Running head: DISCHARGE PLANNING PROJECT
Discharge Planning Project
Johan Diaz
University of South Florida
College of Nursing
NUR4216L
November 19, 2013
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DISCHARGE PLANNING PROJECT
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Discharge Planning Project
The 59-year-old Hispanic female with a history of hypertension, hypothyroidism and
chronic renal insufficiency presented to the Emergency Department (ED) with epigastric pain on
09/30/13. The patient stated that the onset of the epigastric pain was “around 4 p.m.” on the day
of the admission. The patients characterized the pain as constant and sharp. The patient denied
radiating pain, nausea/vomiting, and diarrhea. An EKG revealed sinus bradycardia (54 bpm)
with no evidence of acute ischemic changes. Abdominal ultrasound revealed cholelithiasis. BUN
was 64, and creatinine was 4.28, indicating renal failure. Patient was kept NPO until
laparoscopic cholecystectomy was completed. The patient is now on a renal diet.
Discharge diagnosis
The patient understands that she was hospitalized because of the pain related to cholelithiasis
(gallstones). The patient also understands that during the laparoscopic cholecystectomy her
gallbladder was surgically removed.
Associated Core Measures
The associated core measures for this patient were all met and are provided by the Joint
Commission in the table below.
(The Joint Commission, 2012)
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Medications
There is a reconciled list of the patient’s medications. There are no new prescriptions or
refills needed for this patient. The discharge plan includes information on when the last dose of
medication was given and when the next dose is due. The only medications that this patient will
continue at home until follow-up will be her clonidine (0.2mg, TD patch, 1xweek) and her
synthroid (30 mcg, PO, 1xdaily). The patient verbalized understanding of all of her medications,
including the indications and side effects. Sweating, headache, abdominal cramps, insomnia, and
irritability are the common side effects for synthroid. Drowsiness, dry mouth, dizziness,
nausea/vomiting are the common side effects for clonidine. The patient understands that she
must remove the patch before placing a new one and alternate placement locations. The patient
understands that she must take her synthroid 30 minutes before breakfast.
Home assessment
The patient lives in a one story home with her husband of 32 years. The patients living
situation has been assessed and determined to be safe. The patient’s husband and children are
reliable mechanisms for self-care upon discharge including the following: transportation to get
medications, food, follow-up appointments, etc. The patient verbalized understanding of not
driving until she is no longer taking her pain medication. The patient has insurance and has no
financial concerns regarding medications or access to follow-up appointments at this time.
Follow up
There is no need for home health services or durable medical equipment at the home. A
follow up appointment will need to be scheduled with the primary care provider and the surgeon
within a month of discharge. The patient will also need to follow up with her nephrologist to
determine the plan of care for her chronic renal insufficiency. Physical therapy should be
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included in the discharge planning process. This will allow the patient to prevent complications
from surgery by increasing mobility.
Summary
Patient education is an essential part of preventing readmission for this patient. Not only
education about her admitting diagnosis but also about her pre-existing co-morbidities. The
nutritional consult was completed for the patient before discharge. The new diet will be part of
the treatment plan. The patient will be taught how to care for her incision site. The patient will be
educated on the importance of maintaining the follow-up appointments. The patient will be
educated on the signs/symptoms of infection (especially at the incision site) and when it is
appropriate to call the provider.
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References
The Joint Commission. (2012). Surgical Care Improvement Project. Retrieved from
http://www.jointcommission.org/core_measure_sets.aspx