Discharge planning Flashcards
What is discharge planning
process used to determine patients needs from one level of care to another
Nurses role in discharge planning
evaluate patients appropriateness for discharge
discuss with patient and caregiver
plan the discharge
make referrals
arrange follow-up care
Changes during discharge planning
Medications
health treatment plan
Major surgery or diagnosis
Wounds or equipment
what does discharge planning improve?
health outcomes
what does discharge planning decrease
Readmission
poor discharge planning can lead to what?
Medication mis-management
Health decline
Safety issues/concerns
Result in readmission to hospital
What is important to consider when discharge planning
Enough time to teach and return demonstration?
Assistance/help at home? 24 hrs/day versus minimal.
Learner type (verbal, written hands on etc)
Need caregiver at bedside to hear discharge instructions
What makes discharge planning difficult
Healthcare issues Lack of time Trying to get patient out quickly due to demand of room Family hesitancy to go home Social issues/transportation
Appropriateness for Discharge
Is patient ready for discharge
Discuss how the team and nurses decides this
Do they have a place to go?
Do we have a safe discharge plan?
If patient or caregiver feels like it is too early, you can appeal.
determining post-discharge site of care
Home Home with home health Skilled Nursing Facility Inpatient versus outpatient rehab Long-term acute care facility
Areas of Discharge Planning
Medication Reconciliation Diagnosis Procedure Surgery Diet Activity Case Management/ Social Services Follow-Up Appointments
Medication Reconciliation discharge planning
Review home medications Review hospital medications Anticipate new medications Why How they should be taken Special considerations Side effects How will they obtain medications? Insurance or not Co-pay
Diagnosis of discharge planning
Give a brief description of the diagnosis
How did we treat it in the hospital
Special requirements/recommendations
When to call the HCP
When to go to the nearest ED or seek IMMEDIATE attention
Procedure and Surgery discharge planning
Give brief description of procedure or surgery
Home care
Follow up care
When to seek medical attention
Diet discharge planning
What diet?- not just the name, they need specifics
What foods are good/bad
Consult dietician
Plan a grocery list
Talk through favorite foods – do they need to modify
