Coordinating Care

300 words.

Question: Terri is a 83-year-old widow who has been hospitalized and is being prepared for discharge. Terry was hospitalized after suffering a stroke on the right side. She has residual left-sided weakness, difficulty swallowing and communicating, and aspirates easily. The doctor has initiated aspiration precautions and her diet includes pureed foods and nectar thick liquids. While in the hospital, she receives PT, OT, ST, and assistance with her basic hygiene needs. Terri was independent at home, cooked her own meals, drove a car, and did her own laundry and housekeeping. Her closest relative is her 82-year-old brother who suffers from DM and is blind in the right eye. He lives 30 minutes away. How can Terri’s APRN direct and manage, or organize and coordinate, Terri’s discharge and who should be part of this process?