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EXTENDED CARE
Patients in the acute care setting may be discharged to an extended care facility. Patients requiring relatively short-termrehabilitation and those needing long-term care/permanent nursing care are included in this group. The level of care and needs of the patient (e.g., physical, occupational, rehabilitation therapy; IV and respiratory support) are frequently the deciding factors inthe choice of placement. Although elderly people are the primary population in extended care facilities, increasing numbers of younger individuals are requiring care for debilitating conditions when they cannot be managed in the home setting.
RELATED CONCERNS
Acquired immunodeficiency syndrome (AIDS)Cancer Cerebrovascular accident/StrokeCraniocerebral traumaMultiple sclerosisPsychosocial aspects of careSpinal cord injurySurgical interventionVentilatory assistance (mechanical)
Patient Assessment Database
Data depend on underlying physical/psychosocial conditions necessitating continuation of structured care.
TEACHING/LEARNING
Discharge plan
 
Projected mean length of stay: Depends on underlying disease/condition and
considerations:
individual care needs. Therefore, this may be temporary orpermanent placement.
May require assistance with treatments, self-care activities, homemaker/maintenance tasks, or alternate living arrangements (e.g., group home)
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES (dependent on age, general health,and medical condition)
CBC:
Reveals problems such as infection, anemia, other abnormalities.
Chemistry profile:
Evaluates general organ function/imbalances. Age-related changes include decreased serum albumin, up to20% increase in alkaline phosphatase, decreased urine creatinine clearance.
Urinalysis:
Provides information about kidney function; determines presence of urinary tract infection (UTI) or DM.
 Note:
Bacteria is common in some populations, especially the elderly and bed-ridden, reflecting urinary stasis.
 Pulse oximetry:
Determines oxygenation, respiratory function.
Communicable disease screens:
To rule out tuberculosis (TB), HIV, venereal disease, hepatitis.
 Drug screen:
As indicated by usage to identify therapeutic or toxic levels.
Visual acuity testing:
Identifies cataracts/other vision problems.
Tonometer test:
Measures intraocular pressure.
Chest x-ray:
Reveals size of heart, lung abnormalities/disease conditions, changes of the large blood vessels and bony structureof the chest.
 ECG:
Provides baseline data; detects abnormalities, e.g., ST segment and T wave changes, atrial and ventricular dysrhythmias,and various heart blocks are common in the elderly.
NURSING PRIORITIES
1. Promote physiological and psychological well-being.2. Provide for security and safety.3. Prevent complications of disease and/or aging process.4. Promote effective coping skills and independence.5. Encourage continuation of healthy habits, participation in plan of care to meet individual needs and wishes.
DISCHARGE GOALS
1. Patient dealing realistically with current situation.
 
2. Homeostasis maintained.3. Injury prevented.4. Complications/prevented/minimized.5. Patient meeting ADLs by self/with assistance as necessary.6. Plan in place to meet needs after discharge as appropriate.
NURSING DIAGNOSIS: Anxiety [specify level]/Fear May be related to
Change in health status, role functioning, interaction patterns, socioeconomic status, environmentUnmet needs; recent life changes, loss of friends/SO
Possibly evidenced by
Apprehension, restlessness, repetitive questioning; pacing, purposeless activity; insomniaVarious behaviors (appears overexcited, withdrawn, worried, fearful); presence of facial tension, trembling, handtremorsExpressed concern regarding changes in life eventsFocus on self; lack of interest in activity
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:Anxiety or Fear Control (NOC)
Verbalize understanding of reasons for change, as able.Demonstrate appropriate range of feelings and lessened fear.Participate in routine and special/social events as capable.Verbalize acceptance of situation.
ACTIONS/INTERVENTIONS
Anxiety Reduction (NIC)
Independent
 
Provide patient/SO with a copy of “A Patient’s Bill of Rights” and review it with them. Discuss facility’s rules,e.g., visitors, off-grounds visits, personal property.Ascertain if patient has completed Advance Directives.Provide information as appropriate.Determine patient/SO attitude toward admission tofacility and expectations for the future.Help family/SO to be honest with patient regardingadmission. Be clear about actions/events.
RATIONALE
Provides information that can foster confidence thatindividual rights do continue in this setting and the patientis still “his or her own person” and has some control over what happens.Assures patient/family wishes will be known to providedirection to caregivers.If this is expected to be a temporary placement, patient/SO concerns will be different than if placement is permanent. When patient is giving up own home and wayof life, feelings of helplessness, loss, and grief are to beexpected.Family may have difficulty dealing with decision/reality of permanent placement and may avoid discussingsituation with patient. Honesty decreases “surprises,”assists in maintaining trust, and may enhance coping.
 
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ACTIONS/INTERVENTIONS
Anxiety Reduction (NIC)
Independent
 
Identify support person(s) important to patient andinclude in care activities, mealtime, and so on, asappropriate.Assess level of anxiety and discuss reasons when possible.Develop nurse-patient relationship.Make time to listen to patient about concerns, andencourage free expression of feelings, e.g., anger,hostility, fear, and loneliness.Acknowledge reality of situation and feelings of patient.Accept expressions of anger while limiting aggressive,acting-out behavior.Identify strengths and successful coping behaviors andincorporate into problem solving.Orient to physical aspects of facility, schedules, andactivities. Introduce to roommate(s) and staff. Giveexplanation of roles.Determine patient’s usual schedule and incorporate intofacility routine as much as possible.Provide above information in written or taped form aswell.Give careful thought to room placement. Provide help andencouragement in placing patient’s own belongingsaround room. Do not transfer from one room to another without patient approval/documentable need.
RATIONALE
During adjustment period/times of stress, patient may benefit from presence of trusted individual who can provide reassurance and reduce sense of isolation.Identifying specific problems enables individual to dealmore realistically with them and care provider tointervene as necessary, e.g., patient who is beingneglected or abused or has unrelieved pain may be veryanxious and afraid or unable to verbalize.Trusting relationships among patient/SO/staff promotesoptimal care and support.Being available in this way allows patient to feelaccepted, begin to acknowledge and deal with feelingsrelated to circumstances of admission.Permission to express feelings allows for beginningresolution. Acceptance promotes sense of self-worth.
 Note:
Psychosocial and/or physiological disturbances canoccur as a result of transfer from one environment toanother (i.e., relocation stress syndrome).Building on past successes increases likelihood of  positive outcome in present situation. Enhances sense of control and management of current deficits.Getting acquainted is an important part of admission.Knowledge of where things are and who patient canexpect assistance from can be helpful in reducing anxiety.Consistency provides reassurance and may lessenconfusion and enhance cooperation.Overload of information is difficult to remember. Patientcan refer to written or taped material as needed to refreshmemory/learn new information.Location, roommate compatibility, and place for personal belongings are important considerations for helping the patient feel “at home.” Changes are often met withresistance and can result in emotional upset and decline in physical condition.
 Note:
Persons with severe behavioral problems/cognitive dysfunctions may require a privateroom.
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