The Role of Preliminary Care Coordination Plan in Nursing


Care coordination is a healthcare approach in which all of the patient’s needs are coordinated through the primary contact person. In this case, the patients and their families are provided with the complete information about the disease and receive the most appropriate treatment. One important role of the care coordinator is to ensure that the patients are receiving the care they need. For example, if a patient needs physical therapy, the coordinator makes sure that he or she sees a physiotherapist regularly. The coordinators also confirm that health care providers have the information they need, such as a complete list of a patient’s medications and a medical history of the patient. This process improves the quality of service as well as patient satisfaction.

Health Interventions for Chronic Kidney Disease

Every nurse who cares for patients with chronic kidney disease must carry out diagnostic and therapeutic measures. It is important to be able to conduct a nursing examination, perform procedures, and manipulations, such as measuring blood pressure, prepare the patient for urine collection for microscopic and microbiological examination, and others. The nurse has to prepare the patient for health interventions, register medical documentation, and provide first aid if needed (Hemmelgarn et al., 2017). Teaching the patients and their relatives the rules of medical nutrition is also a necessary step. The nurse should know the causes, clinical manifestations, possible complications, and methods of diagnosing a patient’s problems.

Before health interventions, the care professional should communicate with the patient, as well as conduct an objective study. Then the nurse has to interview the patient on past illnesses, changes in urine, and so on (Hemmelgarn et al., 2017). The patients and their relatives need proper information about the illness and methods of its treatment. Patient-centered care includes informing the relatives about the essence of the disease, the principles of treatment, as well as explains the course of certain instrumental and laboratory tests and preparation for them.

Patient-centered care for such people includes monitoring the manifestations of the disease, daily measurement of blood pressure, the amount of fluid drunk and excreted, and other indications. The care also includes identification of complications signs, monitoring compliance with the diet and treatment prescribed by the doctor, as well as identifying the side effects of drugs (Hemmelgarn et al., 2017). Teaching the patients and their relatives skills to control the general condition of the patient is also an important task, including determining the pulse, blood pressure, and urine output.

Patient-centered Care for Patients with Asthma

First of all, the nurse should develop a personalized, patient-centered asthma education plan that addresses learning needs, cultural and linguistic context, health literacy, and empowerment. Asthma education must become an integral part of patient-oriented care. The nurse should teach the patient the necessary skills of self-management based on the patient’s learning needs, including asthma pathophysiology, medication, device techniques, self-observation, action plan, trigger identification, and management (Kaye et al., 2020). The care coordinator also has to evaluate non-drug interventions for efficacy and potential drug interactions. At each visit, it is necessary to teach the patient correct inhalation device technique. It is also important to involve the patient with asthma in collaborative decisions regarding the choice of inhalation device.

Patients must be educated on the difference between drugs that control the disease and those that relieve symptoms, their indications, and their potential side effects. They should also know how to measure peak expiratory flow whenever possible. To support self-management, care coordinator of the asthma patient should develop and revise a documented action plan. Integrated self-management must be provided for an uncontrolled asthma patient at potential risk of severe exacerbations (Kaye et al., 2020). This must be done through multiple formats such as home visits or telemedicine. Besides, the nurse should refer and link asthma patients with a PHC representative trained in a disease management program.

Care Coordination for Patients with Rheumatoid Arthritis

Care for rheumatoid arthritis is one of the main components of treatment to improve the quality of life. First of all, the nurse should examine a person suffering from rheumatoid arthritis and clarify the complaints during the conversation with the patient and his or her relatives. On examination, it is necessary to measure temperature, blood pressure, and evaluate the skin. Particular attention should be paid to examination and palpation of the affected joints, assess the degree of their mobility and gait (Bergsten et al., 2019). Analysis of the data obtained and identification of difficulties that prevent the patient from leading a normal life are the next steps. All problems are divided into existing (pain, limitation of mobility, psychological discomfort) and anticipated (formation of pressure ulcers in bedridden patients, decreased mood in case of loss of working capacity).

Goal setting and planning is another important stage, at which the nurse needs to set real short-term and long-term goals. It is imperative to involve the patient and his or her family in the planning process. The immediate goals are aimed at improving the patient’s condition while the remote ones help to relapse prevention and patient adaptation (Bergsten et al., 2019). In accordance with the goals set, activities must be carried out. Having developed a plan of actions, the nurse ensures their implementation. People with rheumatoid arthritis often fall into depression due to their condition, such as the inability to move freely, work, and self-care.

