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Discharge Planning

Discharge Planning Paper


Samuel Turner, BSPH
University of South Florida

Discharge Planning

Brief Patient Description and Hospitalization Course


Patient is a 38 year old, African-American male who suffered penetrating
head injury when struck in head with helicopter rotor on 3/23/12 while on active
duty, resulting in severe open head injury with extensive right hemispheric damage
and disruption of the superior sagittal sinus. On 3/24/12 patient underwent R
parietal decompressive craniectomy with debridement of crushed and prolapsed
brain, reconstruction of superior sagittal sinus, dural extension plastic with lyodural
graft, closure of open brain injury, debridement/wash out R hand lac with
cauterization of transected palmar digital artery of R thumb, L parietal ICP monitor,
and ventriculostomy placed. On 3/29/12 patient underwent posterior craniectomy
and C1 laminectomy. On 4/1/12 patient underwent perc trach. On 4/12/2012
patient underwent decompression, evacuation of hematoma and I&D wound.
Patient has had numerous complications and procedures since and is now in
polytrauma with a poor prognosis.
The patient has quadriplegia/quadriparesis and cannot do any of his ADLs.
He is has no movement in most of his extremities with the exception of his right
arm. His communication ability is severely limited. His responses are mostly yes
or no coupled with maam or sir. He relies on his mother to communicate in his
place. He is currently undergoing physical and occupational therapy three times a
week to help him possibly gain more strength and/or movement in his right arm and
hand. He is set to go home with his mother and cousin who will take care of him.

Discharge Planning

Discharge Diagnosis
The patient understands why he was hospitalized. He can only answers yes sir if
asked. However his mother fully understands and can verbilize his history, what has been done
since and why, as well as what the prognosis for the future looks like. I did not have to provide
any education to the mother on the prognosis or anything specific to the process of his diagnosis
as she has been dealing with it and receiving education and training on it since it occurred back
in 2012. If I had to include teaching to a family member of this particular patient, I would
include teaching about the pathophysiology of the condition such as it will not get better and also
teaching about the care of the patient such as turning every 2 hours to prevent skin breakdown,
proper lifting/turning/positioning procedures to prevent injury, how to suction, give breathing
treatments, tube feeding, crushing and administering medications, administration of oxygen, oral
care, peritoneal care, and the need for interaction for the patient (i.e., treat the patient as a person,
even if not verbal, he knows what is going on and can benefit mentally from human interaction).
No current core measures have been identified.

Medications
There are a lot of medications for this patient. I would go over each one and make sure
the caregivers (mother and cousin) know what they are, why he takes them, how they are given,
what they do, and what side effects and reactions that needs to be watched for. Here is a list of
the most pertinent things I would cover:
Name Albuterol

Concentration (mg/ml) 1.25mg/3ml vial

Route inhalation

Frequency Q4H

Pharmaceutical class Bronchodilator

Both

Indication Relaxes smooth muscle airways to dilate to allow for better air passage

Dosage Amount (mg) 1.25mg

Discharge Planning

Side effects/Nursing considerations Watch for paradoxical bronchospasms, nervousness, restlessness, tremor, headache, chest pain, palpitations
Name Baclofen Tab

Concentration 10mg/Tab

Route G Tube

Dosage Amount 5mg

Frequency TID

Pharmaceutical class Antispasticity agent

Both

Indication To reduce spasticity due to spinal cord injury


Side effects/Nursing considerations Seizures, dizziness, drowsiness, fatigue, weakness, confusion, nausea ****half tab****
Name Bisacodyl Supp, RTL

Concentration 10mg/suppository

Route RTL

Dosage Amount 10mg

Frequency Q2D

Pharmaceutical class Stimulant Laxative

Both

Indication To treat constipation


Side effects/Nursing considerations abdominal cramps, nausea, diarrhea, rectal burning, muscle weakness, hypokalemia
Name Budesonide/formoterol

Concentration 32mcg/spray

Route inhalation

Dosage Amount 64mcg

Frequency BID

Pharmaceutical class corticosteroid

Both

Indication Reduces inflammation of airways, therapy for asthma


Side effects/Nursing considerations Rinse mouth after use, anaphylaxis, bronchospasm, cough, abdominal pain, D/N/V, back pain
Name Guaifenesin Liquid

