Running head: DISCHARGE PLAN 1

Discharge Plan

Madison Pleasants

Cedar Crest College

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Abstract

Discharge is a transitional time for patients. During this time, it is the responsibility of the

healthcare team to prepare the patient for life outside of the acute-care setting. A beneficial

discharge begins on admission and includes past medical history, current health status, social

history, and available resources. Furthermore, preparation needs to depict in detail current

medications, environment of living situation, necessary exercise, health teaching, treatments,

observable signs and symptoms of disease progression, diet, and spiritual needs. As a registered

nurse, it is crucial to act as a patient advocate. To excel, the healthcare team must customize the

aspects of discharge as they fit the patients specific needs.

Keywords: discharge, COPD, chronic, disease, maintenance, acute, exacerbation

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Discharge Plan for "Justin Case"

Justin Case (J.C.) is a 70-year-old male admitted to the hospital on 7/6/17 with the chief

complaint of shortness of breath. His wife told the healthcare team that he has no known

allergies aside from dog and cat dander. While in the emergency room, J.C. was placed on biPAP

to increase oxygen saturation (which was 87% on arrival) and decrease restlessness related to

dyspnea. A chest x-ray showed chronic bibasilar wall thickening, an abdomen CT with contrast

showed a right kidney staple, and an EKG depicted normal sinus rhythm with paroxysmal SVT.

The CBC with differential showed a WBC of 10.8 and a CO2 level of 30. His admitting

diagnosis was acute COPD exacerbation. While in the emergency room, the client has a past

medical history including chronic bilateral lymphedema, GERD, angiomylipoma, paroxysmal

SVT, diastolic CHF, history of DVT/PE, HTN, and DM II. The patient could ween from biPAP

to his usual 4L oxygen via nasal cannula. On the medical-surgical floor, consistent nebulizer

treatments along with IV antibiotics improved his overall condition enough to be discharged

home.

Discharge Goals

Pt demonstrated satisfactory understanding of nebulizer and inhaler usage by proper teach-back

method before discharge. Pt will use action plan to effectively medicate himself if he begins to

feel any pulmonary discomfort. "Medication adherence in COPD is crucial for optimizing

clinical outcomes..."(Darba et al., 2015, p. 6).

Pt will begin smoking cessation treatment following discharge. Pt will remain in contact

with PCP to have his pulmonary health and smoking cessation re-evaluated. "Smoking cessation

is the most effective way of slowing the progression of this disease (Darba et al., 2015, p. 5).
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The patient will continue physical therapy for at least 1 month after discharge to improve

strength and physical well-being. "By utilizing aerobic training and resistance training, there was

a significant improvement in cardio-pulmonary exercise outcomes (Reid et al., 2012, p. 312).

Written Discharge Instructions using METHODS

Medications

I am reviewing the medications you had been given while in the acute-care setting and

those that will go home with you. Be sure to take all your medications as directed. If you don't

know why you are taking the medication or have any questions talk to your primary care

provider (PCP) before discharge. Be aware, over-the-counter (OTC) medications must only be

taken once they have been reviewed by your PCP as the medication combination may have

adverse effects. It is important to have the resources to receive your medications, if you are

experiencing issues related to transportation or income your PCP may be able to assist you.

The following list are the medications you have been receiving in the acute-care setting:

Ammonium lactate 12% lotion TP BID, Aspirin 81mg oral daily, Lipitor 40mg oral daily,

Delsym 30mg/5mL liquid 30mg oral BID, Pepcid 20mg oral BID, Advair 1 puff BID, Lasix

40mg oral daily, Mucinex 600mg oral BID, Lantus 35 units subq daily, Humalog ISF 20 1-9

Units TID, Humalog ISF 60 1-4 units nightly, Humalog 1-25 units QID 1 unit for every 8gm

CHO within 30 minute of a meal, Ipratropium-Albuterol 0.5-2.5mL/3mL QID, Levaquin

750mg/150mL IV daily, Lisinopril 2.5mg oral daily, Methylpredisolone 40mg/1mL 30mg IV

BID, and Xarelto 20mg oral nightly. These aside from Levaquin and Methylpredisolone will

become your take-home medications.

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You are receiving Advair 1 puff twice a day which is a corticosteroid and bronchodilator.

The corticosteroid, fluticasone, is used to delay respiratory damage and maintain current lung

function. You must rinse your mouth thoroughly after each use to prevent oral candidiasis that

can be caused from the steroid. This is very important. The bronchodilator, salmeterol, is used as

a maintenance treatment to prevent bronchospasm in COPD. Other patients using the Advair

diskus have experienced headache but the most life-threatening adverse reactions include

laryngeal edema and bronchospasm (Vallerand, Sanoski, & Deglin, 2015, p. 1370). Patients

using a pMDI (pre-metered dose inhaler) like yours have a better medication adherence rate than

those that use inhalers such as a DPI (dry powder inhaler). Research shows that this is related to

the route and administration of the medication. (Darba et al., 2015, p. 5).

You will need to take Furosemide (Lasix) 40 mg by mouth twice a day for fluid balance.

