NURS FPX 4050 Assessment 4 Final Care Coordination Plan

NURS FPX 4050 Assessment 4 Final Care Coordination Plan

Final Care Coordination Plan

NURS FPX 4050 Assessment 4 Final Care Coordination Plan 

A care coordination plan is critical to the proper rehabilitation of stroke patients. As outlined in the preliminary care coordination plan, a stroke is a debilitating disease with long-term consequences ranging from mild to severe. The two types of strokes that can occur are ischemic and hemorrhagic. In ischemic strokes, the brain suffocates due to a lack of oxygenated blood flow, while in hemorrhagic strokes, the brain has a bleed that leaks blood causing intense pressure and a lack of oxygenation (Kuriakose & Xiao, 2020). In both situations, the survival rates are bleak, with every one out of six patients dying (CDC, 2021).

Due to the irreversible damage a stroke does to the brain, patients survive with more than one secondary ailment that will require meticulous care coordination to address. This final care coordination plan will address three common health issues stroke survivors face and provide coordinated plans to help patients deal with each of them. The three health issues that I will address are paralysis or motor movement loss, aphasia or the inability to understand language like before, and emotional issues stemming from fear, depression, and anxiety. The goal is to create a synergistic environment where patients have well-rounded care with teams that communicate well, leading to better healthcare outcomes overall (Williams et al., 2019).

  • Paralysis: Motor Movement Loss

Partial or complete paralysis is one of the most common problems a patient faces after a stroke (HHS, 2022). Due to the nature of a stroke that affects the left or right hemisphere of the brain, the loss of motor movement is typically more prevalent on one side of the body. The debilitating effects of paralysis can thoroughly affect a survivor’s ability to carry out activities of daily living (ADLs), ranging from things as simple as changing their clothes to feeding themselves. In more complicated situations, survivors have difficulty swallowing food known as dysphagia, which leaves them at risk for aspiration (HHS, 2022).

To deal with paralysis, the two primary specialists that need to be recruited into the coordinated care team are the occupational therapist and the physical therapist. The primary goal of the occupational therapist is to assist survivors with the process of relearning their fine motor skills, specifically the ones needed to perform ADLs independently. On the other hand, the physical therapist aims to assist patients with gross motor movements involving strength, balance, and coordination. Both experts must start working with the patient as quickly as possible since the longer a patient waits, the less likely they will recover.

One of the objectives of the Department of Health and Human Services (HHS) Healthy People 2030 initiative is to increase the participation rate of stroke survivors in rehabilitation services (, 2022). Patients must be given information and physical and occupational therapy access to achieve this goal. Below are three community resources that provide these services in Ft. Myers, FL.

  • Advanced Physical Therapy and Rehabilitation
    • Voted best physical therapy provider for the last 7 years
    • (239) 432 0556
  • Apex Physical Therapy
    • Offer cutting-edge and emerging modes of therapy
    • (239) 337 2739
  • Stroke Recovery Foundation
    • An affordable non-for-profit organization focusing on stroke recovery only
    • (239) 254 8266
  • Aphasia: Loss of Language Comprehension

One of the scariest moments of a stroke survivor’s journey is when they realize for the first time that they are having a difficult time comprehending or speaking a language like they used to. Aphasia happens because sometimes, the affected part of the brain is the same area that controls language and speech comprehension. There is no exact way aphasia manifests because the symptoms vary from patient to patient and can even include an inability to understand written language (HHS, 2022). The three forms of aphasia are expressive, where a person cannot speak or write; receptive, which causes comprehension difficulties; and global, which is all-encompassing.

The care coordination team specialist brought on to assist with aphasia is known as a speech-language pathologist (HHS, 2022). The primary goal of the speech-language pathologist is to try and help the survivor regain their pre-stroke language capabilities as much as possible. However, in most cases, complete recovery is unachievable. The speech-language pathologist then works with the survivor to create new methods of communication that they can use to interact with family and society. Regarding the issue of dysphagia discussed earlier in this paper, the speech-language pathologist is also the care team member that works with the stroke survivor to overcome swallowing problems.

Listed below are some resources for stroke survivors suffering from aphasia:

  • National Aphasia Association
    • Maintains database of all aphasia support organizations in the USA
    • Lists all available resources in Florida
  • Expressable
    • Unique service that allows for online speech therapy sessions
    • Specialize in aphasia but not dysphagia
  • Fort Myers Rehab
    • Local stroke rehab facility covering a range of therapies
    • Personalized and cover both aphasia and dysphagia
    • (239) 936 0203
  • Emotional Issues

One of the most understated and overlooked post-stroke issues that a survivor deals with is not physical at all. Instead, the emotional toll that the experience places on the patient lead them to suffer from various issues such as anxiety attacks, post-traumatic stress disorder (PTSD), major depression, a lack of self-confidence, anger, and frustration (HHS 2022). Many survivors no longer enjoy the independence they once had as they are limited in mobility and feel isolated from society. This isolation leads to various other health issues as it impacts the survivor’s eating habits, and physical activity, and furthers mental degradation.

NURS FPX 4050 Assessment 4 Final Care Coordination Plan 

To help survivors deal with the emotional effects, survivors are often referred to psychologists. One of the objectives of the Department of Health and Human Services (HHS) Healthy People 2030 initiative is to increase the proportion of adults with depression who get treatment (, 2022). In keeping with this plan, the care coordination team must include a licensed psychologist to help treat a survivor’s mental and emotional issues. In more severe cases, the survivor may need the assistance of a psychiatrist as mood-altering medications may be necessary. The most common treatments for emotional problems include counseling, therapy, and anti-depressive medications.

