| Course | NR 578 Primary Care Management of Older Adults |
|---|---|
| Week | 4 |
| Paper type | Transition of care plan |
| Length | About 1,120 words, 5 pages |
| Format | APA 7 student paper |
| School | Chamberlain University |
| Program | MSN, Adult-Gerontology Primary Care NP (AGPCNP) |
| Updated | October 2026 |
Free sample paper for NR 578 Week 4
Transition of Care Plan for an 87-Year-Old Going Home After Five Days in Hospital for Heart Failure: The First Fourteen Days, Who Is There and the New Baseline
Student Name
College of Nursing, Chamberlain University
NR 578: Primary Care Management of Older Adults
Instructor Name
Month Day, Year
Transition of Care Plan for an 87-Year-Old Going Home After Five Days in Hospital for Heart Failure: The First Fourteen Days, Who Is There and the New Baseline
The Patient at Discharge
An 87-year-old going home after five days in hospital for fluid overload, with heart failure of the preserved-pumping type, atrial fibrillation, stage 3b kidney disease and macular degeneration. Home is a row house where the bedroom and the only bathroom are on the upper floor, and the patient lives there alone. Daughter works full time, 25 minutes away. Cognitive impairment noted last month, workup in progress.
The New Baseline
Before admission: walked six blocks to the market on Saturdays, climbed the stairs twice a day without help, bathed at the sink.
At discharge: walks 30 feet with a four-wheeled walker and one person nearby; needs a hand to stand from a low chair; managed eight stairs with a rail and the therapist beside, slowly, with a rest at the top. Hospital stays often leave older adults less able than before and some never regain what they lost (Covinsky et al., 2011). The plan below is written for the person who is coming home, not the person who went in.
The First Fourteen Days
Table 1
Who Is Present and What Happens on Each of the First Fourteen Days
| Day | Who is in the house | What happens | Who arranges and who drives |
|---|---|---|---|
| Day 0, discharge at 14:00 | Daughter, staying overnight | Daughter drives home; neighbor has the spare key; bed made up in the front room | Daughter took two days of leave |
| Night 0 | Daughter | Calls at 03:00 go to the daughter, sleeping in the front room | Daughter |
| Day 1 | Daughter until 17:00, then alone with phone | Home health nurse first visit at 10:00: weight, medicines, lungs, home safety | Hospital case manager confirmed the start date before discharge |
| Night 1 | Daughter | Second night with the daughter | Daughter |
| Day 2 | Alone, neighbor checks at 12:00 | Pharmacist phone call at 11:00 to go over the new furosemide dose | Clinic pharmacist |
| Day 3 | Alone, neighbor at 12:00 | Physical therapy at home, first visit | Home health agency |
| Days 4 to 6 | Alone, neighbor daily at 12:00, daughter calls at 08:00 and 20:00 | Daily weight before breakfast, written on the fridge chart | Patient, with the daughter checking by phone |
| Day 7 | Daughter, half day off | Primary care visit at 15:00 | Daughter drives |
| Day 8 to 13 | Alone with the same checks | Nurse visit on day 9, therapy on days 8 and 11 | Home health agency |
| Day 14 | Daughter | Cardiology visit by video at 16:00 from the patient's kitchen | Daughter sets up the laptop |
Equipment, With Delivery Dates
Four-wheeled walker with a seat: issued by the hospital therapy department on the day of discharge. Bedside commode: delivered on day 0 by the home medical equipment company, confirmed by phone at 11:00. Fall alert pendant: ordered before discharge, delivered and tested on day 1. Bathroom scale: the patient's own, checked for accuracy by the home health nurse on day 1. Grab bar beside the toilet: requested; installation not yet scheduled, which is recorded as an open item for the nurse to chase on day 1.
The Stairs and the Bedroom
The patient wants to sleep upstairs, in the bed of 60 years. At discharge, the stairs are possible but slow and risky twice a day. For the first two weeks, a bed is made up in the front room and a bedside commode placed beside it, which the patient agreed to for "two weeks, no more." Physical therapy will work on stairs specifically, and the move back upstairs will be decided at the day 14 review with the therapist's report. Building the plan around the patient's own priority, sleeping upstairs, follows the approach of care aligned with patient priorities (Tinetti et al., 2019).
Medicines Compared
Furosemide increased from 20 mg to 40 mg each morning. Potassium chloride, 10 mEq each morning, added because of the higher diuretic dose. Amlodipine stopped in hospital because of low standing pressure. Apixaban continued at the reduced dose. The daughter fills the pillbox with the new list on day 0; the pharmacist confirms on day 2.
The Weight and When to Call
Weight each morning after the toilet and before breakfast. If the morning weight is 3 pounds above the day before, or 5 pounds above the same day last week, or if the patient is more short of breath lying flat, call the home health nurse line before 10:00. If there is chest pain or severe breathlessness, call 911.
The Morning After Discharge
Day 1 is the day most likely to go wrong, so it is written out. At 07:30 the patient weighs in with the daughter present and writes the number on the new fridge chart. At 08:00 the morning tablets come from the newly filled pillbox, including the higher water tablet dose. At 10:00 the home health nurse arrives, checks weight, lungs and ankles, looks at the stairs and the bathroom and confirms the medicines against the discharge list. At 12:00 the daughter leaves a lunch in the refrigerator. At 17:00 the daughter goes home, after checking that the pendant works and the phone is charged, and calls at 20:00 to confirm the evening tablet.
The Night Problem
From night 2, the patient is alone at night. The patient wears a fall alert pendant, ordered before discharge and delivered on day 1. The daughter's phone is on overnight. The neighbor has agreed to be the second call.
