CNA345: Nursing Care Plan for Joseph Russo's Discharge

This nursing care essay presents a detailed care plan for Joseph Russo, an elderly patient facing discharge from the hospital. The essay emphasizes the importance of patient-centered care, considering Joseph's medical conditions, mobility limitations, and the needs of his wife. It outlines goals and courses of action for a smooth transition from hospital to home, including multidisciplinary team involvement (discharge nurse, physician, physiotherapist, occupational therapist, podiatrist, and social worker) to address his foot ulcer, potential infections, and social support needs. The plan incorporates strength-based care by focusing on Joseph's optimism and independence, and culturally safe care by addressing his potential language barriers and respecting his cultural background. The essay also discusses legal and ethical factors, including patient autonomy and confidentiality, and provides referral services to assist Joseph and his family with aged care support. The author concludes by highlighting the knowledge gained from the assignment to plan and implement safe, effective care for elderly patients.

Running head: NURSING CARE ESSAY
Nursing care essay
Name of the student:
Name of the university:
Author note:

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Introduction:
The impact of illness or disease can not only affect the lifestyle of the patient but it
also has the potential to cause long lasting or permanent impact on the social and persona life
of the patient as well. Although, there are various tools and practice frameworks that can be
employed in the care scenario which can help the issues of the patients can be addressed and
the patients can develop better coping strategies (Backman et al. 2018). This essay will
provide a patient centred and specific care plan, strength based and culturally sensitive
approach with referral services and transferring or discharge planning in mind.
Transfer of care from hospital to home:
A crucial aspect of transition from hospital to home care is the change in the nature of
the care activities so that the care planned and being implemented can match with the home
environment as well. It has to be mentioned in this context that the care quality and
effectiveness is extremely high for the hospice stay, due to the infrastructure, continuous
monitoring and the uninterrupted attention and assistance by skilled staff (Lea et al. 2016).
Although, in the home environment, the lack of infrastructure and continuous monitoring is a
grave concern undoubtedly, however, the lack of skilled clinical assistance is extremely
important. In this case, care is required to ensure a thorough assessment and specific planning
for after discharge so that the individualized care needs can be adequately met. In this case,
Joseph Russo had many considerations including his foot ulcer, mobility restriction and his
sick wife.
Goals and course of actions for the transfer of care:
Discharge planning plays a fundamental role in the aged care perspective, not only it
is based on thorough and comprehensive assessment of the present health adversities that the
patient may be suffering from, the distance planning also lays out the possible physical,

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social, and psychological needs that the patient might have after being discharged and
strategies to address those needs correctly (Ellis et al. 2018).
Discharge Planning is a multidisciplinary approach which involves setting for our
goals and designing intervention strategies which can help the patient achieve the goals that
has been set. The discharge planning involvesinput from a variety of different healthcare
professionals, including a discharge nurse, the physician in charge, a case manager, a
dietician, a nutritionist, and an occupational therapist. this multidisciplinary team is also
known as the aged care assessment team which in turn will assess the variety of needs that
the patient, Joseph Russo in this case is representing. According to Brown (2018), the
discharge team can be easily customized or personalized as per the specific needs of the
patient. In this case, the personalized multidisciplinary discharge planning team will have a
discharge nurse, a physician, a physiotherapist, an occupational therapist, a podiatrist, and a
social worker. The entire responsibility of conducting the assessments and addressing the
care needs that the patient might have. The social worker will be in charge of helping Joseph
handle his financial strain, provide living support to both him and his ailing wife. The
podiatrist will help assessing and healing the ulcer and the physiotherapist or occupational
therapist will help him enhance mobility. The physician will supervise the medical issues and
nscessary medications that he will need to take (Hegarty et al. 2016).
Joseph would require a extensive and thorough health assessment prior to the
discharge, and most of which will need to be followed up effectively even after the discharge.
First and foremost, he had exhibited signs of central line associated bloodstream infection,
which is very difficult to be completely eradicated completely. Hence, the CLABSI infection
will need to be assessed completely and effectively. Similarly, he also had a fully developed
fluid filled blister on his left leg which is red swollen and considerably big in size. As a
result, the assessment and care planning will also need to focus extensively on his ulcer. He

