Seven Disciplines, One Discharge: Coordinating Interprofessional Care for a 75-Year-Old Moving From Bypass Surgery to Home
[Student Name]
University of Phoenix
NSG/302: Professional Contemporary Nursing Role and Practice
Week 3 Assignment
[Instructor Name]
[Date]
The patient and all clinical details are a composite written for a model paper.
In Week 2, Mr. R., a 75-year-old man four days after bypass surgery, developed atrial fibrillation with a rapid rate, fluid overload and pain that kept him in bed. By the next morning his rate was controlled with metoprolol, his breathing had improved after diuresis and he had walked twice. He now needs a team that can carry him from the intensive care unit to home without losing the gains or the details. This paper identifies that team, describes how the nurse coordinates it and outlines how Mr. R. is handed off at discharge.
The Care Providers and What Each Contributes
The cardiac surgeon and the surgical nurse practitioner lead his recovery from the operation: the incisions, the pacing wires, the decision about when he is ready to leave and the surgical follow-up visit.
The cardiologist decides the long-term plan for the atrial fibrillation, including whether he needs anticoagulation once he is safely past the bleeding risk of surgery, and whether a rhythm-control drug is warranted if the arrhythmia returns.
The clinical pharmacist reconciles his home and hospital medications. Mr. R. now takes a higher dose of metoprolol, a statin, aspirin, a short course of furosemide and possibly an anticoagulant, and he stopped metformin before surgery. The pharmacist checks doses against his kidney function and teaches the purpose of each drug.
The physical therapist assesses his strength and balance, progresses his walking and decides whether he is safe to climb the twelve steps to his front door.
The cardiac rehabilitation team provides supervised exercise and education in the weeks after discharge. Referral to cardiac rehabilitation before discharge from a hospital stay for bypass surgery is a recognized quality measure because participation reduces later death and readmission (Thomas et al., 2018).
The registered dietitian teaches a heart-healthy, carbohydrate-conscious diet that fits his diabetes and his wife's cooking, and addresses the temporary fluid restriction.
The case manager or social worker confirms his insurance coverage, arranges home health nursing for the first two weeks, and checks that his wife can manage the care at home.
The primary care provider receives him after discharge and resumes management of his diabetes and blood pressure.
Coordinating the Team During the Stay
The bedside nurse is the one member present with Mr. R. around the clock, which makes coordination a nursing responsibility rather than an extra task. Coordination means that each discipline knows what the others have decided, and that Mr. R. hears one plan instead of seven. On our unit, this happens through daily interprofessional rounds at the bedside, where the nurse reports overnight events, the rhythm, the fluid balance and his walking distance, and asks each discipline for its plan for the day. The Interprofessional Education Collaborative describes this as working in teams and communicating in a responsive, responsible way that supports a team approach to care (Interprofessional Education Collaborative, 2023).
The nurse also engages disciplines that are not on rounds. If Mr. R. is too tired to walk when physical therapy arrives, the nurse reschedules the session for after his pain medication rather than letting it be missed. If the pharmacist recommends a change, the nurse makes sure the surgeon has seen it before the next dose is due.
Three decisions depend on more than one discipline, and the nurse makes sure they are made together: whether he goes home on an anticoagulant, which needs the cardiologist and the surgeon; whether he is safe at home with stairs, which needs physical therapy and the case manager; and whether his diabetes regimen changes, which needs the pharmacist, the dietitian and the primary care provider.
Transitioning to the Next Providers
Discharge is the moment when information is most likely to be lost. Structured handoffs reduce this risk; after a handoff program was introduced in nine hospitals, preventable adverse events fell by 30% (Starmer et al., 2014). For Mr. R., the transition includes four parts.
First, a reconciled medication list, reviewed by the pharmacist with Mr. R. and his wife, with the reason for each change written in plain language. Second, a written summary sent to the primary care provider and the cardiologist that names the atrial fibrillation, the anticoagulation decision and the date of each follow-up visit. Third, teaching that uses the teach-back method: Mr. R. demonstrates how to check his pulse and names the signs that require a call, such as a racing heart, weight gain of more than 1 kg in a day, fever or redness at the incisions. Fourth, a follow-up telephone call from the unit within 72 hours.
