Case Report: Discharge Planning Using SBNC for Mr. De Jong and Family

This case report examines the complex case of Mr. De Jong, who required hospitalization and mechanical ventilation, and outlines a comprehensive discharge plan centered on strength-based nursing care (SBNC) and shared transfer of care principles. The report addresses Mr. De Jong's specific needs, including delirium management, skin care, and fall prevention, while also considering the needs of his family, particularly his wife with COPD and diabetes and his son with autism. The discharge plan emphasizes the importance of respecting Mr. De Jong's preference for home care and leverages community resources within the Western Sydney Local Health District (WSLHD) to provide 24-hour nursing support, home-based delirium care, and support for his wife's health needs. The plan aims to empower Mr. De Jong's daughter, Hanna, by providing her with information and access to services, ensuring an integrated approach to care through effective communication among healthcare providers and community staff. The report highlights the application of SBNC values such as self-determination, holism, and collaborative partnership to ensure optimal health and well-being for Mr. De Jong and his family, and provides references to support the strategies.

Running head: CASE REPORT
Case report
Name of the student:
Name of the University:
Author’s note

1CASE REPORT
Introduction and case overview:
The main purpose of this case report is to analyze the full case history of Mr. De Jong
Lars and his family and facilitate his discharged from hospital to home. Mr. De Jong was
hospitalized for a long period of almost 15 days during which he was in mechanical ventilation
and his clinical symptoms fluctuated significantly for four days. He was also agitated and
withdrawn at times leading to the diagnosis of delirium. On the eighth day of hospitalizations,
Lars was found to sustain a 6cm x 10cm skin tear as he slipped on the floor while going to the
toilet. Lars daughter, Hanna visited her father each day and she was going through a tough time
too because she had to take care of her mother Isa and her son, Charles too back at home. Lar’s
wife Isa was diagnosed with COPD, type 2 diabetes and she had difficulty in walking because of
weight gain. Lars used to take full care of his wife, however after his admission to the hospital,
Hanna had to take care of her mother too. Her nine year old son Charles was diagnosed with
autism and taking care for him was also a responsibility for her. Considering the current situation
of Lars at the time of discharge and the care responsibilities that Hanna had at home, the main
purpose of this report is to apply strength based approach to nursing care to make proper
discharge plan for Lars. The discharge plan will also apply the principles of shared transfer of
care and consider community services available in Western Sydney Local Health District
(WSLHD) to meet care needs of Lars and her family. The discharge plan will ensure that
additional services are provided to help Hanna easily care for the family without feeling any
burden.

2CASE REPORT
Application of strength based approach to care in the discharge plan:
The discharge plan for Lars and his family will be prepared based on strength based
nursing care (SBNC) and applications of the principle of shared transfer of care. SBN is an
approach to care that focuses on interpreting deficits and problems with a broader context to
uncover inner and outer strengths too. Nurses using this approach aim to identify inner and outer
strengths of patient and improve patient’s health through empowerment and self-efficacy. This
approach to care enables creating an environment that alleviates sufferings of patient and
increasing their capacities for healing (Gottlieb 2012). The eight inter-related values that is
integral part of SBNC include health and healing, uniqueness, holism, subjective reality, person
and environment, self-determination, learning, timing and readiness and collaborative
partnership (Gottlieb 2014). For this discharge plan, these values of SBNC will be applied so that
Lars and his family gets optimal environment for health and healing. To promote empowerment
of the family, community strengths will be utilized too by looking at services and options
available in Blacktown area of WSLHD and ensuring that family members are not deprived of
emotional care.
Based on the review of Lars condition currently, some of his important health needs
include full time care and support as he was seriously ill in the hospital and under mechanical
ventilation, support for Lars during the period of delirium and skin care due to injuries to the
elbows. Due his current health condition, he is also at risk of falls and he may require fall related
support and interventions too. As Lars has denied discussions related to residential care, his
decision need to be respected too according to the SBN value of self-determination, it is crucial
to ensure that patient’s choice are respected (More and Phillips 2019). Hence, as Lars has denied
all forms of residential care, a successful discharge plan would be one that identifies all services

