University of San Carlos

Department of Nursing
Cebu City

DISCHARGE PLAN AND PATIENT EDUCATION FORM

(2ndRevision 2019)
A. PATIENT INFORMATION
Name ___Ms. Pepito____________ Age_39 yrs. old Sex _F____ Religion ___n/a_____________
Diagnosis _Respiratory distress_____________________________________________________
Surgery undergone, if any __n/a____________________________________________________
Hospital ___n/a_____________________________ Rm/Ward-Bed No. ______n/a___________
Attending Physician _Dr. Sanches_______________Insurance____n/a_____________________

B. OBJECTIVES:
 The patient will verbalize the importance of the medication given.
 The patient will be able to identify ways to manage asthma attacks.
 The patient will show interest to the teachings taught.
 The patient will share feedback and concerns during the discussion.

C. 1. MEDICATION INSTRUCTIONS

Name of Drug(s) Dosage and Route Curative Effects Side Effects

Frequency
Albuterol 2 puffs Oral Inhalation Relaxes the muscles around  nervousness or
every 4-6hours the airways so that they shakiness
open up which allows you to  headache
breathe more easily.  throat or nasal
irritation
 muscle aches
Vanceril 2 inhalations Oral Inhalation When inhaled at therapeutic  dry mouth
3-4 times daily doses it has a direct anti-  headache
inflammatory action on the  throat irritation
bronchial mucosa.

2. EXERCISE/ACTIVITY INSTRUCTIONS

Type of Activity allowed/to be continued: Swimming, walking, hiking, recreational biking, and sports with
short bursts of activity.

Restrictions: High-intensity activities such as running, jogging, or soccer, and exercising in cold and dry
environments.

3. TREATMENT INSTRUCTIONS (Prescribed treatment to be continued at home or to a referred health

Institution/Facility): Recognize your triggers, take steps to avoid triggers and track your breathing to make sure
your medications are keeping symptoms under control. Take your asthma medicines exactly as your provider
tells you. Be sure to always have a quick-relief inhaler with you.
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4. INSTRUCTIONS IN CASE OF EMERGENCY, (PLEASE REPORT)

a. OBSERVED signs and symptoms:

 Severe shortness of breath
 Chest tightness or pain
 Coughing or wheezing
 Being to breathless to eat, speak or sleep
 Drowsiness, confusion, exhaustion, or dizziness
 Cyanosis
 Fainting
 Symptoms that fail to respond to use of a quick-acting (rescue) inhaler.

b. INTERVENTIONS/HOME REMEDIES: Do your best to keep calm, take a puff of your rescue medication
inhaler, and stand or sit up straight.

5. DIET INSTRUCTIONS

a. Prescribed diet:
 Vitamin D-rich foods, such as milk and eggs
 Beta carotene-rich vegetables, such as carrots and leafy greens
 Magnesium-rich foods, such as spinach and salmon

b. Restrictions: Eggs, cow's milk, peanuts, soy, wheat, fish, shrimp and other shellfish.

6. SPIRITUAL AND PSYCHOLOGICAL INSTRUCTIONS:

 Encourage to continue to seek God’s guidance and enlightenment.
 Emphasize the importance of prayers in healing.
 Encourage to continue to have a positive outlook in life.
 Encourage to keep the faith in God and not to give up easily when hard times come.

7. What to do to handle anxiety:

 Do deep breathing exercise.
 Take asthma medications when you have asthma attack.
 Encourage patient to call healthcare provider.

8. HEALTH TEACHINGS TO AVOID ALLERGENS

 Wear mask when doing laundry.
 Segregate her husband's used clothing when he comes home and put it in the plastic.
 Use liquid detergent instead of powder.
 Pace the patient's activities. Provide rest periods.
 Avoid physical exertion when doing laundry.
 Always bring asthma relief medication/inhaler.
 9. ADDITIONAL HEALTH TEACHINGS
[✓ ] clinic appointment schedule
[ ] follow-up laboratory examinations
[] understanding and knowing what to do with side effects of medications
[] use of alternative medicines
[] relapse prevention measures
[ ] others ________________________________________________________________

D. DISCHARGE DETAILS

a. Date and time of discharge: __November 15, 2020____________________________________________

b. Accompanied by: _Mr. Pepito_____________________________________________________________
c. Mode of transportation: _Car_____________________________________________________________
d. General condition upon discharge: _Patient maintained optimal breathing pattern and____________
oxygenation.____________________________________________________________________________
e. Consultation time/ Follow up with Dr Sanches: December 15, 2020, possibly 9:00

EXPLAINED IN ENGLISH AND/OR IN DIALECT, THESE DISCHARGE INSTRUCTIONS WERE READ AND UNDERSTOOD
BY THE PATIENT, FAMILY, AND/OR RELATIVE.

________Franchie M. Hsu________________ _________Franchie M. Hsu___________

PATIENT/RELATIVE STUDENT NURSE
(Signature over printed name) (Signature over printed name)

________Br. Noel M. Tecson, SVD__________

CLINICAL INSTRUCTOR
(Signature over printed name)
(Tecson, 2006)