NURS FPX4050 Assessment 1 Preliminary Care Coordination Plan

NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan

NURS FPX 4050 Assessment 1

Capella University


July 2023

Table of Contents

NURS FPX 4050 Assessment 1 Preliminary Care Coordination Plan

Preliminary Care Coordination Plan

NURS FPX 4050 Assessment 1 the foremost priorities of healthcare institutes are the provision of the finest-quality interventions to the patients and their well-being enhancement. The purpose of a preliminary care coordination design is to ensure elite treatment for the patients and the finest care provision which is effective and on time. The creation of an extensive and well-collaborated care design highlights different healthcare facilities and interventions needed by patients. The initial stage of a care coordination design consists of determining the patient’s needs (Karam et al., 2021). At this stage, a healthcare organization can determine the present medications, chronic state, or any other related health concerns of a patient.

The initial care coordination design assists in decreasing healthcare expenditures as it reduces the requirement for irrelevant interventions or facilities. An effective and well-organized care design can be made by healthcare workers by aiming at patient-centric needs, decreasing the requirement for unnecessary or irrelevant interventions. There are two focal aspects of care coordination: to assess and execute innovative technological tools for the patient’s well-being. Moreover, the focus of the healthcare staff is to participate persistently in identifying and evaluating patient’s needs (King et al., 2019).

Health Concerns and Best Practices for Health Improvement

Chronic inflammatory lung illness which is called chronic obstructive pulmonary disease (COPD) is a lung disorder causing disruption of air passageway and breathing problems. The main causes of COPD are persistent exposure to harmful material or particle matter i.e., air pollution, chemicals, cigarette smoke, and dust (Elonheimo et al., 2022). The initial symptoms of COPD are wheezing asthma, or cough. These signs can become adverse with the passage of time and people with bad COPD condition need an oxygen supply or supporting medications to handle their problem. The Centers for Disease Control and Prevention (CDC) has considered COPD as the fourth major cause of death. In 2019, 15.7 million people suffered from COPD (Fitzsimmons et al., 2020).

Finest Practices for Health Enhancement 

There are different fine health improvement interventions that can assist in handling COPD because it is a dangerous illness and needs the best care provision and focus (Slevin et al., 2019).

NURS FPX 4050 Assessment 1

Quitting Smoking

The preliminary and initial care approach is to quit smoking to handle COPD. Various smoking quitting plans and recovery centers are there to assist smokers in abandoning smoking (Recovery Centers of America, 2021). Besides this, medicines and drugs can assist in handling the signs and decrease lung swelling. Two medications that are usually recommended to COPD patients are corticosteroids and bronchodilators (Tsiligianni et al., 2021). 

Pulmonary Rehabilitation Plans

An important approach is to aim at recovery programs to assist COPD patients in enhancing lung functioning and life quality. It also impacts a patient’s psychological condition because COPD patients experience depression, anxiety, and trauma as it is a chronic condition and has a costly intervention. Pulmonary recovery programs can assist in handling anxiety, stress, and depression by meditation, breathing exercises, and education strategies for disease management. By participating in these rehabilitation programs, patients can understand about factors and causes of COPD and its management to handle this problem (Sami et al., 2021).

Chronic Care Model and Supplemental Oxygen

Care coordination can be enhanced by chronic care plans. It is a patient-focused strategy that assists in enhancing the condition of COPD people (Anderson et al., 2020). Severe patients with COPD need additional oxygen support to sustain sufficient blood oxygen concentration. Furthermore, COPD patients should prevent environmental exposure to lung irritants i.e., chemicals, air pollutants, and particulate matter (Manisalidis et al., 2020).


Furthermore, COPD patients should have regular vaccinations for pneumonia and influenza to decrease the probability of respiratory diseases (Fekete et al., 2020).

Emotional Assistance

It is difficult to handle COPD and assistance groups such as healthcare workers can give emotional and practical support to handle the disease (Rzadkiewicz & NasiŇāowski, 2019).

Underlying Assumptions 

COPD is a chronic disease condition in which people suffer from depression and mental trauma. The finest healthcare practices and strategies can help to resolve many problems and concerns. The underlying assumption for this analysis is to assist COPD patients in handling issues and having a healthy life. To handle COPD, people should prevent anxiety and self-management strategies.