Concentration 200mg/10ml

Route G Tube

Dosage Amount 200mg

Frequency BID

Pharmaceutical class Expectorant

Both

Indication Thin & release mucus secretions


Side effects/Nursing considerations Dizziness, headache, N/V/D, rash
Name Ipratropium Soln

Concentration 500mcg/vial

Route Inhalation
Pharmaceutical class anticholinergic

Dosage Amount 500mcg

Frequency BID
Both

Indication Dilate airways


Side effects/Nursing considerations Avoid if allergic to soy & peanuts, bronchospasm, cough, dizziness, headache, sore throat, blurred vision, palpitations
Name Levetiracetam

Concentration 1000mg/10ml

Route G Tube
Pharmaceutical class pyrrolidines

Dosage Amount 1000mg

Frequency Q12H
Both

Indication reduce seizure activity


Side effects/Nursing considerations Toxic epidermal necrolysis, suicidal thoughts, aggression, agitation, anger, anxiety, irritablility
Name Modafinil Tab

Concentration 100mg/Tab

Route G Tube
Pharmaceutical class CNS Stimulant

Dosage Amount 100mg

Frequency BID @ 7am & 1pm


Both

Indication Increase wakefulness, stimulate CNS


Side effects/Nursing considerations Suicidal Ideation, headache, aggression, nausea, arrhythmias, rhinitis, seizures, insomnia, anxiety
Name Ondansetron Tab

Concentration 4mg/Tab

Route G-Tube
Pharmaceutical class five ht3 antagonists

Frequency Q6H PRN


Both

Dosage Amount 4mg

Discharge Planning

Indication Prevention of nausea & vomiting


Side effects/Nursing considerations headache, dizziness, torsade de pointes, qt interval prolongation, constipation, diarrhea, extrapyramidal reactions

Home Assessment
The patient will be going home with the mother and a cousin who will be the primary
caretakers. The home is a safe living environment for the patient. The patients mother has been
working with the social worker and various programs to make sure all items are taken care of for
a smooth transition of the patient to home care. The patients mother has had the home set up for
wheelchair access and is also in the process of getting a wheelchair accessable van. She has also
got a hospital bed with no pressure system, a lift system to get him in and out of the wheelchair,
a cough assist machine, a suction machine, and a ventilator. She also has got supplies for tube
feeding, skin care, peritoneal care, oral care, and medication administration. She has also talked
with the social worker about setting up skilled nursing care for a day off a couple times a week
so she does not get burned out. She does know that there is help available if it is ever needed.
There are no financial concerns as the patient was injured during active duty so the VA is taking
care of all costs involved as well as the patient continues to get his active duty pay.
Follow Up
The need for home health services has already been taken care of between the patients
mother and social worker. The social worker has also worked with the patients mother to set her
home up with all durable medical equipment needed as discussed under the home assessments
area of this paper above. The patient will have many follow up appointments, though most will
be in-home consultations such as speech therapy, occupational and physical therapy.

Discharge Planning

There are numerous other people that are included in making the discharge planning for
this particular patient. I must include his social worker, primary physician, his team of
specialists (neurologist, cardiologist, and gastroenterologist), dietician, speech therapist,
occupational and physical therapists in on the discharge planning as they will need to set up their
portion of either home visits or scheduling follow-up appointments.
Summary
It is important that each specialty area is addressed in discharge planning and teaching
and is put in writing so the patients primary care takers know exactly what needs done and what
future appointments are needed. The primary care takers need to be well trained in the daily
needs and handling of the patient and diligent in giving his medications correctly and promptly.
The primary caretakers should be monitoring the patient at all times and call the primary
physician and/or 911 depending on severity with any signs of distress. All appointments need to
be kept to ensure the patient is progressing without infection, pain, spasticity, skin breakdown or
other complications. Overall our goal is to allow the patient to live out his life without or with
minimal pain and suffering and to keep from having to readmit the patient to the hospital where
it could be avoided.

Discharge Planning

References

Core Measure Sets. Retrieved November 29, 2014, from


http://www.jointcommission.org/core_measure_sets.aspx