The Care Transitions Intervention, which gives patients a personal health record, a follow-up visit and coaching from a transition coach, reduced readmissions in older adults, and its main ideas can be applied without a full program (Coleman et al., 2006). The home health nurse visiting in the first week plays the coaching part for Mr. R.
Mr. R. and His Wife as Members of the Team
A team that plans around a patient without including him tends to produce a discharge he does not follow. Mr. R. has clear preferences: he wants to be home before his granddaughter's birthday, he dislikes taking pills he does not understand, and he worries that his wife, whose hands are stiff from rheumatoid disease, will struggle to help him bathe. The nurse brings these facts to rounds because they change the plan. The pharmacist simplifies his regimen to a once-daily schedule where possible, the case manager adds a shower chair and a home health aide for the first week, and the physical therapist practices the stairs with him twice so that he, not the team, decides he is ready. His wife attends the final teaching session and writes her own questions on the discharge folder. Treating the couple as members of the team does not slow the discharge; it removes the reasons it might fail.
The Baccalaureate Nurse's Part
Coordinating seven disciplines draws on all three roles in the course. The nurse practices by assessing Mr. R. and reporting accurately, leads by keeping the team's decisions connected and on time, and teaches by making sure Mr. R. and his wife leave with a plan they understand.
Conclusion
Mr. R.'s recovery after bypass surgery and new atrial fibrillation needs at least seven disciplines. The nurse holds the team together during the stay and makes the handoff to home and to the primary care provider complete. Week 4 turns to a bedside practice question and the evidence behind it.
References
Coleman, E. A., Parry, C., Chalmers, S., & Min, S.-J. (2006). The care transitions intervention: Results of a randomized controlled trial. Archives of Internal Medicine, 166(17), 1822-1828. https://doi.org/10.1001/archinte.166.17.1822
Interprofessional Education Collaborative. (2023). IPEC core competencies for interprofessional collaborative practice: Version 3.
Starmer, A. J., Spector, N. D., Srivastava, R., West, D. C., Rosenbluth, G., Allen, A. D., Noble, E. L., Tse, L. L., Dalal, A. K., Keohane, C. A., Lipsitz, S. R., Rothschild, J. M., Wien, M. F., Yoon, C. S., Zigmont, K. R., Wilson, K. M., O'Toole, J. K., Solan, L. G., Aylor, M., ... Landrigan, C. P. (2014). Changes in medical errors after implementation of a handoff program. New England Journal of Medicine, 371(19), 1803-1812. https://doi.org/10.1056/NEJMsa1405556
Thomas, R. J., Balady, G., Banka, G., Beckie, T. M., Chiu, J., Gokak, S., Ho, P. M., Keteyian, S. J., King, M., Lui, K., Pack, Q., Sanderson, B. K., & Wang, T. Y. (2018). 2018 ACC/AHA clinical performance and quality measures for cardiac rehabilitation. Journal of the American College of Cardiology, 71(16), 1814-1837. https://doi.org/10.1016/j.jacc.2018.01.004
How this NSG 302 Week 3 example is structured
Public listings for NSG/302 Week 3 describe reusing the Week 2 patient to identify the interdisciplinary care providers he needs and to outline how the nurse coordinates, engages and transitions him to them, often in a paper of about 860 words with a tolerance of 10 percent. This sample runs longer so the reasoning is fully visible; a submission should follow the count your classroom sets. It moves from the team, to coordination during the stay, to the handoff at discharge. Students search this week as NSG 302 Week 3, NSG302 Wk 3 or NSG/302 Wk 3; all three are the same assignment.
NSG/302 Week 3 questions, answered
What does NSG/302 Week 3 usually ask for?
Public listings describe identifying the interprofessional providers needed by the Week 2 case study patient and explaining how the nurse would coordinate their care, engage them and transition the patient to other providers. Many sections set a word count of about 860 words.
Which disciplines belong on the team after heart surgery?
Commonly the cardiac surgeon and cardiologist, nursing, pharmacy, physical therapy, cardiac rehabilitation, dietetics, case management or social work, and the primary care provider who takes over after discharge.
What makes a transition of care safe?
A complete, accurate handoff of medications and follow-up plans, a patient who understands the warning signs, a named person to call, and an early appointment with the next provider.
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