Points of Uncertainty in the Analysis

This hypothetical design does not determine the healthcare worker‚Äôs economic, social, or behavioral components for the patients. So, knowledge gaps and shortcomings are uncertain in this plan. It is important to regard the norms, cultures, and values of the patients to support them. The healthcare workers have to target the patient’s cultural values and perspectives.¬†

Objectives to Address Healthcare Problems

COPD- chronic obstructive pulmonary disease is a chronic illness in which an individual faces many respiratory and life quality problems. Enhancement of lung functioning is a key objective to manage COPD. This objective can be attained by pulmonary recovery, medicines, breathing strategies, and lifestyle alterations i.e., ultimately quitting smoking. Healthcare workers should aim to awareness provision to COPD patients for problem management and improve the patient’s life quality by efficient solutions (Brooks & Levy-Milne, 2022). The goal or objective should be scalable, feasible, and practical i.e., 

Scalable Goal

COPD is a dangerous and lethal disease that causes adverse health impacts and hospitalization. The scalable objective is that healthcare workers handle disease signs by providing appropriate medication and helping patients for medical examinations. COPD patients have a common disease sign which is exercise resistance. A scalable objective should enhance exercise tolerance through recovery programs. Physical exercises such as physical activity for 15 to 45 minutes for three to four weeks can create exercise tolerance. Besides this, appropriate medicines should be used while abandoning smoking (Centers for Disease Control and Prevention, 2021).

Feasible Goal

Chronic obstructive pulmonary disease is a chronic condition that can be handled by the finest interventions and emotional assistance. It is a key responsibility of healthcare workers to give social and emotional assistance. Also, COPD people need motivation to aim for self-management strategies such as preventing stressors and having medical assistance in time of need. Thus, the objective is to encourage self-management techniques in COPD patients. Workers should focus on strong communication and coordination with patients to increase their esteem. Besides this, workers should provoke awareness about different assistance groups for managing COPD disease for a healthy life. American Respiratory Care Association is a support group whose responsibility is to manage the problems of COPD patients (Varekojis et al., 2021).

Practical Goal

One of the key concerns of COPD patients is expensive treatment. Most of the lower income families suffer from economic issues so they cannot afford expensive procedures and treatment for COPD. Poor socio-economic status can provoke stress and depression which badly affect the patient’s well-being. The objective is that healthcare workers should give awareness regarding strategies to manage economic crises i.e., affordable insurance policies, and attention to self-management strategies which can assist in managing huge burdens (Pollock et al., 2020). 

The well-being of patients is dependent on the patient’s and his family‚Äôs involvement in the intervention process. A patient and his family should have awareness of the illness and its intervention process. Families should pay attention to giving appropriate and timely medication to prevent adverse diseases. COPD can be managed when patients aim at lifestyle changes and avoid tobacco consumption (Pahal et al., 2019).¬†

NURS FPX 4050 Assessment 1

Available Community Resources

COPD-chronic obstructive pulmonary disease is a chronic illness that impacts many people globally. Patient’s quality of life can be enhanced with assistance from healthcare workers. 

American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR)

This organization provides important resources that can assist patients in having the finest and most effective interventions. Pulmonary recovery programs are developed to assist COPD patients to enhance their life quality and well-being. These programs have education, awareness, and counseling regarding disease and its management. Healthcare organizations and community associations give exercise and nutritional programs to patients with COPD (Xiang et al., 2022).

COPD Foundation

Emotional and social assistance to the patients by the healthcare providers can be ensured by COPD foundation groups. Assistance groups can give a protective and helping environment to the patients for sharing their experiences, connecting, and inquiring about the disease so that others can understand their condition. COPD assistance groups can be found in community centers, healthcare clinics, hospitals, or online resources (Hurst et al., 2020).

COPD- Assisted Home Health and Hospice

Home healthcare facilities are also needed to give continuous care to the patients such as highly abled nursing workers, training about oxygen support, medication handling system, assistance materials, financial help, and related COPD assistance. Patients can have home healthcare facilities by regional healthcare workers or by connecting with insurance managers. 

 Telehealth tool is another innovative service to help COPD patients digitally. Telehealth facilities can assist patients and healthcare workers in coordinating. It includes conference calls with healthcare workers, remote patient monitoring, and virtual educational repositories (Haleem et al., 2021).


In the US, the fourth major cause of mortality is COPD. A preliminary care coordination design is established to determine the underlying factors of this problem and care coordination provision to COPD patients so that mortality rates can be decreased. Different effective approaches and community assistance programs can help patients to enhance their life quality and quit smoking which is a key reason for COPD.


