Discharge Planning Project

Pamela Chong
November 23, 2014
University of South Florida

On October 27, 2014, a 66 year old male patient was admitted to the emergency room
with a complaint of increasing abdominal distention, pain, and redness around the site where
paracentesis was performed earlier in the month. The patient has a past medical history of ascites
secondary to non-alcoholic steatohepatitis (NASH). The patient states that he undergoes
paracentesis approximately once a month. Prior to this admission, the patient noticed some
redness, swelling, and mild pain in the upper quadrant of his abdomen, where paracentesis was
performed, and thought it may be infected. Upon admission, the patient was afebrile with normal
white blood cells.
The patient was offered paracentesis on the night of admission, but declined, stating he
would prefer to undergo the procedure in the morning. With a new diagnosis of cellulitis of the
abdomen, the patient was admitted to the floor, where he would await blood cultures and be
monitored for further signs of infection. The patient was started on oral antibiotics and was
having his dressing changed by the nurse as needed, at least once a shift. The patient was also
being monitored on telemetry due to his history of Atrial Fibrillation. This continued until
November 4, 2014, when he was discharged home.
The patients discharge diagnosis was cellulitis, a bacterial infection of the dermis and
subcutaneous tissue, typically caused by Staphylococcus aureus. The patient understands that the
infection was likely caused by bacteria entering the body through the site of paracentesis which
may occur if the site is not kept clean. A sterile dressing may be indicated to keep the wound free
from bacteria until it has healed. It is important to teach the patient sterile technique if the patient
changes his own dressing. It is also important to teach proper and frequent hand washing to
prevent the spread of infection. Since the patient undergoes this procedure often, it is extremely

important to teach the patient the importance of keeping his wound clean to prevent future
infections.
The patient was discharged with an updated medication list, with the only new
medication being Doxycycline, an oral antibiotic. The patient was made aware of possible side
effects of this medication, including, but not limited to headache, psuedomembranous colitis,
diarrhea, nausea, vomiting, hepatotoxicity, and superinfections. The patient was instructed to
take the medication as directed, around the clock, every twelve hours. The patient was taught the
importance of finishing the entire dose of antibiotics, even if he started to feel better. On the day
of discharge, the patient received a 100 mg. dose of Doxycycline at 10:00 a.m. and was
instructed to take it again at 10:00 p.m. the same evening. In addition to the new medication, the
entire list of home medication was reviewed with the patient to ensure he had no questions
regarding his medication.
In addition to the new medication, the patient takes 10mg of Oxycodone for pain. Side
effects of this medication include constipation, respiratory depression, confusion, sedation,
dizziness, and physical dependence. The patient also takes 0.125 mg of Digoxin once daily for
Atrial Fibrillation. Side effects include fatigue, headache, weakness, blurred vision, yellow or
green vision, arrhythmias, bradycardia, electrolyte imbalances with acute digoxin toxicity. The
patient was informed of the signs of Digoxin toxicity, including seeing green halos, and to notify
his provider immediately if this happens. The patient takes 6mg of Warfarin everyday for the
prevention of blood clots associated with Atrial Fibrillation. He understood at discharge to notify
his provider if any abnormal signs of bleeding occur. The patient is on several medications for
his diabetes including 100mg of Metformin twice daily, 5 units of Insulin Aspart, a rapid acting
insulin he takes with meals, and 90 units of Insulin Glargine, a long-acting insulin taken twice a

day. The patient stated that he understood the importance of monitoring his blood glucose and
was able to identify signs and symptoms of hypoglycemia. The patient takes 100 mg of
Spironolactone, a potassium sparing diuretic for cirrhosis of the liver. He was advised to avoid
salt substitutes and foods that contain high levels of potassium. Lastly, the patient takes 20mg of
Simvastatin four times a day for his hyperlipidemia. An adverse effect of this medication is
rhabdomyolysis and was informed to notify his provider if any unexplained muscle pain
occurred, especially if accompanied by fever or malaise.
The patient lives in a house with his wife and states that it is safe and accommodating to
his needs. He has been living with an above the knee amputation for 10 years and does not have
any trouble getting around or performing self care. The patient states his wife does most of the
grocery shopping and cooking. He ensured he has adequate transportation to get to follow up
appointments and pick up prescriptions, usually via his wife. The patient states that he is very
independent, yet his wife is there to help if need be. The patient has Medicare that pays for most
of his prescription costs and states that he does not have financial issues regarding his healthcare.
The patient is being discharged home with home healthcare to assist with his dressing
changes every two days or as needed. He has a follow up appointment two weeks from the date
of discharge that has already been scheduled. No follow up appointments with specialists are
required for this admission. The next paracentesis procedure has not yet been scheduled. It may
be helpful to have social work and dietary involved in discharge plan to ensure a smooth
transition and meet any dietary needs he may have.
The most important considerations to prevent readmission to the hospital are to ensure
the patient knows how to properly care for his wound following paracentesis. He must be able to
identify proper and frequent hand washing skills, especially if coming in contact with the site of

paracentesis. If there is a dressing on the wound following the procedure, he must keep it dry and
intact as the doctor orders, and changed when necessary. Additionally, the patient must
understand the importance of completing his full prescription of antibiotics so that bacterial
resistance does not occur. These are extremely important patient teaching, especially since the
patient undergoes this procedure often.