What Would End the Plan Early
The plan assumes the patient can be alone during the day from day 2. Three findings would end that assumption and bring the plan back for revision: a fall at home, a weight gain that needs extra diuretic more than once in the first week, or new confusion beyond the patient's usual state. Any of these would prompt a same-day call to the primary care clinic and a decision about short-term rehabilitation or more help at home.
How This Plan Fits the Evidence
A transitions intervention in which a coach helped older patients manage medicines and recognize warning signs after discharge reduced readmissions over the following month (Coleman et al., 2006). This plan borrows its elements, adapted to a patient who lives alone: medicines reviewed by a pharmacist within two days, warning signs written down, a primary care visit within a week and a named person to call.
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
Covinsky, K. E., Pierluissi, E., & Johnston, C. B. (2011). Hospitalization-associated disability: "She was probably able to ambulate, but I'm not sure." JAMA, 306(16), 1782-1793. https://doi.org/10.1001/jama.2011.1556
Tinetti, M. E., Naik, A. D., Dindo, L., Costello, D. M., Esterson, J., Geda, M., Rosen, J., Hernandez-Bigos, K., Smith, C. D., Ouellet, G. M., Kang, G., Lee, Y., & Blaum, C. (2019). Association of patient priorities-aligned decision-making with patient outcomes and ambulatory health care burden among older adults with multiple chronic conditions: A nonrandomized clinical trial. JAMA Internal Medicine, 179(12), 1688-1697. https://doi.org/10.1001/jamainternmed.2019.4235
Reading the NR 578 Week 4 instructions
The Week 4 plan should look like fourteen days rather than a summary, dense at first and thinning out. Say who is in the house on the first night, who has the spare key, who answers the phone at three in the morning, when the first appointment falls and who is driving to it. State the new baseline plainly, since someone who walked to the corner shop last month may now need help to stand. Most prompts want dates for every service, so a reader can tell whether the first days are covered. Medicines should be compared with what the patient took before. Expect to say what would make the plan fail.
How the NR 578 Week 4 example is put together
The plan opens with the patient's conditions and home, then sets the old baseline beside the new one, citing work on hospital-associated disability. A table runs through the fourteen days, naming who is present, what happens and who arranges and drives. Equipment is listed with delivery dates and one open item. The stairs and bedroom are settled for two weeks with the patient's agreement. A medicine comparison, weight triggers, a written-out first morning and a plan for nights follow. A section names three findings that would end the plan early, and the plan closes by linking its elements to a transitions trial.
Reading the NR 578 Week 4 grading rubric
The priciest gap is a plan that lists services without saying when any of them start; every service here has a day. Next is the plan built for the function the patient had before admission, which the new baseline section prevents. Nobody named for the first nights loses the next row, and the table names someone for each night. Medicines not compared with the prior list cost points. Equipment without delivery dates leaves days uncovered. Naming what would end the plan early, and following the patient's priority about the bedroom, earn the final criteria. Writing out the first morning in detail shows the plan was tested against the hardest day.
NR 578 Week 4 help: mistakes that cost points
The most common NR 578 Week 4 problem is a list of services with no start dates. Another is a plan written for the patient as they were before the hospital stay. Many plans forget the first night and the phone at three in the morning. Some leave out who drives to the first appointment. Medicine changes are often listed without the old doses. Equipment is ordered without a delivery date. If your patient's discharge differs, send the discharge summary and what you know about the household; a fourteen-day plan can be built with a name against each day. Put a name against every night and every trip, and write the new baseline before anything else.
Get a NR 578 Week 4 example written to your instructions
Send the Week 4 discharge case and whatever form or required elements your classroom publishes, and a custom transition plan is written into it and returned inside 24 to 48 hours, the first one free. Every step in the example carries a date, a named person and a telephone number rather than the name of a service.
More NR 578 papers and AGPCNP samples
- NR 578 Week 1: Older Adult Preference Discussion Post
- NR 578 Week 2: Functional Assessment Write-Up
- NR 578 Week 3: Cognitive Assessment Note
- NR 578 Week 5: Caregiver Education Plan
- NR 578 Week 6: Comprehensive Visit Note
- NR 578 Week 7: Complex Geriatric Case Analysis
- NR 578 Week 8: Practice Reflection
- NR 577 Week 4: Chronic Disease Visit Note
- NR 576 Week 4: Clinical Reasoning Write-Up
- NR 568 Week 4: Allopurinol in CKD Case Analysis
NR 578 Week 4 questions, answered
The case gives me only a discharge summary. How much of this can be written?
Quite a lot, provided you name what is missing. A summary rarely says who is at home or how many stairs there are, and a plan that quietly invents those details is weaker than one listing them as the first things to establish, with the call that would establish them. Sections generally reward the visible gap over the confident guess.
Is the medicine comparison the main point of this week?
It is one section and not the paper. The comparison earns its place because two lists in one kitchen produce doubled doses, but the assignment is usually marked on whether the whole two weeks is workable. A plan with an immaculate medicine section and no named person for the first weekend has missed what a transition actually is.
What if the house in the case obviously cannot manage?
Then say so in the plan and price the alternative. Naming a gap is a clinical finding here rather than a failure of planning. Write which tasks have nobody attached, then what would fill them: paid hours, a respite bed, a place at a day center, a move the family has not yet discussed. A plan assuming willing relatives will appear is the version that loses points.
Where can I find a free NR 578 Week 4 sample paper?
The full fourteen-day transition plan for the 87-year-old, with the day-by-day table and the new baseline, is on this page.
Who covers the first nights in the NR 578 Week 4 plan?
The daughter stays the first two nights, a neighbor holds the spare key and checks daily, and from night 2 the patient wears a fall alert pendant with the daughter's phone on overnight.