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As a coordinator of patient care, nurses occupy roles in leadership.  Choose one patient from this week’s scenario and  identify different health care team members across the care continuum that are either involved in or impacted by care coordination and discuss how you would establish relationships to collaborate to improve patient care outcomes in transitions of care.  Include at least 2 current references. 

 

You are an RN, working 7 AM to 730 PM on a 30 bed medical unit in a community teaching hospital. The day staff consists of a nurse manager, 5 RNs, 4 PCTs (Patient Care Technicians), and a unit clerk. Patient rounds with the hospitalist, nurse practitioner, physician specialists and charge nurse occur at 8 AM. A Hospitalist and Nurse Practitioner coordinate the medical care of patients admitted to this unit. A Registered Dietician (RD), Pharmacist, Case Manager, and Social Worker are assigned to this unit. 

You arrive and receive report for your assignment as follows: 

Sharon HaskinsAge: 56 years 

Weight: 84 Kg
Admitting Diagnosis: Uncontrolled Diabetes Mellitus, Renal Insufficiency 

Past Hx: Hypertension, Peripheral Arterial Disease Diet: 1800 cal 2 Gm Na ADA diet 

Medications:
Metformin 1000 mg po bid 

Glipizide XL 10 mg po daily
Lisinopril 10 mg po daily
Cilostazol 100 mg po bid
Morphine sulfate 3 mg IV q3h prn pain left leg 

Received Morphine x 2 during night with moderate relief Fingerstick blood sugar 0600: 328
Labs: 

HgA1c: 11.2
Hg 10.1 Hct 34.2 K 5.2
BUN 86
Cr 2.1 

Diagnostics:
Ankle brachial index: 

Left: 0.54 Right: 1.1 

Consults:
Vascular surgeon to discuss possible AV shunt placement, angioplasty left lower extremity Endocrinologist re: insulin therapy 

SCIENCE
HEALTH SCIENCE
NURSING
NUR MISC