3CASE REPORT
that could be given to Lars at home. This is also necessary based on the principles of shared
transfer of care which ensures that professional and integrated care for patient and their family is
a focus of the transfer or discharge plan. Shared transfer of care is based on several principles
such as keeping patients and family at the centre of care, providing evidence based quality
services to them, promoting equity in access to care, promoting strength based care and
enhancing interdisciplinary approach (Primary Health Tasmania 2018). Thus, shared transfer of
care will complement SBN model of care and support nurses in providing holistic and integrated
care for Lars and his family.
Lars is a patient with delirium and due to this condition, Lars may become agitated and
restless. Delirium is a condition characterized by impaired consciousness, poor attention,
changes in attention, altered cognition and acute onset of symptoms throughout the day. As such
onsets can be distressing for care givers and it will be difficult for Hanna to manage the symptom
of delirium at home as she had to take care of her mother and son too, it is planned to implement
home-based delirium care support for Lars. The WSLHD has various models in place that could
deliver services and support for patients with delirium. The model of care that would be
appropriate for Lars would be one where continuity of care is maintained and specialized
delirium related care could be provided to him at home (NSW Government 2019). Referral will
be made to specialist delirium care services at WSLHD so that staffs could provide regular
professional assessment and intervention, provide assistance with mobility, hearing aids and
activities to maintain alertness. Referral to community based pharmacist needs to be done too so
that they visit Lars and engage in medication reconciliation throughout the patient care journey
(Department of Health, State of Western Australia 2010). As the SBN care approach emphasizes
that relationship is the key to healthy functioning, Lar’s daughter Hanna should also be

4CASE REPORT
empowered to take care of her father by increasing the provision of information and education
related to dementia. This knowledge will enable Hanna to give transparent information about
changing cognitive state of Lars to the interprofessional team. Rosen, Gurr and Fanning (2010)
supports too that local community based centers are better services to develop partnership with
families and enhance recovery through collaborative social actions.
Lars is also at risk of fall and at need of skin care due to his ankle tear. As Lars wants to
remain in home and Hanna is already burdened by the need to take care of Isa and his son, it is
planned to provide 24 hour nursing staff by Lars side so that all his hygiene, food and toileting
needs could be addressed. The nurse will be involved in fall assessment and fall prevention too
by modifying the environment of the hospital. Two important factors that have increased fall risk
for Lars include ageing and frailty due to prolonged hospitalization (Cheng and Chang 2017).
The key advantage of professionals nursing care is that that can assess risk of fall through regular
assessment and they can actively apply fall prevention strategies to reduce the incidence of falls
and increase Lar’s quality of life. Many NGOs in Blacktown, WSLHS are also working to
improve fitness, strength, balance and health of older people in the community. The
interdisciplinary health care team can collaborate with these NGOs to increase nurse’s
knowledge about balance and strength exercises for elderly people like Lars (NSW 2014).
According to the SBN approach to care, it is necessary to address family care needs of
Lars too. This is particularly important considering the fact that Lars was the carer of his wife
prior to hospital admission. Hence, to enhance mental and emotional well-being, adequate care to
Isa should be available too so that family health needs are addressed and Hanna is under less
pressure due to care giving burden. Focusing on respecting needs and preferences of family into
care plan can facilitate better outcome for patient and it can enable building the family strength