Lasix is a diuretic and it helps you get rid of extra fluid you may be accumulating in your legs,

feet, hands, and lung field. Lasix can decrease blood pressure and prevent further respiratory

complications. Often patients become accidently dehydrated or experience electrolyte imbalance

while taking a diuretic, ensure you are well hydrated (Vallerand, Sanoski, & Deglin, 2015, p.

597).

In addition, you will be incorporating Ipratropium-Albuterol 0.5-2.5mL/3mL nebulizer

four times a day into your routine. This is an anticholinergic agent combined with a Beta-2

Agonist, both act by dilating and relaxing the bronchial. This inhaler may cause side effects such

as dry mouth, constipation, drowsiness, and irregular heart rate (Vallerand, Sanoski, & Deglin,

2015, p. 116). The overall goal of the combined treatment is to decrease pulmonary edema and

expand the airway to decrease shortness of breath and increase total oxygen saturation
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(Vallerand, Sanoski, & Deglin, 2015, p. 704). If you experience any life-threatening side effect

or have a traumatic head injury, seek immediate medical attention.

Environment/Exercise

Upon discharge, you and your family should check things around the house that may be

unsafe or cause you to fall. The COPD can make you more tired, and without your normal

strength combined with shortness of breath, you are likely to fall. Be sure to clear the house of

anything that you could trip over. Common items that should be removed include rugs and

furniture that blocks walkways. Ensure the home is properly equipped with lights so there is

never a dark spot when walking. Place rubber bath mats or strips in bathtubs and showers and

install both grab rails as well as an in-shower seat. Specifically related to COPD, ensure that all

commonly used items are well within reach so you do not use copious amounts of energy

reaching for things such as canes, tissues, medications, and the telephone

Reid, at al (2012) depicted the necessary exercise for a patient with both COPD and heart

failure. The researched proved that "both aerobic training and resistance training significantly

improved numerous cardiopulmonary exercise outcomes, including VO2 max, 6MWD, maximal

workload, and anaerobic threshold. It also improved several cardiac system factors, including

increasing the heart rate and cardiac output during maximal exercise, improving left ventricular

ejection fraction, and the end-diastolic and end-systolic ventricular volume (p. 312). The

frequency, length of exercise, and total training time are patient specific.

Effective coughing, as well as sitting in the tri-pod position, assists in clearing the lungs

and expanding the chest wall. Other breathing exercises include abdominal breathing and pursed-

lip breathing. To effectively complete abdominal breathing, lie on your back with your knees
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bent and place a book on your abdomen. Next, breath so that the top of the book rises on

inhalation and the bottom falls on expiration. Pursed-lip breathing requires you to breath in

through your nose and out through your mouth that is in a whistle position (Ignatavicius &

Workman, 2016, p. 563).

Treatment

During this hospitalization, your doctors diagnosed you with Chronic Obstructive

Pulmonary Disease (COPD). Ignatavicius and Workman (2016) state that COPD is a

combination of emphysema, an alveolar problem, and chronic bronchitis, an airway problem.

The significant issues resulting from emphysema are the loss of lung elasticity and lung

hyperinflation causing trouble breathing and increased respiratory rate (Ignatavicius &

Workman, 2016, p. 557). Bronchitis is an inflammation of the bronchi and associated lung. This

inflammation causes an increase in the number and size of mucus glands leading to large

amounts of thick mucus that impair airflow and harbor infection (Ignatavicius & Workman,

2016, p. 557). It should be noted that there is a genetic risk factor for developing COPD.

Approximately 100,000 citizens of the United States have a Alpha1- antitrypsin deficiency

causing lung disease.

PCPs use incentive spirometry to evaluate the level of disease severity. The most

common treatment for COPD is smoking cessation, prescribing medications are compliant with

the Global Initiative for Chronic Obstructive Lung Disease(GOLD), and a complete a patient

specific action plan (Silver et al., 2016, p. 2-4). The client is instructed to complete the exercises

and breathing techniques previously discussed. Keeping in contact with your PCP is crucial

throughout treatment. It is possible to live a productive and meaningful life with COPD. If it
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becomes necessary, seek emotional support groups for comfort through this time.

Health Teaching

https://www.dropbox.com/s/nk9j61ewfvnivg6/Video%20Aug%2005%2C%208%2001%20

57%20PM.mov?dl=0

Observable Signs and Symptoms

A multitude of clinical manifestations occur with COPD. Ignatavicius and Workman

(2016) notes that a patient with COPD is thin with loss of muscle mass in extremities but

increased neck muscles. The patient is often unknowingly in the tri-pod position and is short of

breath after activities such as changing and bathing. On exam, the respiratory rate will be rapid

and shallow appearing as uneven or random. The chest will often be barrel-shaped with little

movement and retractions. Wheezes and decreased breath sounds are often present although no

breath sounds may indicate a medical emergency. The overall appearance of these patients is

blue-tinged and dusky skin with excessive mucus production, delayed capillary refill, and finger

clubbing (Ignatavicius & Workman, 2016, p. 561). If you experience any sign or symptoms that

feels abnormal, contact your PCP or call an ambulance for immediate hospital transport. The

respiratory system is extremely complex; any change can be life-threatening.

