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Discharge Planning
Discharge Planning
Discharge Diagnosis
The patient understands why he was hospitalized. He can only answers yes sir if
asked. However his mother fully understands and can verbilize his history, what has been done
since and why, as well as what the prognosis for the future looks like. I did not have to provide
any education to the mother on the prognosis or anything specific to the process of his diagnosis
as she has been dealing with it and receiving education and training on it since it occurred back
in 2012. If I had to include teaching to a family member of this particular patient, I would
include teaching about the pathophysiology of the condition such as it will not get better and also
teaching about the care of the patient such as turning every 2 hours to prevent skin breakdown,
proper lifting/turning/positioning procedures to prevent injury, how to suction, give breathing
treatments, tube feeding, crushing and administering medications, administration of oxygen, oral
care, peritoneal care, and the need for interaction for the patient (i.e., treat the patient as a person,
even if not verbal, he knows what is going on and can benefit mentally from human interaction).
No current core measures have been identified.
Medications
There are a lot of medications for this patient. I would go over each one and make sure
the caregivers (mother and cousin) know what they are, why he takes them, how they are given,
what they do, and what side effects and reactions that needs to be watched for. Here is a list of
the most pertinent things I would cover:
Name Albuterol
Route inhalation
Frequency Q4H
Both
Indication Relaxes smooth muscle airways to dilate to allow for better air passage
Discharge Planning
Side effects/Nursing considerations Watch for paradoxical bronchospasms, nervousness, restlessness, tremor, headache, chest pain, palpitations
Name Baclofen Tab
Concentration 10mg/Tab
Route G Tube
Frequency TID
Both
Concentration 10mg/suppository
Route RTL
Frequency Q2D
Both
Concentration 32mcg/spray
Route inhalation
Frequency BID
Both
Concentration 200mg/10ml
Route G Tube
Frequency BID
Both
Concentration 500mcg/vial
Route Inhalation
Pharmaceutical class anticholinergic
Frequency BID
Both
Concentration 1000mg/10ml
Route G Tube
Pharmaceutical class pyrrolidines
Frequency Q12H
Both
Concentration 100mg/Tab
Route G Tube
Pharmaceutical class CNS Stimulant
Concentration 4mg/Tab
Route G-Tube
Pharmaceutical class five ht3 antagonists
Discharge Planning
Home Assessment
The patient will be going home with the mother and a cousin who will be the primary
caretakers. The home is a safe living environment for the patient. The patients mother has been
working with the social worker and various programs to make sure all items are taken care of for
a smooth transition of the patient to home care. The patients mother has had the home set up for
wheelchair access and is also in the process of getting a wheelchair accessable van. She has also
got a hospital bed with no pressure system, a lift system to get him in and out of the wheelchair,
a cough assist machine, a suction machine, and a ventilator. She also has got supplies for tube
feeding, skin care, peritoneal care, oral care, and medication administration. She has also talked
with the social worker about setting up skilled nursing care for a day off a couple times a week
so she does not get burned out. She does know that there is help available if it is ever needed.
There are no financial concerns as the patient was injured during active duty so the VA is taking
care of all costs involved as well as the patient continues to get his active duty pay.
Follow Up
The need for home health services has already been taken care of between the patients
mother and social worker. The social worker has also worked with the patients mother to set her
home up with all durable medical equipment needed as discussed under the home assessments
area of this paper above. The patient will have many follow up appointments, though most will
be in-home consultations such as speech therapy, occupational and physical therapy.
Discharge Planning
There are numerous other people that are included in making the discharge planning for
this particular patient. I must include his social worker, primary physician, his team of
specialists (neurologist, cardiologist, and gastroenterologist), dietician, speech therapist,
occupational and physical therapists in on the discharge planning as they will need to set up their
portion of either home visits or scheduling follow-up appointments.
Summary
It is important that each specialty area is addressed in discharge planning and teaching
and is put in writing so the patients primary care takers know exactly what needs done and what
future appointments are needed. The primary care takers need to be well trained in the daily
needs and handling of the patient and diligent in giving his medications correctly and promptly.
The primary caretakers should be monitoring the patient at all times and call the primary
physician and/or 911 depending on severity with any signs of distress. All appointments need to
be kept to ensure the patient is progressing without infection, pain, spasticity, skin breakdown or
other complications. Overall our goal is to allow the patient to live out his life without or with
minimal pain and suffering and to keep from having to readmit the patient to the hospital where
it could be avoided.
Discharge Planning
References