Running Head: DISCHARGE PLANNING PROJECT

Transcription

1 Running Head: DISCHARGE PLANNING PROJECT Discharge Planning Project Stephanie Skukalek Medical Surgical Nursing II Clinical University of South Florida

2 2 The patient I chose to do my discharge planning project on is B. J., the 74-yearold male with hyperlipidemia as the only pre-existing medical condition. He presented to the FHT Radiation department via walk-in on 2/16/2015 for a scheduled ASD closure. Previously on 1/3/2015, he presented to the FHT ED with acute onset left upper extremity weakness. He stated that he noticed the signs and symptoms upon waking up that morning. He stated that he could not grasp any object and that he did not have any fine motor skill with his left side. The duration of the symptom was consistent, with no periods of rest. There were no aggravating factors or relieving factors for his symptoms. There were no other associated symptoms including no headache and no visual disturbances. He stated upon admittance that his grandfather had a history of a stroke. A CT and ECHO were done on 1/3/2015. After tests, an embolic stroke was confirmed. This was concerning considering the patient has never had heart issues. His PT was elevated at 19.9, INR was 1.06, and troponins were normal at A bubble study was then done and the results were positive, indicating that the patient had a CVA as a side effect of his Atrial Septal Defect (ASD). By the first discharge on 1/8/2015, the patient already had improved symptoms of left-sided weakness. The ASD closure was planned for 3-4 weeks after that discharge, which was then later scheduled for 2/16/2015. The patient went home on Xarelto, the beginning of his 6-month medication regimen with this medication. First and foremost, the patient does indeed understand his diagnosis; the only issue is that he did not know that he had ASD until after he had the stroke. ASD is a congenital disease that consists of a hole between the two atria allowing blood to flow between the two. ASD can cause dyspnea on exertion, palpitations, and easy fatigability,

3 3 but he did not experience any of these symptoms throughout the course of his life from birth untill now at age 74 (Domino, Baldor, Golding, Grimes, 2014). The patient is also aware of what a CVA is, and how the CVA was caused by the ASD. He understands that his CVA was an embolic stroke, and how his previous heart anatomy with the ASD caused a clot to be formed and travel to the cerebral tissue, which there caused ischemia in the brain. The specific teachings for a CVA include assessing for skin breakdown if a severe stroke with weakness has occurred. Our patient does not need any specific patient teaching on CVAs because he has almost fully recovered from his CVA the month previous. The patient is going to be on blood thinners because he had a CVA and an ASD closure, therefore it is important to teach the patient about contacting their provider if any signs of bleeding occurs including: dark, tarry, or bright red stools or bleeding from orifices. It is important to teach the patient to rest whenever is needed and to not overexert because he just had heart surgery. The patient needs to be taught to avoid lifting heavy objects. The patient also needs to be taught how to properly clean the wound near his groin with soap and water. Lastly, he needs to know to contact the provider if any of the following occur: fever or chills, red, swollen, or draining pus from the wound, heart beat irregularly, heart beats too fast, trouble breathing, or nausea and vomiting. When the patient was admitted for the first time when the CVA occurred, the Core/Quality measures were followed and were successful. Thrombolytic therapy (tpa) was started because the patient came to the ED within the first 1 hour of his stroke symptoms. The patient did also have a dysphagia screening before he consumed anything for the first time after his stroke. The results of this study confirmed that he was not at

4 4 risk for aspiration so he continued a normal diet. A NIH Stroke Scale was also completed, with a result of 4, indicating that the patient had a minor stroke. Being that the patient does not have a past medical history before his CVA other than hyperlipidemia, he is not going home on very many medications. The patient has been advised to contact his health care provider before starting any other medication, including OTC medications, to prevent any possible drug-to-drug interactions. His home medication regimen will include: acetaminophen, aspirin, clopidogrel, rivaroxaban, and simvastatin. The acetaminophen is prescribed in 650 mg doses, PO, every 4 hours PRN for fever. The patient will take two 325mg tablets to equal the dose of 650mg. The patient is aware that he will take them if he is above the low-grade fever limit of degrees Fahrenheit. The next dose that is possible to be taken is on 2/17/2015, if needed. The patient has been informed of the following side effects: N/V and hypertension. The patient was advised to call his healthcare provider if he notices any signs of the following adverse effects: Stevens-Johnson syndrome, Acute Generalized Exanthematous Pustulosis, and Toxic Epidermal Necrolysis. The patient has been taught that acetaminophen causes hepatotoxicity in high doses over an extended period of time, so to follow the PRN regimen as stated. The patient has been advised to avoid alcohol because 3 or more drinks a day increase the risk for liver damage. The patient has been advised to inform the healthcare provider and to stop taking the medication if a rash occurs, as this may forewarn Stevens-Johnson syndrome (Vallerand, Sanoski, Deglin, 2014). The aspirin is prescribed in 81 mg doses, PO, once a day, meaning he will take one 81mg pill per day. He has been told that he is going to be taking the baby aspirin as a

