NR 529 Module 2 Assignment_Leading Person-Centered Care.

Part 1: Case Scenario This patient is an 84-year-old male with severe spinal arthritis and bone spurs, and was initially referred to physical therapy for medical management. He has a history of obesity, controlled non-insulin-dependent diabetes, and controlled hypertension. He has a supportive and healthy 82-year-old wife who is a retired nurse and his primary caregiver. He has had low back pain for over five years, but the pain has become debilitating over the past three months. He states he fell twice when his legs “gave out.” He also reports, physical therapy has aggravated his back pain, and he needs to use a wheelchair instead of walking. He was referred to neurosurgery and underwent spinal injections for pain with minimal relief. Surgery was scheduled four months after the first injection. Related health concerns with this patient start with his age and mobility and his pre- existing medical conditions. His mobility is poor going into surgery, so it is a concern that he will have limited mobility post-surgery. Inpatient rehab post-surgery is imperative, given his restrictions, age, and assistance at home. Even though his wife is mobile, she cannot physically move her husband on her own if needed. His diabetes and hypertension are under control, but diabetes will hamper healing, and the prevention of a decubitus ulcer should be evaluated given the limited mobility. Issues of concern that can be managed with in-patient rehab include improved pain control, customized treatment plans, and mental support. Addressing these issues with in-patient care can reduce the patient's risk for injury and reduce his risk for hospital readmission. It will give him time to understand the treatments and allow his wife time to prepare for his return. The points of care for this patient involve the neurosurgeon's office, the operating room, in-patient rehabilitaion, outpatient physical therapy rehabilitation at home. through different levels of the healthcare system to benefit patients and keep them safe. Using these skills and maintaining a holistic approach is imperative to improve overall health outcomes. This paper will identify transitions in point of care delivery and how nursing leaders use principles of care coordination to transition patients effectively through their care. Point of Care Transitions The points of care for this patient involve the neurosurgeon's office, the operating room, in-patient rehab, outpatient rehab at home. Advanced nurses should have overall patient goals and specific goals for each transition to evaluate the process and look for ways to improve. The first transition for this patient is from the surgeon's office to the operating room. A pre-surgical exam and clearance need to be done, given the medical history and age of the patient. For a smooth transition into the operating room, the surgical booking person should communicate a surgical date that works for the operating room staff, surgeon, and ultimately the patient. When booking dates, the in-patient rehab center should also be consulted to confirm availability for suggested dates. One of the best outcomes for the patient is in coordination with all of the