Anderson, E., Soylemez Wiener, R., Resnick, K., Elwy, A. R., & Rinne, S. T. (2020). Care coordination for veterans with COPD: a positive deviance study. The American Journal of Managed Care, 26(2), 63‚Äď68. https://doi.org/10.37765/ajmc.2020.42394¬†

Brooks, K., & Levy-Milne, R. (2022). Educating frontline health workers to support evidence-based management and treatment for chronic obstructive pulmonary disease patients: A literature review. Canadian Journal of Respiratory Therapy, 58, 127‚Äď135. https://doi.org/10.29390/cjrt-2021-079¬†

Center for Disease Control and Prevention. (2021, July 9). Which Quit Smoking Medicine is Right for You? | Quit Smoking | Tips From Former Smokers | CDC. Www.cdc.gov. https://www.cdc.gov/tobacco/campaign/tips/quit-smoking/quit-smoking-medications/which-quit-smoking-medicine-is-right-for-you/index.html 

Elonheimo, H. M., Mattila, T., Andersen, H. R., Bocca, B., Ruggieri, F., Haverinen, E., & Tolonen, H. (2022). Environmental Substances Associated with Chronic Obstructive Pulmonary Disease‚ÄĒA Scoping Review. International Journal of Environmental Research and Public Health, 19(7), 3945. https://doi.org/10.3390/ijerph19073945¬†

Fekete, M., Pako, J., Nemeth, A. N., Tarantini, S., & Varga, J. T. (2020). Prevalence of influenza and pneumococcal vaccination in chronic obstructive pulmonary disease patients in association with the occurrence of acute exacerbations. Journal of Thoracic Disease, 12(8), 4233‚Äď4242. https://doi.org/10.21037/jtd-20-814¬†

Fitzsimmons, K., Pechter, E., & Sparer-Fine, E. (2020). Chronic Obstructive Pulmonary Disease and Employment Among Massachusetts Adults. Preventing Chronic Disease, 17. https://doi.org/10.5888/pcd17.200116 

Haleem, A., Javaid, M., Singh, R. P., & Suman, R. (2021). Telemedicine for healthcare: Capabilities, features, barriers, and applications. Sensors International, 2(2), 100117. https://doi.org/10.1016/j.sintl.2021.100117 

Hurst, J. R., Winders, T., Worth, H., Bhutani, M., Gruffydd-Jones, K., Stolz, D., & Dransfield, M. T. (2020). A Patient Charter for Chronic Obstructive Pulmonary Disease. Advances in Therapy. https://doi.org/10.1007/s12325-020-01577-7 

NURS FPX 4050 Assessment 1

Karam, M., Chouinard, M.-C., Poitras, M.-E., Couturier, Y., Vedel, I., Grgurevic, N., & Hudon, C. (2021). Nursing Care Coordination for Patients with Complex Needs in Primary Healthcare: a Scoping Review. International Journal of Integrated Care, 21(1), 16. https://doi.org/10.5334/ijic.5518 

King, J., O’Neill, B., Ramsay, P., Linden, M. A., Darweish Medniuk, A., Outtrim, J., & Blackwood, B. (2019). Identifying patients’ support needs following critical illness: a scoping review of the qualitative literature. Critical Care, 23(1). https://doi.org/10.1186/s13054-019-2441-6 

Manisalidis, I., Stavropoulou, E., Stavropoulos, A., & Bezirtzoglou, E. (2020). Environmental and health impacts of air pollution: A review. Frontiers in Public Health, 8(14), 1‚Äď13. https://doi.org/10.3389/fpubh.2020.00014¬†

Pahal, P., Hashmi, M. F., & Sharma, S. (2019). Chronic Obstructive Pulmonary Disease (COPD) Compensatory Measure. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK525962/ 

Pollock, A., Campbell, P., Cheyne, J., Cowie, J., Davis, B., McCallum, J., McGill, K., Elders, A., Hagen, S., McClurg, D., Torrens, C., & Maxwell, M. (2020). Interventions to Support the Resilience and Mental Health of Frontline Health and Social Care Professionals during and after a Disease outbreak, Epidemic or pandemic: a Mixed Methods Systematic Review. The Cochrane Database of Systematic Reviews, 11(11), CD013779. https://doi.org/10.1002/14651858.CD013779 

Recovery Centers of America. (2021, January 5). Can you smoke cigarettes in rehab? Learn about nicotine use in treatment. Recovery Centers of America. https://recoverycentersofamerica.com/blogs/can-you-smoke-cigarettes-in-rehab/ 

Rzadkiewicz, M., & NasiŇāowski, J. (2019). Psychosocial Interventions for Patients with Severe COPD‚ÄĒAn Up-to-Date Literature Review. Medicina, 55(9), 597. https://doi.org/10.3390/medicina55090597¬†

Sami, R., Salehi, K., Hashemi, M., & Atashi, V. (2021). Exploring the barriers to pulmonary rehabilitation for patients with chronic obstructive pulmonary disease: a qualitative study. BMC Health Services Research, 21(1). https://doi.org/10.1186/s12913-021-06814-5 

