Discharge Planning for Elderly Patients: A Nursing Assignment

This nursing assignment discusses the process of discharge planning for elderly patients, focusing on the case of Joseph Russo. It covers the course of action before the discharge procedure, the care plan, legal and ethical principles, and the application of strength-based nursing care. The assignment also emphasizes the importance of culturally safe care in providing holistic support to elderly patients.

Running head: NURSING ASSIGNMENT
NURSING ASSIGNMENT
Name of the Student
Name of the university
Author’s note

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Discharge planning
Introduction
Discharge planning is a process that involves carer, patient, family and staffs involved in
the patient care. The aim of the discharge planning is to ensure a safe and a smooth discharge
from the hospital, whether to residential care or another location (Hegarty et al. 2014). Discharge
planning is an interdisciplinary approach to the continuity of care and the process includes
identification, assessment, goal setting, planning, implementing, coordinating and evaluating
(Francischetto et al. 2016). A structured patient specific discharge planning reduces the length of
the hospital stay, hospital readmissions leading to reduced health care costs.
This report aims to discuss about the course of action of Joseph’s discharge from the
hospital and transfer to home. Joseph is an elderly patient would had been admitted to the
emergency department for carbon monoxide poisoning. Joseph had undergone brain damage due
to the poisoning. He had also displayed symptoms of CLABSI, while in care. Before the
discharge he had been diagnosed with a pressure injury at his left heel. Joseph’s wife is not
functionally active and normally Joseph takes care of his wife, hence any care plan made for
Joseph would also consider the needs of the family of Joseph including the healthcare and the
physical needs of Joseph and his wife. This paper would also demonstrate the legal and the
ethical principles for the decision making. While planning for the discharge, Joseph’s cultural
aspect should also be considered.

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Course of action before the discharge procedure
Before the discharge Joseph, there should be a medical evaluation that can
comprehensively lay out both the physiological and the psychological condition of the patient, a
short term and a long term outlook and further treatment that the doctor might consider to be
necessary (Gonçalves‐Bradley et al. 2015). The actual process of discharge planning is normally
completed by a discharge planning team or an aged care assessment team (ACAT) that consisted
of a physician, a nurse, a case manager, an occupational therapist, a nutritionist and the social
worker. They would assess the physical, medical, cultural, restorative, social and the cultural
needs of patients like Joseph. The nurse leaders creates documents explaining the activities and
the needs of the patient and hold meetings with the multidisciplinary team to address any
escalated issue. They are responsible for making contacts with the referral service and arrange
for the follow-up services (Hunter and Birmingham 2013). The multidisciplinary team (MDT)
should also consist of an occupational therapist for assisting the patient to cope up with daily
activities of living (ADLs), cultivating the life, social skills, relationship and self-efficacy. An
OT can also help the personal caregivers to arrange of home modifications suitable to the
mobility of the patient (Hickman et al. 2016). The home carers also play a large role in the
discharge planning of Joseph Russo. Emma in this case is Joseph Russo’s daughter and the hence
should be involved in the discharge planning. The social worker in this case would refer to some
homecare packages that would supply home support in affordable cost to provide support to both
Joseph and his wife Sophia. Joseph Russo stays in Blacktown and there are parent home care
support services which can be contacted by the social care workers on behalf of the patient.

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Care plan
Since discharge planning involves a proper medical evaluation, it is necessary to keep in
mind some of the clinical priorities prior to the discharge (Shepperd et al. 2016). Some of the
issues of concern related to Joseph are hypotension, brain damage due to the exposure to carbon-
monoxide, chances of a central line associated Blood stream infection (CLABSI). It can also be
seen that Joseph had developed a pressure injury on his left heel. Hence, before discharging
Joseph, it has to be made sure that all these priorities have been addressed and resolved.
Persistent infection might lead to serious clinical complications in future (Hegarty et al. 2016).
Thus a transfer plan of Joseph would include further assessment of the subjective and the
objective symptoms of the patient. Joseph had developed a pressure injury at his left heel and the
discharge summary should also consist of a wound management plan. Referrals to allied health
specialists such as wound specialist or clinic, a dietician, a podiatrist and a physiotherapist
(Hegarty et al. 2016). It is necessary to talk to the patient and the carers about the type of
dressing regime that has to be followed. The patient’s family would also be educated about the
mandatory reporting in case of an delirium in the patient, as leaving the patient untreated can
have adverse effect in the patient . Proper intervention mapping can be considered as a powerful
tool for assessing and prioritising the intervention strategies and then tailoring them to the needs
of the patient (Hesselink et al. 2013). The transfer plan would also involve liaising the patient to
understand the insurance plans, including the financial assistance to the patient, as well as the
cost in home medical equipment and the fees of the medical experts and the home support
services (Lopez-Hartmann et al. 2015). There are many support care services in the `black town
area, NSW such as The “Anglicare” that provides home care services to help the patient with
shopping support, meal preparation and help the patient to lead an active life. Uniting Care

