Discharge Planning for Elderly Patients: A Nursing Assignment

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

1NURSING ASSIGNMENT
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.

2NURSING ASSIGNMENT
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.

3NURSING ASSIGNMENT
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