Running Head: ON THE ROAD 1

On the Road to Becoming a Registered Nurse

Wendy M. Keil

University of South Florida

On the Road to Becoming a Registered Nurse

Over the course of the last ten years, I provided nursing care to many patients in different

care settings as a licensed practical nurse (LPN) in the Army. My assignments varied from a

bedside nurse, a clinic supervisor, and an evening/night staffing supervisor for a level II trauma

center. I have always considered myself to be a good nurse which was validated by the three

daisy awards I received. One of the most valuable lessens I learned early on was treating my

patients with respect and providing basic care such as toileting and bathing outweighed the most

complex care I could provide within my scope of practice to my patients. I challenged myself

with learning as much as I could to provide the best possible care to my patients, but the patients

seemed to remember how they were treated over any treatment performed. As I near graduation

for my Bachelor of Science in Nursing, I find myself reflecting on what was my most valuable

lesson learned. There are many nursing tasks that are new to me, but the concepts of nursing

provide valuable information. This will be the first time I have to consider cost of care and

insurance coverage, because previously, all of my patients’ care was covered thanks to the Army.

Discharge planning needs to start the day of admission, and the patient’s status needs to be

completely assessed and addressed.

During my preceptorship, I encountered a patient who was scheduled for discharge. It

seemed this would be an easy patient assignment. After receiving report, I conducted a nursing

assessment which was unremarkable. The patient had been admitted for treatment of a urinary

tract infection (UTI), but a perianal abscess was discovered during the initial nursing assessment.

The abscess was treated surgically with an incision and drainage. The UTI had been managed

with intravenous antibiotics, and the perianal wound was healing well. The doctors had ordered
ON THE ROAD 3

that the dressing remain in place with no dressing change for 48 hours. There was a referral in

for social work, and I was awaiting final disposition before discharge.

After the breakfast meal was delivered, I noticed the patient had eaten very little. I

discussed this with the patient only to determine that the patient has had a poor appetite for a few

months. Concerned that his nutritional intake could affect healing of the perianal wound, I

requested a nutritional consult and offered an Ensure nutritional supplement. The nutritional

consult was completed, and a diabetic supplement prescription was provided. This referral was

completed quickly on the day of discharge but should have been addressed earlier in the patient’s

stay.

Later when I went to check on the patient, he had informed me that social work had been

to the room and informed him that a nurse would come to his home three time a week to change

his perianal dressing. Knowing that the patient would not be capable of changing his dressing

the other days, social work was paged and asked to return to the patient’s bedside. She again

informed the patient that in-home care would only be covered for three days a week because he

had refused to go to a skilled nursing facility. It was then I realized how important insurance

coverage affects discharge planning.

Nurses are part of an interdisciplinary team and the goal of the team is to promote good

health outcomes and discharge the patients. Every member of the team should be

communicating from the time the patient is admitted. Many roles intertwine and it’s not always

clear who is responsible for each task. According to Eaton in a 2018 article, bedside nurses may

not always have the time necessary to obtain critical resources needed for discharge, but the

nurse should initiate the referral, be informed of the discharge plan, and advocate for the patient.

In this case, I advocated for my patient explaining that each time the patient had a bowel moment
ON THE ROAD 4

the dressing was becoming contaminated, and it would be necessary for the patient to have daily

dressing changes. The social worker said that she would petition for an exception, but it was not

guaranteed that the exception would be awarded. Since the patient had discharge orders, he left

the hospital, and the social worker said she would contact him the next day with the decision.

The patient was offered placement at a skilled nursing facility which was covered by his

insurance, but he declined it due to being the sole provider of and adult child with disabilities.

According to Wales et al., an enhanced discharge plan including home visits and follow-ups cost

significantly more and take more time to coordinate, but the outcomes are significantly better

(2018). I am uncertain if my patient was able to receive daily in-home wound care, or if the

perianal abscess has healed.

Discharge planning can be complicated and require a lot of input from the

interdisciplinary team, but it is very important for the health of our patients. I honestly don’t

know if we sent this patient home with the best plan, and his responsibilities at home made the

planning more difficult. I now realize there’s a lot of effort put in to create a good discharge

plan, and it should be initiated when the patient is admitted.

References

Eaton, C. K. (2018). Social workers, nurses, or both: Who is primarily responsible for hospital

discharge planning with older adults? Social Work in Health Care, 57 (10),851-863, DOI:

10.1080/00981389.2018.1521892

Wales, K., et al. (2018). A trial based economic evaluation of occupational therapy discharge

planning for older adults: the HOME randomized trial. Clinical Rehabilitation, 32(7),

919–929