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would require both topical and oralintravenousantibiotics toavoid the risk of CLABSI and the
foot ulcers. Similarly, few additional strategies such as hydrocolloid dressing and elevated
foot rest will help him heal and recover faster. During his discharge planning, both nurse and
podiatrist must educate him and and his children on the care activities to help him adhere to
the regime properly (Hole et al. 2015).
Lastly, as both of his daughters have a hectic professional and personal life, both
Joseph and his sick wife would require social support and referral care. In the locL area of
Sydney, there are a variety of different aged care homes from where Joseph and his wife cab
get assistance from. Anglicare is a not for profit organisation that provide residential support
and assisted care to the aged people in the locality which can provide easy and cost effective
services for the family (Anglicare.org.au 2019). Similarly, Pendle Hill aged care is another
aged care home located in the New South Wales where Joseph and his family can
availexcellent support and assistant living aid in low costs (Allity.com.au 2019). The third
referral service which can aid Joseph is Opal Aged Care, which is located in the city of
Sydney itself which is the closest to both of his children so that his family can visit him at
any time (Opal Aged Care 2019).
Legal and ethical factors:
Alike any other sector, the aged care sector is also sought with a variety of legal and
ethical factors and dilemmas. In this case as well, for Joseph,the nurse must ensure the legal
and ethical rights of the patient. According to the code of ethical conduct, the nurses must
adhere to the decision making rightsof the patient and prioritize their choices over any thing
else (Nursingmidwiferyboard.gov.au 2019). Similarly, ethical principles such as justice,
autonomy, confidentiality and nonmaleficence is needed to be addressed at all costs. The
autonomy allows the patients to make their own choices, which in ages care can be affected.

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Similarly, for aged care sector confidentiality breach, neglect and abuse is common. Whereas,
the non maleficence ensures nurses nog engaging in any activity that harms the patient and
confidentiality protects the personal information (Burkhardt and Nathaniel 2013).
Strength based care:
Strength based care is a novel aproach in the care prospect and it is gaining rapid
popularity in the care environment. It can be defined as the care approach which relies or
depends on the values, principles and beliefs of the patient and draws from the strengths of
them and their families. Here Joseph had been living his life somehow managing his
expenses and caring for his wife full time, and even then he had been caring, optimistic and
self dependent. Taking a strength based approach for him will ensure that the patient is
empowered and the specific strength and capacities are being utilized in the most optimal
manner. It has to be mentioned that nurses are required to prioritize the skills,capacity,values,
experiemce and knknowledof the patient when planing and implementing care. Hence, in this
case, the lived experience of the patient, his skills and knowlefge and most importantly his
optimism is needed to be involved in the care planning to help him recover faster. Along with
that his independence has a strong relation with his identity, hence, empowerment and
independence is also required to be implemented in the strength based care (Shepperd et al.
2013).
Culturally safe care:
Culturally safe care is a very important and integral aspect of the care planning and
implementation in the present day care scenario. Cultural aspects or consideration and most
importantly, the lack of cultural safety plays a fundamental role in affecting the help seeking
behaviour among the patients with respect to healthcare (Brown 2018). In this case as well,
the last and one of the most important aspect to be considered in the care planning is
culturally safe care. From the case study of Joseph Russo, his cultural background is not

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clearly mentioned. Although the case study starts with the fact of his migration to Australia
years ago, which indicates at the probability of him being an ethnic immigrant. The case
study also described him making friends in Italian community which also hints at him having
a possible italian background and he also had very limited English language proficiency.
Hence, language barrier is a overwhelming challenge for him as well. In this case, he would
require the assistance of a cultural liaison officer and a language interpreter. Moreover, the
care planning will need to ensure his cultural identity, traditional customs and beliefs are
respected at all circumstances to ensure optimal cultural safety (Verhaegh et al. 2014).
Conclusion:
On a concluding note, this is an excellent opportunity that this assignment provided to
assessthe challenges and care issues expressed by a geriatric patient and how to address them
with effective strength based and culturally safe care with proper referral. The knowledge and
expertise gained from the exercise will help me plan and implement safe, effective and
optimal plan of care for the aged patients with complexcare needs.

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References:
Allity.com.au. 2019. Pendle Hill Aged Care NSW | Allity. [online] Available at:
https://www.allity.com.au/locations/pendle-hill-aged-care [Accessed 16 Jan. 2019].
Anglicare.org.au. 2019. Aged Care & Community Services | Not For Profit | Anglicare
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Backman, A., Ahnlund, P., Sjögren, K., Lövheim, H., McGilton, K.S. and Edvardsson, D.,
2018. Leading towards person-centred care–Nursing home managers' experiences of leading
person-centred care in highly person-centred Swedish nursing homes.
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Burkhardt, M.A. and Nathaniel, A., 2013. Ethics and issues in contemporary nursing. Nelson
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Smith, M.L., 2015. Visibility and voice: Aboriginal people experience culturally safe and
unsafe health care. Qualitative health research, 25(12), pp.1662-1674

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Lea, E., Mason, R., Eccleston, C. and Robinson, A., 2016. Aspects of nursing student
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Opal Aged Care. 2019. Opal Aged Care | Aged Care Facilities | Nursing Homes. [online]
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Shepperd, S., Lannin, N.A., Clemson, L.M., McCluskey, A., Cameron, I.D. and Barras, S.L.,
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