Care begins with conversations with the patient when nurse explains the peculiarities of the course of the disease and instills confidence in success, taking the patient’s attention away from changes in joints and gait. The nursing staff explains the need to give up bad habits, adhere to the diet, and then monitors the implementation of these recommendations. In the room, the nurse monitors the maintenance of the optimum temperature and humidity, as well as controls the frequency of ventilation. When the disease is in an acute period, the care coordinator helps the recumbent patient to take a comfortable position. The affected joint is fixed with a bandage, a splint in a functional position to reduce pain. If necessary, the nurse provides the person with crutches and teaches how to use it (Bergsten et al., 2019). If there are open wounds or fistulas, the nurse changes the dressings. The care specialist also monitors the intake of prescribed drugs and tells the patient about the need for constant treatment and the rules for taking medications to prevent complications.

Ethical Decisions in Designing Health Interventions

Taking into account the described patient-centered care plans for the particular diseases, it is extremely important to consider ethical decisions in designing health interventions. Fundamental ethical principles in health care include respect for patient autonomy, support and creation of conditions for making informed decisions, as well as the relationship between the benefits of treatment and its risks. Ethical decisions also include acting on behalf of the patient and the avoidance of actions likely to entail harm to the patient. Equity or sharing the benefits, risks, and costs of getting health care is another ethical principle. Also, ethical issues concern the rights and responsibilities of the patient, his or family and medical workers, organizations, fairness of health policies, and equality in access to health services.

Communication is closely related to treatment effectiveness, chronic disease management, health outcomes, and the quality of life, which is inseparable from the ethical aspects of communication. It covers the necessary information for making a decision, including an explanation of the complex diagnosis, treatment process, advantages and disadvantages of each of the treatment courses, and providing answers to questions. Cultural and linguistic aspects are recognized as barriers to these interactions. Patients in different parts of the world react to same things in a different way. For example, in a study conducted in China, it was shown that the families of patients are opposed to announcing the diagnosis to the patient, while the patients themselves often want to know the truth about their condition (Henderson et al., 2018). In the study in Saudi Arabia, patients want clear and understandable information about the diagnosis (Henderson et al., 2018). That is why it is important to take into account the elements of cultural competence in communication between doctors and patients.

Health Policy Implications for Care Coordination

Nursing in the United States continues to evolve towards improving competencies and skills in leadership and innovation. Collaboration is strengthened with other professionals in the field of health care and the reorganization of health care system. The role of nurses in telemedicine is predicted to grow in the future. Building and strengthening coalitions with stakeholders both inside and outside nursing is another proposed tool to achieve the goal of improving access to quality health care service for all Americans (Healthy People 2030, 2020). Medical care continues to be an indispensable social service for the population. Full partnerships in health care, as well as health policy change efforts, require nurses to be in the lead and participate in ongoing reform, research work, and the translation of research into action.

According to Healthy People 2030, the proportion of adults with arthritis who have moderate or severe joint pain must be reduced. The number of people with arthritis whose disease limits their work will decrease. The burden of chronic kidney disease and related complications. What concerns chronic kidney disease, the proportion of new cases in adolescents and adults will decrease. The number of dialysis patients will be reduced as well. Moreover, kidney donation rates will increase as well (Healthy People 2030, 2020). Changes to health policy can help to achieve these goals. The health policy now pays particular attention to enhancing opportunities for cooperation between different professions related to the provision of health care. The policies also encourage nurses to work in leadership positions, including health systems, insurance companies, government agencies, and advisory committees. Thus, care specialists will be able to participate in reforming the system of medical care.


A well-designed care coordination plan, based on the advances of health policy and ethical decisions, can improve patient outcomes. Care plans are not algorithms that explain how procedures are performed but rather a decision support tool for care specialists. When applying preliminary care plan in practice, the type of healthcare organization, the preferences of patients, and other factor must be considered. Following the plan does not negate the responsibility of the care professional to make appropriate ethical decisions and use the plan reasonably. Ethical issues in decision making and communication with patients and their relatives must be taken as the basis to care coordination plan. Ethical aspects of communication between health care professionals and patients are complex and multifaceted. They are influenced by various cultural and social factors and the changing communications infrastructure. All this should be carefully studied and taken into account when implementing a proper patient care.


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