Listed below are some resources for stroke survivors suffering from emotional issues:

  • Dr. David S. Geiser, Ph.D
    • Local neuropsychological expert serving the area for 20 years
    • Offers telepsychology services
  • Telespecialists
    • Easy online access to once-a-month stroke support group
    • Free sign up and easy to access
  • Stroke Recovery Foundation
    • An affordable non-for-profit organization focusing on stroke recovery only
    • (239) 254 8266

Ethical Decision Making

The registered nurse (RN) must take an active role in the creation, and continuum of care coordination for stroke survivors. As outlined above, there will generally be more than one specialist dealing with a survivor at any given time focused on a specific issue. This scenario opens the door to ethical dilemmas concerning patient confidentiality. There is a need for information sharing among care team members, but the patient also retains a right to deny access to their protected health information (PHI). The RN plays a unique position in all of this since they are typically the most trusted resource in the patients’ eyes (McCarthy, 2021).

This position gives the RN a lot of power that the RN can abuse if not guided by the four foundational ethical principles of nursing: autonomy, justice, beneficence, and non-maleficence (Varkey, 2021). The patient must always be given the autonomy to have the final say in their medical care decisions. Beneficence and justice must be upheld when deciding whether to share private patient information with care team members not critical to care. RNs must remember that part of the job is maintaining patient confidentiality and trust.

NURS FPX 4050 Assessment 4 Final Care Coordination Plan 

The principle of justice also comes into play for the team at large. There will inevitably be some sicker patients than others, and some will be more complex to work with than others. In these scenarios, RNs and care team members must remember that each patient reserves the right to be treated fairly. Resources should be distributed evenly even if the care team member feels the patient will waste them. As the saying goes, hurt people hurt people. With this in mind, the RN must remember the principle of non-maleficence (Varkey, 2021) when working with a problematic or verbally abusive patient. Retaliation goes against nursing ethics.

Impact of Relevant Health Policies

The Affordable Care Act (ACA) is perhaps the single most impactful legislation passed in the last two decades that positively affects care coordination efforts. Through the expansion of Medicare and Medicaid, low-income stroke survivors and those from more rural areas have been able to gain better access to rehabilitation and medical services (Moy, 2022). The ACA led to the creation of Affordable Care Organizations (ACOs), whose sole purpose is to establish care coordination among multiple providers at cheaper or packaged rates, supported by government funding. ACOs allow survivors that need multiple rehabilitation options to receive it all from one place at a more affordable rate since care coordination is the basis of the system. These efforts have been shown to reduce hospitalizations and rehospitalizations since President Obama passed it in 2010 (Moy, 2022).

NURS FPX 4050 Assessment 4 Final Care Coordination Plan 

Care Plan Collaboration Priorities

When educating the patient and family on the importance of care coordination, the immediate priority is to explain how the plan would benefit the patient. Ultimately, buy-in happens when the primary stakeholder understands the benefits and recognizes that they have a say in the process. The RN is probably the most valuable team member when teaching the patient and the family about the importance of having a coordinated care plan since they are usually the most trusted person on the team (McCarthy, 2021). The RN must assist the patient and the family with assigning the correct roles to reduce burn-out as long-term care is an undertaking that can quickly negatively affect the family caregivers’ health. With proper collaboration and buy-in from all parties, the patient’s recovery and quality of life will have a better chance of improvement.

Using Literature as a Guide for Best Practices

When evaluating any elaborate care coordination plan, it is critical that the plan is aligned with current acceptable standards and future goals of the HHS. When comparing this care plan to the Department of Health and Human Services (HHS) Healthy People 2030 initiative, it becomes evident that the objectives are aligned. The initiatives and focus of this coordinated care plan support the rehabilitation and mental health goals outlined in the Healthy People 2030 initiative (, 2022) as evidenced above.

NURS FPX 4050 Assessment 4 Final Care Coordination Plan 


Although we still have a long way to go in adequately educating the population regarding stroke prevention and rehabilitation, data from the Healthy People 2030 initiative (, 2022) shows progress. When careful care coordination plans are created in accordance with the HHS’s goals, not only will the patient benefit, but in the long run, the country will as a whole. Meticulous care coordination is the best way to treat and deal with stroke survivors. It allows for care planning and recruitment of the correct team members needed to ensure that the patient has a successful recovery process.


CDC. (2021, May 25). Stroke facts. Centers for Disease Control and Prevention. Retrieved March 9, 2022, from 

Kuriakose, D., & Xiao, Z. (2020). Pathophysiology and Treatment of Stroke: Present Status and Future Perspectives. International journal of molecular sciences21(20), 7609.

U.S. Department of Health and Human Services. (n.d.). Post-stroke rehabilitation fact sheet. National Institute of Neurological Disorders and Stroke. Retrieved March 11, 2022, from 

HHS. (n.d.). Healthy people 2030. Retrieved March 11, 2022, from

 McCarthy, N. (2021, June 29). America’s most & least trusted professions [infographic]. Forbes. Retrieved March 10, 2022, from

Varkey, B. (2021). Principles of clinical ethics and their application to practice. Medical principles and practice: international journal of the Kuwait University, Health Science Centre. Retrieved March 10, 2022, from 

Moy HP, Giardino AP, Varacallo M. Accountable Care Organization. [Updated 2022 Feb 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from:

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