5 5 prophylaxis of future blood clots. The next dose he will be taking is on 2/18/2015. The patient has been informed of the following side effects: epigastric distress, N/V, abdominal pain, and rash. The patient has also been informed of the possible adverse effects including: GI bleeding, anaphylaxis, and laryngeal edema. Therefore, the patient was instructed to contact his healthcare provider immediately if he sees any dark, tarry or bloody stools, has swelling in the neck or throat, or has any trouble breathing. The patient has been instructed to take his aspirin with a full glass of water and to remain in an upright position for 15 to 30 minutes afterwards. The patient has also been instructed to avoid any consumption of alcohol, as this may cause increased gastric irritation (Vallerand, Sanoski, Deglin, 2014). The clopidogrel, also known as Plavix, is prescribed in 75mg doses, PO, every morning. The patient has been instructed that this is an antiplatelet drug and it will be used alongside aspirin and Xarelto to help to prevent any clots from forming. The patient will take one 75 mg tablet every morning to equal the correct dosage amount. The next dose that is possible to be taken is on 2/18/2015. The patient has been informed of the following side effects: depression, dizziness, epistaxis, cough, dyspnea, chest pain, edema, hypertension, back pain, and fever. The patient was advised to call his healthcare provider if he notices any signs of the following adverse effects: GI bleeding, drug rash, or thrombotic thrombocytopenia purpura. The patient has been instructed to inform his healthcare provider of any tarry, dark or bright red stools, a rash on the body, or purple spots on the body. (Vallerand, Sanoski, Deglin, 2014). The rivaroxaban, also known as Xarelto, is prescribed in 20mg doses, PO, every day before dinner. The patient has been instructed that this is an anticoagulant drug. The

6 6 patient will take one 20 mg tablet every day right before eating dinner to equal the correct dosage amount. The next dose that is possible to be taken is on 2/17/2015. The patient has been informed of the following side effects: syncope, blisters, prutitus, wound secretion, extremity pain, and muscle spasms. The patient was advised to call his healthcare provider if he notices any signs of the adverse effect of bleeding, including dark, tarry or bright red stools, or bleeding from any orifice. The patient has been instructed to not drink alcohol, other non-prescribed medications or OTC medications as these can all affect the medication regimen (Vallerand, Sanoski, Deglin, 2014). The simvastatin, also known as Zocor, is prescribed in 40mg doses, PO, every day at bedtime. The patient has been instructed that this is a drug for his high cholesterol, but considering her has been taking it since 2004 he already knew that. The patient will continue to take one 40 mg tablet every day right before bedtime to equal the correct dosage amount. The next dose that is possible to be taken is on 2/17/2015. The patient has been informed of the following side effects: amnesia, confusion, dizziness, headache, insomnia, memory loss, weakness, abdominal cramps, constipation, diarrhea, flatus, and heartburn. The patient was advised to call his healthcare provider if he notices any signs of the adverse effect of rhabdomyolysis, including sore muscles, pain in the extremities, or muscle tenderness. The patient has been instructed that this medication is important to take in conjunction with his heart healthy diet, which includes low cholesterol intake, low fat intake, and low sodium intake (Vallerand, Sanoski, Deglin, 2014). I inquired about the patient s home and daily settings, and if there were going to be any issues with getting around the house or the town. The patient stated that since he has regained most of his left side strength, there really are no house limitations that would

7 7 prevent him from getting around. Besides the fact that he has almost regained full strength, his house is only one story and there are no stairs to get inside of the house. The patient lives with his wife and it is a safe living situation for him. For now, his wife is his method of transportation to get groceries, to refill his medications and to go to his followup appointments. The patient stated that there are no financial concerns, as he has Aetina Medicare insurance to cover what is needed and money from other sources for the rest. The patient already has follow up appointment dates for his primary care physician as well as his cardiologist. The cardiologist appointment is on 3/17/2015, with Dr. Fakhri at th Ave. Suite 12 Tampa, FL. The patient is going to see his primary care physician two weeks after discharge on 2/17/2015, but the patient still has to call to make the appointment. The patient will also be continuing his rehab 5 days a week, as is patient s preference, to continually regain strength of his left arm and leg. The patient specifically stated, I need to regain strength, even more than my right arm, because my left arm is my dominant arm. Good is not good enough. The most important aspect to consider in discharge planning is how to prevent the patient s readmission into the hospital. It is vital for the patient and the nurse to converse about how to prevent the patient s readmission. It wastes time and money for both the patient and the hospital, as well as decreases the patient s quality of life. To prevent readmission, the patient is aware that it is important to take his medications exactly as prescribed, and to not miss a dose. The patient is aware that this can help to prevent any future TIAs or another CVA by taking his medications as prescribed. He also knows to call and inform his healthcare provider of any signs or symptoms of any adverse reactions, as catching these early can be vital to prevent readmission into the hospital.

8 8 Resources Domino, F., Baldor, R., Golding, J., & Grimes, J. (2014) The 5-Minute Clinical Consult Standard 2015, 23rd Edition. Retrieved from 5-Minute Clinical Consult, Nursing Central from Unbound Medicine Vallerand, A., Sanoski, C., Deglin, J. Nursing Central by Unbound Medicine: Davis s Drug Guide for Nurses, 13th Edition. (2014). Retrieved From Guide/All_Entries/A