Care Coordination: What It Is and How It Can Benefit You

Name: Carol Davis 

DOB: 8 th August 1949 

Address: 123 NewYork 

Payor Source: 

Secondary Source: 

Current Problems With Status Summary (Write a brief summary of current and co-morbid illnesses and the reason for care coordination planning.) 

A 70-year-old female is admitted for high blood pressure. The patient’s blood pressure is stable but she has developed pain in her right knee. Her knee is warm and red and when she is touched she screams in pain. According to the patient, it hurts to move the knee and when a blanket touches her knee, she feels excruciating pain. At night it is more painful and she describes the pain as a crushing and a throbbing pain. The doctor diagnosed it as gout and the patient states that her father has gout but this is the first time she had a gout attack and it is very painful. The patient rates the pain as 9 on a 1 to 10 scale. Besides gout, the acute pain is also connected to reflex muscle spams and tissue trauma, as illustrated by the patient who rates the pain as 9 out of ten and describes it as excruciating pain. 

Pain is subjective and the patient must describe the feeling to plan effective treatment. The nurse must comprehensively assess pain to include the onset, intensity, characteristics location, duration and frequency of pain. 

Every person expresses and experiences pain differently, based on various sociocultural adaptation methods. The nurse should consider cultural influences on pain response including cultural beliefs about pain that may cause stoic attitudes. 

Personal factors may influence pain tolerance and pain. As such, the nurse must reduce factors that augment or precipitate pain to boost the pain management coordination plan (Al‐Harthy, Ohrbach, and Michelotti, 2016). The nurse should eliminate or reduce factors such as fatigue, fear, lack of knowledge and monotony that increase the patient’s pain experience. 

Use of noninvasive pain relief may boost the production of endorphins and boost the therapeutic effects of pain relief drugs. The nurse should teach the patient how to use nonpharmacologic methods such as music therapy, massage, relaxation guided imagery and distraction, during, before and after painful experiences (Improving Chronic Illness Care). The techniques should also be applied before pain increases or occurs and with other pain relief measures. 

Every client expects maximum pain relief. Using analgesics for optimal pain relief involves determining the preferred drug, route, frequency and dosage for every patient. If the pain is tolerable, ambulation or turning activities should be enhanced and before the activity, the level of sedation should be assessed. 

The patient uses pain management resources in the local community including an 8 week program involving three sessions every week. The sessions include two exercise essions lasting one hour each and a 3 hour discussion session. In the alst half of the program, there are two hydrotherapy sessions and a class on relaxation skills. The exercise seeions are offered in the community gym. 

Routine Health Maintenance 

Physician: Doctor Martin 

Physician’s Address: 

Physician’s Phone Number: 

Preferred Hospital: John Hopkins Hospital 

General Dentist: Doctor Larren 

Dentist’s Address: 

Dentist’s Phone Number: 

Pharmacy: John Hopkins pharmacy 

Pharmacy’s Address: 

Pharmacy’ Phone Number: 

Hospital Care (List history of hospitalizations.) 

Date of Hospitalization:12/12/2019 

Hospital Name: John Hopkins Hopsital 

Reason: Hypertension 

Length of Stay: One week 

Discharged to Location: 

Patient Education (List any educational program or coordination that the patient has completed.) 

Name of Program: Record keeping 

When: 2000 

Where: Stanford University 

Rehabilitation Services (List any rehabilitation stays, including in-patient, out-patient, Long Term Acute Care (LTAC), or Skilled Nursing Facility (SNF) stays.) 

Out-patient: John Hopkins Hopsital 

When: 11/11/2019 

Where: John Hopkins out-patient 

Length of Stay: three days 

Medication List (List all medications, dosage, and purpose.) 

Medication: Thiazide diuretics or water pills 

Dosage: One tablet daily 

Purpose: The drugs work on the kidneys to assist the body in elimtaing water and sodium to reduce blood volume. 

Medication: Angiotensin-converting enzyme (ACE) inhibitors such as lisinopril (Zestril), benazepril (Lotensin), and captopril (Capoten) 

Dosage: one pill daily 

Purpose: relax blood vessles by inhibiting the formation of natural cehmicals that reduce the size of blood vessles. 

Medication: Angiotensin II receptor blockers (ARBs) such as candesartan (Atacand), and losartan (Cozaar) 

Dosage: One pill daily 

Purpose:They relax blood vessles by inhibiting action of the natural chemical that narrows blodd vessles. 

Medication: Calcium channel blockers including amlodipine (Norvasc), and diltiazem (Cardizem, Tiazac 

Dosage: One pill daily 

Purpose:Relaxes te muscles of blood vessles. 

Durable Medical Equipment 

Equipment Owned:Cardiovascular monitoring equipment 

Provider: The hospital 

Home Health Care Infusion Supplies 

Enteral Nutrition Provider: Vygon 

Website: www.vygon.com 

Nursing 

Hourly Nursing Services 

Name: 

Services: 

Indication: 

Treatment Goals: 

To ensure the patient is comfortable with the treatment plan (Mcdonald et al., 2014). 

Reduction of pain intensity. 

Enhancement of physical functioning. 

Adopt relaxation methods to reduce skeletal muscle tension to reduce the pain’s intensity. 

Nurture a non disruotive and quiet atmpsophere with comfortable temperature and dim lights. The quiet and comfortable atmosphere promote a relaxed feeling for the client to focus on relaxation instead of external disctraction. 

Every person may find some imagery or relaxation techniquies more helpful than others and the nurse should use different relaxation techniques to ensure the patrients find the best. The nurse should individualize the relaxation techniques by seeking siggestions from the patient. 

Cultural Needs 

Ensure the patient’s cultural beliefs minimally influence their experience of pain by reducing the intensity. Also, the patients should believe that the pain can go away. 

Signatures 

RN Care Coordinator 

Patient 

Patient Contact Information (e-mail or phone) 

References 

Al‐Harthy, M., Ohrbach, R., Michelotti, A., & List, T. (2016). The effect of culture on pain sensitivity.  Journal of oral rehabilitation ,  43 (2), 81-88. 

Improving Chronic Illness Care. (n.d). Care Coordination: Background. 

McDonald, K.M., Schultz, E., Albin, L., Pineda, N., Lonhart, J., Sundaram, V., Davies, S (2014). Care Coordination Measures Atlas Update.