Slevin, P., Kessie, T., Cullen, J., Butler, M. W., Donnelly, S. C., & Caulfield, B. (2019). A qualitative study of chronic obstructive pulmonary disease patient perceptions of the barriers and facilitators to adopting digital health technology. DIGITAL HEALTH, 5, 205520761987172. https://doi.org/10.1177/2055207619871729 

Tsiligianni, I., Hoeines, K. J., Jensen, C., Kocks, J. W., St√§llberg, B., Vicente, C., & Pech√©, R. (2021). Towards Rational Prescription of Common Inhaler Medication in the Multimorbid COPD Patient. International Journal of Chronic Obstructive Pulmonary Disease, Volume 16, 1315‚Äď1327. https://doi.org/10.2147/copd.s298345¬†

Varekojis, S. M., Schweller, J., & Sergakis, G. (2021). Introducing the Advanced Practice Respiratory Therapist. Chest, 160(2). https://doi.org/10.1016/j.chest.2021.03.053 

Xiang, X., Huang, L., Fang, Y., Cai, S., & Zhang, M. (2022). Physical activity and chronic obstructive pulmonary disease: a scoping review. BMC Pulmonary Medicine, 22(1). https://doi.org/10.1186/s12890-022-02099-4 


NURS FPX 4050 Assessment 1


What are some available community resources that can support stroke patients in their recovery?

Community resources play a crucial role in supporting stroke patients throughout their recovery journey. Available resources in the community are vital for ensuring a safe and effective continuum of care for individuals who have experienced a stroke. Recovering from a stroke can be a lengthy process, often accompanied by chronic disabilities that can make transitioning back to a normal daily routine challenging. To address these needs, various organizations are dedicated to providing support and resources to stroke survivors and their caregivers.

One key resource for stroke patients is joining local stroke support organizations, where individuals can connect with others who have shared experiences and access valuable information and educational materials related to stroke recovery. These organizations, such as the National Stroke Association, American Stroke Foundation, American Stroke Association, and local support groups like Grand Strand Health in NY, offer a supportive community environment for stroke survivors, caregivers, and the wider community.

These organizations often host regular meetings where individuals can gather to share experiences, receive education on rehabilitation strategies, learn about stroke risk factors, and explore various therapies that can aid in the recovery process. Additionally, some groups may provide practical services such as free blood pressure testing, further emphasizing their commitment to supporting stroke patients in their journey towards recovery. By connecting with these community resources, stroke survivors can access much-needed support, guidance, and assistance as they navigate the challenges of post-stroke rehabilitation and adjustment to daily life.

Why are community resources important for the safe and effective continuum of care for stroke patients?

Community resources are crucial for ensuring a safe and effective continuum of care for stroke patients for several reasons. Firstly, the availability of community resources plays a vital role in supporting the recovery process of stroke patients, which can often be lengthy and challenging. These resources offer essential assistance and services that aid in the transition to a normal daily living routine, particularly for those dealing with chronic disabilities resulting from a stroke.

Moreover, having access to community resources provides stroke patients with the necessary support and guidance after their discharge from medical facilities. This ongoing support is essential for the well-being and successful recovery of the patients as they navigate the complexities of managing their condition outside of a hospital setting. By having access to these resources, stroke patients can feel empowered and assured that they are not alone in their journey towards recovery.

In essence, community resources play a pivotal role in contributing to a safe and effective continuum of care for stroke patients by offering support, guidance, and essential services that are instrumental in their rehabilitation and overall well-being.

NURS FPX 4050 Assessment 1

What are some strategies and goals that can be implemented to improve care for stroke patients?

To enhance care for stroke patients, implementing strategies such as computerizing and digitizing medication practices can be highly beneficial. This would involve storing detailed patient information on computers to facilitate effective care coordination. Additionally, increasing the number of healthcare professionals in facilities handling stroke cases is crucial for ensuring optimal patient outcomes during treatment and recovery. These strategies, along with setting specific goals aimed at improving the quality of care for stroke patients, can contribute significantly to enhancing the overall care experience and outcomes for individuals affected by stroke.

What are the major types of strokes and their causes?

There are two major types of strokes: ischemic strokes and hemorrhagic strokes. Ischemic strokes typically occur when a blood clot obstructs a blood vessel, leading to reduced blood flow to the brain. Hemorrhagic strokes, on the other hand, can result from various causes, with a common factor being the rupture of a blood vessel.

What are the available community resources for stroke patients to aid in their recovery and transition to daily living routine?