Diet/Nutrition

Your physician has ordered a low-sodium, cardiac diet. It is important that your blood

sugar is controlled to prevent further systemic damage. Low-sodium must be followed to reduce

edema, both systemic and pulmonary. In addition, hydration is especially important following

this diagnosis. By drinking water continuously throughout the day, mucus is thinner for easier

removal. Most importantly, patients with COPD often become tired from strenuous activities
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such as eating. Be sure to rest before eating, eat more food in the morning if you're usually more

tired later in the day, avoid foods that cause gas or bloating as they make breathing more

difficult, and eat four to six small meals a day to allow your diaphragm to move freely (U.S.

National Library of Medicine, 2017).

Your overall daily diet should include five servings of fruit or vegetables, three servings

of whole grains, two to four servings of milk or milk products, 20-30g of fiber, and four to six

ounces of meat. This diet aims to decrease saturated fats, trans fats, and cholesterol while

increasing omega-3 fats. The following is an example of a daily menu that follows the prescribed

diet. Breakfast includes cup oatmeal with 1 small banana and 1 cup skim milk with 1 cup

brewed coffee. Lunch includes 2 slices whole wheat bread, 2oz turkey breast, 1oz low-fat cheese,

1 medium sliced tomato and shredded lettuce. In addition, 1 pear and 1 cup skim milk can be

consumed. Dinner includes 3oz broiled fish, 1 cup brown rice, 1 medium carrot, and a tossed

salad (The academy of nutrition and dietetics, n.d., p. 4).

Spiritual/Psychological Needs

During your hospitalization, we discussed names of supportive counseling and supportive

groups to utilize after discharge. There are names and phone numbers in the folder with your

discharge medication list. In addition, your healthcare team offered chaplain services in which

you received yesterday.

Discharge Details

The patient was provided with health teaching using the teach-back method. The patient

and family verbalized understanding by repeating the appropriate information back to the nurse.

The patient and family were provided with a copy of the written discharge instructions which
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include; dietary restrictions, complication signs and symptoms to monitor at home, questions and

concerns were addressed, and follow-up appointments were arranged. The patients discharge

condition remained unchanged from previous assessment (at 7/9/17 1200) neurologically intact,

vital signs unchanged from previous, and pain controlled (5/14/17). The discharge team will

follow-up with a phone call in one to three days following discharge. The patient and family

were provided with phone numbers to call for any questions and concerns. The patient was

escorted to the front door via wheelchair and left in the care of their family by car at 1600 on

7/9/17.

Conclusion

The entire healthcare team utilized observed, collected, and recorded data to create a

discharge plan that promotes patient healing and decreases disease exacerbation. By thorough

explanation of medications, exercise/environments, health teaching, treatment, observable signs

and symptoms, and diet the patient has the resources to continue disease maintenance. This

discharge plan aims for satisfactory use of all medications including the nebulizer and inhaler,

completed smoking cessation, and physical therapy to improve strength and maintain ability to

complete activities of daily living. During this transitional time, the patient is strongly

encouraged to apply the provided resources for optimal health maintenance.

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References

The academy of nutrition and dietetics. (n.d.). Carbohydrate counting for people with diabetes

[Pamphlet]. The academy of nutrition and dietetics.

The academy of nutrition and dietetics. (n.d.). Cardiac nutrition therapy [Pamphlet]. The

academy of nutrition and dietetics.

Darba, J., Ramirez, G., Sicras, A., Francoli, P., Torvinen, S., & Sanchez-de la Rosa, R. (2015).

The importance of inhaler devices: The choice of inhaler device may lead to suboptimal

adherence in COPD patients. Dovepress, 10(1), 2335-2345.

https://doi.org/10.2147/COPD.S90155

Ignatavicius, D. D., & Workman, M. L. (2016). Medical-surgical nursing (8th ed.). St. Louis,

MI: Elsevier.

Reid, W. D., Yamabayashi, C., Goodridge, D., Chung, F., Hunt, M. A., Marciniuk, D. D., . . .

Camp, P. G. (2012). Exercise prescription for hospitalized people with chronic

obstructive pulmonary disease and comorbidities: A synthesis of systemic reviews.

International Journal of COPD, 7, 297-320. https://doi.org/10.2147/COPD.S29750

Silver, P. C., Kollef, M. H., Clinkscale, D., Watts, P., Kidder, R., Eads, B., . . . Quartaro, M.

(2016). A respiratory therapist disease management program for patients hospitalized

with COPD. Respiratory Care, 62(8). https://doi.org/10.4187/respcare.05030

U.S. National Library of Medicine. (2017, July 2). COPD. Retrieved July 24, 2017, from

MedlinePlus: Trusted Health Information for You website:

https://medlineplus.gov/copd.html
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Vallerand, A. H., Sanoski, C. A., & Deglin, J. H. (2015). Davis's drug guide for nurses (14th

ed.). Philadelphia, PA: F.A. Davis Company.