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health living for the seniors is another support service that provides services in personal care,
household assistance, meals and shopping and social support. The community also have
provision for “meals on wheels” that are services meant for family like joseph and his wife,
where good nutritious food can be provided on ordering. These services are especially meant for
the ones that has functional disability or restricted mobility.
Determination of the responsibilities of the caregivers is also necessary (Lopez-Hartmann
et al. 2012). In this case Emma should be educated as of how to take care of Joseph. Joseph’s
plan of care would also require counselor or psychiatrist, who can provide psychological support
to his family, especially Emma, who was finding hard to juggle between her works, taking care
of her father and at the same time look after her son, who suffers from ASD. Emma was
constantly suffering from guilt that she was unable to take care of her father, that he had reached
this state.
Legal and ethical principles
Ethical principles that are widely accepted are taken in to account in many international
declarations and recommendations. In case of elderly patients the ethical principles would go
further than pure clinical assessment and should include every consequences of starting or
withholding care and cure (Morris et al. 2017). The oldest ethical principle is beneficence and
non-maleficence, which are the ethical obligations of the physicians and the nurses (Lopez-
Hartmann et al. 2017). In this case Joseph should be involved in the decision making process. It
is evident from the case study that neither Joseph nor Sophia wants to visit a residential care unit
and wants to spend their last days of life in their own house. Although residential care would
have been suitable for both Joseph and Sophia, as Sophia has impaired functioning ability due to

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her health problem and Joseph who used to take care of Sophia was also not in the condition to
take care of Sophia or himself, but it is necessary to respect the wish of the elderly people and
help them lead a life with integrity and dignity.
Apart from autonomy, another ethical issues that elderly patients often face are the
breaching of the privacy and confidentiality of the patient information. It has to be mentioned
that patients are always on the vulnerable side as they have to depend for health care. Joseph’s
health care information should only be disseminated to the concerned family members and the
health care professionals taking care of Joseph, and definitely not with the home support.
Poor communication with the elderly patients can undermine the care provided to the
patients. Communicating with the elderly people like Joseph, who had always lived on his own
terms can be complex as they might often feel insecured and vulnerable while taking the care.
Their cultural background and the wide range of life experiences often influences their
perception about illness or their adherence to the medical regimen. Hence it is necessary to
communicate with them with respect, empathy and compassion.
Application of strength based nursing care
Strength based nursing is an approach where the eight core values guides the action of
nursing, promoting hope, self-efficacy and empowerment (Gottlieb 2014). The nurses focuses on
the inner strengths and the outer strengths, of the families. Across all the levels of care, from the
primary care of the healthy patients to the critical care of the elderly patients. The SBM affirms
the nursing goals for the promotion of health, facilitating healing and reducing the sufferings of
the patient by the creation of an environment that bolster the capacities for the health and the
innate mechanism of healing (Gottlieb 2014). The required nursing assessments involves

