NURS FPX 6610 Assessment 3 Transitional Care Plan

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Assessment 3: Transitional Care Plan
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Student Name
Capella University
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Course Name
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Prof Name
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MAR 8, 2024
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Transitional Care Plan
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Transitioning between healthcare phases demands meticulous planning and communication to
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uphold patient safety and quality of care. This assessment centers on Mrs. Snyder, a
56-year-old diabetic patient admitted to Villa Hospital with an infected toe. The following outlines
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a comprehensive transitional care plan for Mrs. Snyder while addressing communication
barriers affecting the overall transition.
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Key Elements & Essential Information for Effective Treatment

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Ensuring Mrs. Snyder's well-being hinges on precise diagnosis, continuous medical record
tracking, and medication reconciliation. Access to her medical history aids in identifying
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concurrent health issues like depression, hypertension, and cardiac concerns. Moreover,
medication reconciliation guarantees that prescribed drugs align positively with her health
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objectives, particularly crucial for insulin dosing accuracy.
Emergency and Advance Directive Insight

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A patient-centered approach mandates understanding Mrs. Snyder's religious beliefs and

accessing advance directive information from primary healthcare providers. This insight into
past treatments helps prevent potential complications and ensures continuity of care.
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Patient Feedback Integration
Incorporating patient feedback on medical personnel behavior and treatment processes fosters
a patient-centric approach. Understanding Mrs. Snyder's preferences and needs enables
healthcare professionals to deliver tailored information and engage her actively in her
healthcare journey.
Plan of Care Customization and Education
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Customizing the transitional care plan to Mrs. Snyder's unique requirements involves offering
community-based healthcare services and facilitating seamless information exchange among
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healthcare providers. Adequate training ensures healthcare professionals can deliver
patient-centric care effectively.
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Community and Healthcare Resource Utilization
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Access to community services such as transportation options, social support networks, health
education programs, and outpatient services is pivotal for preventing readmissions and
improving Mrs. Snyder's well-being.
Insightful Patient Needs Assessment

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A thorough patient assessment encompassing medical test results, post-discharge
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prescriptions, counseling documents, and follow-up plans is essential for a smooth transition.
Comprehensive information transfer reduces treatment delays and enhances Mrs. Snyder's
safety.
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Significance of Transitional Care Plan Elements

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Each element contributes to Mrs. Snyder's care by ensuring preparedness for potential issues,
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understanding her beliefs, and addressing her concerns. Access to community resources and
healthcare facilities optimizes her mobility and treatment outcomes, while medication
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reconciliation and patient feedback guide treatment decisions and prevent errors.
Effects of Incomplete or Inaccurate Information

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Incomplete or inaccurate patient information poses risks of treatment delays, errors, and
adverse events, underscoring the importance of precise data transfer in transitional care.
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Importance of Effective Communication
Effective communication fosters trust, encourages commitment to care plans, and mitigates
potential treatment pitfalls. Clear communication is particularly crucial for addressing Mrs.
Snyder's stress and depression, ensuring holistic support during her transition.
Potential Effects of Ineffective Communication
Ineffective communication can lead to delayed or inappropriate treatment, increased costs, and
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compromised care quality, emphasizing the need for streamlined information exchange in
transitional care plans.
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Barriers to Accurate Information Transfer
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Barriers such as staffing shortages, incomplete medical records, and limited EHR technology
knowledge hinder seamless information transfer, necessitating proactive strategies to overcome
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these obstacles.
Strategies for Comprehensive Continued Care Understanding

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Strategic planning, information sharing, and follow-up sessions are vital for ensuring accurate
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information transfer and addressing patient concerns. Collaborative approaches facilitate
effective communication, empowering patients like Mrs. Snyder with the tools for successful
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self-management.
Conclusion
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A robust transitional care plan is indispensable for patients like Mrs. Snyder, ensuring seamless
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transitions between healthcare settings and optimizing treatment outcomes. By addressing

communication barriers and integrating key elements, healthcare professionals can provide Mrs.
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Snyder with the support and resources needed for a successful healthcare journey.
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Assessment 3: Transitional Care Plan

Key Elements & Essential Information for Effective Treatment

objectives, particularly crucial for insulin dosing accuracy.

Emergency and Advance Directive Insight

A patient-centered approach mandates understanding Mrs. Snyder's religious beliefs and

Plan of Care Customization and Education

Insightful Patient Needs Assessment

Significance of Transitional Care Plan Elements

Effects of Incomplete or Inaccurate Information

Potential Effects of Ineffective Communication

Strategies for Comprehensive Continued Care Understanding

transitions between healthcare settings and optimizing treatment outcomes. By addressing

Management, 28(6). https://doi.org/10.1111/jonm.13097

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