5CASE REPORT
so that feelings of vulnerabilities in seriously ill patient as well as their family is reduced
(Alemayehu 2019). While providing care to Isa, her language and cultural values will be
considered. For example, she was found to struggle with English and so those health staffs
should be arranged for her who is acquainted with her language. This is relevant with the NMBA
nursing standard two of registered nurse which shows that therapeutic care and relationship
should be respectful of patient’s dignity, culture, values and beliefs (NMBA 2017). Due to
multiple ailments like COPD, Type 2 Diabetes and difficulty in walking, Isa needed support in
her personal care. As Lars is dependents on others for care too, it is planned to contact home care
team in Blacktown and ensure that all needs of Isa is maintained at home. The advantage of
home care services in Blacktown is that it provides range of personalized private care and this
will ensure that Hanna will not have to go through physical and emotional turmoil during
mobility assistance and hygiene related care (Home Caring 2019).
Another most crucial and important point of discharge planning is that as Lars and Isa are
going to received home based care from both allied health professionals and community based
staffs like NGO teams and home care staffs, there is a need to establish system for effective
communication between each providers. It is necessary for the nurse to ensure that all providers
and community based staffs are aware about the full medical history of Lars and his family and
the current health needs of the family. Such consideration will ensure an integrated approach to
service delivery (Agency for Clinical Innovation 2019).
Conclusion:
The case report gave an overview about the serious health condition of Lars at hospital
and his desire of receiving care at home instead of a residential care setting. By the application of

6CASE REPORT
SBN approach to care and transfer of care model, the case report gave an overview of discharge
planning for Lars. The plan also considered community strength by identifying relevant local
community services available in Blacktown too meet the health needs of the family and decrease
care giving burden of Hanna too. The case report incorporates strength based principles by
looking to empower Lars by fulfillment of his physical health needs as well as his emotional
needs by respecting their values and opinion related to care. By respecting Lars opinion of not
disclosing his diagnosis and providing all care at home, the ethics of respect and autonomy has
been maintained too.

7CASE REPORT
References:
Agency for Clinical Innovation 2019. Transfer of care. Retrieved from:
https://www.aci.health.nsw.gov.au/chops/chops-key-principles/effective-communication-to-
enhance-care/transfer-of-care
Alemayehu, Y.H., 2019. Enhancing Patient and Family-Centered Care: A Three-Step Strengths-
Based Model. International Journal of Caring Sciences, 12(1), pp.584-590.
Cheng, M.H. and Chang, S.F., 2017. Frailty as a Risk Factor for Falls Among Community
Dwelling People: Evidence From a Meta‐Analysis. Journal of nursing scholarship, 49(5),
pp.529-536.
Department of Health, State of Western Australia 2010). Delirium Model of Care. Retrieved
from: https://ww2.health.wa.gov.au/~/media/Files/Corporate/general%20documents/Health
%20Networks/Neurosciences%20and%20the%20Senses/Delirium-Model-of-Care.pdf
Gottlieb, L.N., 2012. Strengths-based nursing care: Health and healing for person and family.
Springer Publishing Company.
Gottlieb, L.N., 2014. CE: strengths-based nursing. AJN The American Journal of
Nursing, 114(8), pp.24-32.
Home Caring 2019. Home Care Services Blacktown. Retrieved from:
https://www.homecaring.com.au/blacktown/
More, K.R. and Phillips, L.A., 2019. The influence of body dissatisfaction on cardiovascular and
strength-based physical activity by gender: a self-determination theory approach. Psychology &
health, pp.1-14.

8CASE REPORT
NSW 2014. Newsletter of the NSW Falls Prevention Network Retrieved from:
http://fallsnetwork.neura.edu.au/wp-content/uploads/2011/03/April-Falls-Links-2014-final-
pdf21.pdf
NSW Government 2019. Dementia and delirium assessment / management. Retrieved from:
https://www.aci.health.nsw.gov.au/networks/aged-health/about/building-partnerships/dementia-
and-delirium-assessment-management
Nursing and Midwifery Board of Australia (NMBA) 2017. Registered nurse standards for
practice. Retrieved from: https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-
Statements/Professional-standards/registered-nurse-standards-for-practice.aspx
Primary Health Tasmania 2018. Guidelines for Shared Transfer of Care. Retrieved from:
https://www.primaryhealthtas.com.au/wp-content/uploads/2018/06/Sharing-Points-Guidelines-
for-Shared-Transfer-of-Care.pdf
Rosen, A., Gurr, R., & Fanning, P. (2010). The future of community-centred health services in
Australia: lessons from the mental health sectorA. Australian Health Review, 34(1), 106-115.