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physical, spiritual, cultural and mental health assessment. Family assessment involves family
values and the beliefs, discussion with Emma. Nursing assessment also involved steps like cue
collection, in case any health complication is discovered prior to the discharge and then
escalating the concerns to the health care teams (Hickman et al. 2016). Assessment should be
done to understand the strength and the weakness of the family that could be utilized in the care.
Culturally safe care
Culturally safe and respectful practice is not a totally new concept. Culturally safe care
helps the nurses to provide care to the nurses in a way that maintains the personal, social and the
cultural identity of the patient (Purnell 2014). Provision of a culturally safe care involves using
culturally safe words while communicating with the patient, respecting the perception and the
culture of the patient by respecting his spiritual or the religious beliefs. According to Nursing and
Midwifery Board of Australia (NMBA) (2013) nurses should be able to value or accept the
diversity of the people. Again, Joseph might prefer for a female home care support such that her
wife does not feel uncomfortable. Hence, gender matching is another step towards the provision
of a culturally safe care.
Conclusion
Older people are vulnerable to comorbidities, negligence of care and breaching of the
standards. A high rate of hospital readmission has been noticed after the discharge of the
planning which could have been avoided by a proper discharge planning. Discharge planning
involves involvement of a community services and multidisciplinary team. Furthermore a
strength based approach should be taken to empower the patient towards self-efficacy.

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References
Francischetto, E.O.C., Damery, S., Davies, S. and Combes, G., 2016. Discharge interventions
for older patients leaving hospital: protocol for a systematic meta-review. Systematic
reviews, 5(1), p.46.
Gonçalves‐Bradley, D.C., Lannin, N.A., Clemson, L.M., Cameron, I.D. and Shepperd, S., 2016.
Discharge planning from hospital. Cochrane Database of Systematic Reviews, (1).
Gottlieb, L.N., 2014. CE: Strengths-based nursing. AJN The American Journal of
Nursing, 114(8), pp.24-32.
Hegarty, C., Buckley, C., Forrest, R. and Marshall, B., 2016. Discharge Planning: Screening
Older Patients for Multidisciplinary Team Referral. International journal of integrated
care, 16(4).
Hickman, L.D., Phillips, J.L., Newton, P.J., Halcomb, E.J., Al Abed, N. and Davidson, P.M.,
2015. Multidisciplinary team interventions to optimise health outcomes for older people in acute
care settings: a systematic review. Archives of gerontology and geriatrics, 61(3), pp.322-329.
Holland, D.E. and Bowles, K.H., 2012. Standardized discharge planning assessments: impact on
patient outcomes. Journal of nursing care quality, 27(3), pp.200-208.
Hunter, T. and Birmingham, J., 2013. Preventing readmissions through comprehensive discharge
planning. Professional case management, 18(2), pp.56-63.

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Lopez-Hartmann, M., Wens, J., Verhoeven, V. and Remmen, R., 2012. The effect of caregiver
support interventions for informal caregivers of community-dwelling frail elderly: a systematic
review. International journal of integrated care, 12.
Morris, M.E., Adair, B., Miller, K., Ozanne, E., Hansen, R., Pearce, A.J., Santamaria, N., Viega,
L., Long, M. and Said, C.M., 2013. Smart-home technologies to assist older people to live well
at home. Journal of aging science, 1(1), pp.1-9.
Nursing and Midwifery Board of Australia (NMBA) 2013, Scope of practice for registered
nurses and midwives, NMBA, Melbourne, May 2013, Access date: 17 January 2018, Retrieved
from: http://www.nursingmidwiferyboard.gov.au/Search.aspx?q=code+of+ethics
Purnell, L.D., 2014. Guide to culturally competent health care. FA Davis.
Shepperd, S., Lannin, N.A., Clemson, L.M., McCluskey, A., Cameron, I.D. and Barras, S.L.,
2013. Discharge planning from hospital to home. Cochrane database of systematic reviews, (1).
Hesselink, G., Vernooij-Dassen, M., Pijnenborg, L., Barach, P., Gademan, P., Dudzik-Urbaniak,
E., Flink, M., Orrego, C., Toccafondi, G., Johnson, J.K. and Schoonhoven, L., 2013.
Organizational culture: an important context for addressing and improving hospital to
community patient discharge. Medical care, 51(1), pp.90-98.

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Appendix
Name Location Services Estimated cost
Anglicare Level 2, 62 Norwest
Blvd, Baulkham hills.
Home support,
social support,
meal preparation,
shopping
assistance,
residential care
$7560.00
Uniting Care health
living for the seniors
Blacktown, NSW Resedential care,
retirement village,
rehabilitation care
centre, GP support
$8270.90
Life without barriers Blacktown, NSW Help at home, mea
assistance,
transport, social
support and
activities, assistive
technologies,
allied health
support
subsidized

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