally, the client needed to know when to seek medical attention and that is; if by any chance the catheter comes out, if they started feeling belly pains and if they notice that the urine levels in the catheter bags dropped or that there is no flow into the bag. These resource connections would be barred from poor communication between the client and the patient and lack of knowledge about catheter management. Hence, there was need to having good communication between the health care provider and the client.

Positive behavior displayed during a customer-colleague interaction. As a result of this effective behavior, rapport is established between the client and the colleague, resulting in the delivery of holistic care. According to Szalados, J. E. (2021), they would simply talk about the patient’s concerns and medical findings and see if the doctor changes the treatment plan. To ensure that he receives the alternatives he desires, the clinic should have provided him with a better and a more accurate choice of both the equipment he needed and perhaps data on the equipment on its need in the facility and whether or not there were enough for other patients in the facility. The urologist, and thus the fitness provider coordinator and the clinic, should have taken advantage of this opportunity to apologize to the customer—positive behavior with a colleague during a customer transaction. As a result of this effective behavior, the health committee establishes a rapport, which leads to the delivery of holistic care. These patients are not permitted to gain weight quickly to avoid fitness issues. Patients must also keep track of their daily weights, which will be used to develop appropriate treatment plans. Detecting weight changes minimizes readmissions and ensures that patients receive appropriate treatment to avoid further worsening in their health. As a result, identifying the proper clinical therapies and knowing how to prescribe them is critical for redesigning care delivery and ensuring patients have access to holistic restoration options. With resource referrals being put into considerations and with the client following them to the latter, the patient requires palliative care, which should be achieved by the home nursing resource. The nurse will ensure that the catheter change and cleaning to avoid disinfection is done correctly. This will see the success of the recover process.

Reflection on the Care Plan

According to Szalados, J. E. (2021), there is a cultural difference in terms of age when communicating with the customer. To acknowledge cultural differences, explaining to the client the method scope and responsibilities of a nurse and a clinical health practitioner is an excellent way to understand how the clinic environment worked is a perfect way to get him to know how the clinic environment worked. By incorporating various concepts into their work, nurses can overcome bigotry and prejudice. As a result, understanding and overcoming cultural differences is critical for rethinking care delivery and ensuring patients access holistic restoration options.   However, due to a lack of communication among nurses and thus the urology team, collaboration across groups is required to acknowledge the afflicted person’s situation. Examining T.K. thoroughly and incorporating the patient’s expectations into care delivery may aid in overcoming the anxiety associated with the foley catheter becoming clogged. The miscommunication presented in the case was how the developmental stage affected the outcome of the case, as the client lacked trust in the nurses and hence held back from speaking out about problems he had with the catheter and hence the many admissions.

An ethical issue encountered during the fieldwork was that the afflicted individual requested that the bills be waived due to a lack of ability to reimburse co-payments. However, this moral quandary was avoided because professionalism is a highly valued trait in my field. According to Nazif, T. M. (2020), coordination was provided within the affected person enterprise offers branch to provide T.K with a symbol of benefits, which eliminated the need to discuss billing adjustments because his coverage covered all of the care he required. When ineffective or illegal healthcare offerings were made, criminal consequences were avoided by avoiding moral quandaries. A legal example is where the client wanted to seek legal action had the facility not dropped the waiver. A regulatory compliance example is where the facility accepted to have a sitting with the committee and the client to discuss the issues in depth to avoid the continuous hospital readmissions under the Hospital Readmissions Regulatory Program (HRRP) (Allen, 2015). The above ethical, legal and regulatory compliances in accordance to care management programs portrayed a different potential level in improving the care plan by bridging the communications between the client and the healthcare providers. The professional qualities and core values led to conveying messages in some different ways since values figured out where approaches to imparting were considered more attractive than others. Struggle in esteem frameworks is a significant reason for correspondence breakdown in interethnic settings, for example, in this case, we find that the nurse had to take instructions from a specific chain of command

The technological strategies that saw the success of the plan were for example the use of computer skills. These skills aided in the preservation of the patient’s clinical information as well as the creation of secure and valuable notes on my patient evaluation. Telemedicine is a virtual in practice that is used in the medical field. This method gained value because it enabled the purchaser to employ the desired power intervention strategies. Different philosophies were enforced by the leaders of the Holmes Regional Center’s various divisions. This aided in forming a solid bond with the affected individual and his immediate family, resulting in effective care delivery. Communication also assisted in achieving readability from my supervisors, resulting in fewer errors throughout the service delivery process.

References

De Kruiff, Verhagen, & Kremer LCM. (2018). Pediatric Palliative Care – Individualized Care Plan Working Group. Pure.rug.nl. Retrieved 9th May 2018, from https://pure.rug.nl/ws/portalfiles/portal/77292724/Complete_thesis.pdf#page=206.

Bello, O. (2017). Effective communication in nursing practice: A literature review. https://www.theseus.fi/handle/10024/130552

Nazif, T. M. (2020). Urologic Complications in Patients Receiving Indwelling Urinary Catheters During Transcatheter Aortic Valve Replacement. J Invasive Cardiol, 32(7), 269-274. http://s3.amazonaws.com/HMP/hmp_ln/imported/articles/images/269-274%20Lambert%202020%20July%20JIC%20wm.pdf

Sibiya, M. N.(2018) Effective communication in nursing. Nursing,19. https://books.google.com/books?hl=en&lr=&id=Ib-QDwAAQBAJ&oi=fnd&pg=PA19&dq=Sibiya,+M.+N.+(2018).+Effective+communication+in+nursing.+Nursing,+19.&ots=7gnCEVs9tL&sig=eqKYerjldfWQkvKZ-m1nKGsy5PA

McIlvennan, C. K., Eapen, Z. J., & Allen, L. A. (2015). Hospital readmissions reduction program.Circulation,131(20),1796-1803. https://www.ahajournals.org/doi/full/10.1161/Circulationaha.114.010270

Szalados, J. E. (2021). Anatomy of Healthcare Contracts: Pitfalls and Avoidance of Liability. In The Medical-Legal Aspects of Acute Care Medicine (pp. 513-534). Springer, Cham. https://link.springer.com/chapter/10.1007/978-3-030-68570-6_25