Various community resources are available to assist stroke patients in their recovery and help them transition back to their daily living routine. Organizations such as the National Stroke Association, American Stroke Foundation, American Stroke Association, and local stroke support groups offer valuable support and information to stroke survivors and their caregivers. For example, the Grand Strand Health support group in NY provides a supportive environment for stroke survivors, caregivers, and the community to connect and access resources related to stroke recovery, rehabilitation, risk factors, and therapeutic interventions. These community resources play a crucial role in aiding stroke patients during their recovery process and facilitating their transition to a normal daily life.

What specific goals should be established for stroke patients in terms of preventative measures and recovery?

For stroke patients, specific goals should be established to address both preventative measures and recovery effectively. Preventative measures should focus on reducing risk factors such as high cholesterol, hypertension, diabetes, and atrial fibrillation by emphasizing physical activity, adopting a healthy diet, minimizing alcohol consumption, quitting smoking, and achieving weight reduction as recommended.

In terms of recovery goals, stroke patients should aim to establish a plan that includes attending regular medical appointments, adhering to prescribed medications, following a nutritious diet, implementing smoking cessation strategies, and engaging in appropriate exercises to maintain a healthy weight. These goals are crucial for addressing the current health issue related to stroke, promoting successful rehabilitation, and reducing the risk of recurrent stroke events. Education plays a key role in empowering patients to understand and actively participate in achieving their goals for prevention and recovery.

What approaches can be used in care plans to improve the quality of care for stroke patients?

In developing care plans to enhance the quality of care for stroke patients, various approaches can be employed. One effective strategy is the implementation of computerization and digitization in medication practices. By utilizing technology to input and save detailed information about stroke patients, healthcare providers can enhance care coordination and ensure the delivery of high-quality treatment. Furthermore, increasing the number of healthcare professionals involved in stroke care is essential to achieving optimal outcomes. Adequate staffing levels during treatment and recovery stages are crucial for providing comprehensive and effective care to stroke patients. Setting specific goals for both healthcare systems and individual patients can further improve the quality of care and treatment outcomes for individuals affected by stroke.

NURS FPX 4050 Assessment 1

What are the main types of strokes and their causes?

The main types of strokes are categorized as ischemic and hemorrhagic. Ischemic strokes typically occur due to a blockage in a blood vessel, leading to reduced blood flow to the brain. Conversely, hemorrhagic strokes are often caused by the rupture of a blood vessel, though they can have various other triggers as well.

Why are community resources important for a safe and effective continuum of care for stroke patients?

Community resources play a vital role in ensuring a safe and effective continuum of care for stroke patients. These resources are essential in supporting stroke patients throughout their recovery journey, as the process can be lengthy and challenging. With the possibility of chronic disabilities following a stroke, transitioning to a normal daily routine can be daunting for patients. Therefore, having access to available community resources is crucial to providing ongoing support and assistance to stroke patients even after they are discharged. By offering a network of support systems and services, community resources empower stroke patients to navigate their recovery journey more effectively and safely, ultimately contributing to an enhanced continuum of care.

What goals can be established to address stroke treatment for both healthcare systems and patients?

Establishing goals to address stroke treatment for healthcare systems involves increasing staff numbers to ensure there are adequate healthcare professionals available to effectively manage stroke patients during treatment and recovery. Additionally, setting goals for the health care system to enhance the quality of care provided to stroke patients is crucial. On the other hand, stroke patients can have specific goals such as actively participating in their treatment plan, adhering to prescribed medications and therapies, and making necessary lifestyle changes to manage and prevent future strokes. By establishing these combined goals, both healthcare systems and patients can work towards better stroke treatment outcomes.

How can the quality of care delivered to stroke patients be improved through specific strategies?

One specific strategy to enhance the quality of care for stroke patients is by implementing computerization and digitization of medication practices. This approach involves entering and saving detailed information on stroke patients into computer systems, allowing for better care coordination. Additionally, increasing the number of healthcare professionals available during treatment and recovery stages is crucial for achieving positive outcomes for stroke patients. Adequate staffing levels are essential to ensure that patients receive the best possible care and support throughout their treatment journey. By utilizing these strategies, healthcare facilities can improve the quality of care provided to stroke patients and enhance overall patient outcomes.

What are the different types of strokes and their causes?

Different types of strokes are categorized into two main groups: ischemic and hemorrhagic strokes. An ischemic stroke typically occurs when a blood clot blocks a blood vessel, leading to reduced blood flow to the brain. Conversely, a hemorrhagic stroke may have several causes, with the primary one being the rupture of a blood vessel in the brain.

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