Hello from the Other Siiide..what I learned about pt discharge when the patient is my dad

Nurses General Nursing

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Don't mind my Adele reference in the title.

I'm an RN who works on a cardiac unit of a hospital. We do a fair amount of discharges. Many of the patients are elderly, but a lot are not. I've known the importance of good patient education, and always do what I can to make sure a patient (and/or their caregiver - whether that's a spouse, child, visiting nurse) has all the education and resources they need. Our unit even does discharge call backs the day after to ask if the patient has received their prescriptions, made the follow up doctor appointments, and to ask again if they have any questions at all. My dad is in his mid 50s and just had a total hip replacement, so this is my first time being "on the other side". This is my dad's second hip replacement, he had the other side done in his mid 40's (its a combination of playing football when he was younger, working in construction for 25 years, and genes). The first hip replacement he was discharged to sub-acute rehab for a few days. This time they wanted him to be discharged home. My mom was nervous, but they explained he would have a visiting nurse and PT come to the house, and that by discharge he would be able to get up and go to the bathroom on his own, and wouldn't need to be doing any wound care, so she felt she could handle it.

This is what I have learned from this experience. It's going to change how I educate pts and give discharge instructions so I thought I'd share. (my hospital has policies to do some of these things, but not to the level I now think they should):

  1. make sure patients know the trade and generic names of drugs, and which can be bought vs. which need prescriptions. -- it sounds silly, but don't assume someone knows acetamenophen is tylenol, or that it can be bought at the drug store. My dad was prescribed senna and docusate, but my mom (who is in her mid 50s and a very intelligent woman working in a field that is not healthcare) didn't know he didn't need a prescription for them, and that they can just be bought at CVS. This really stressed her out, she thought she had missed getting what could be an important prescription.
  2. when someone is discharged on pain meds (especially multiple), tell them to keep a schedule of when they take them and to high-light how often these meds can be taken -- . My dad was discharged on tramadol q6 and nucynta q4. he also is prescribed lorazepam for anxiety. The nucynta is having side effects (i'll get to that) so my dad isn't with it enough to know when to take his meds, and my mom, who works full time from home, wasn't sure which was which, when he last took one, if they could be taken at the same time, or how the lorazepam played into it. It was a hot mess. - now my mom is keeping a log and it's sorted out, but if I wasn't here I am worried about what could have happened.
  3. make sure your patients and families know when and how to call their doctor or nurse...and make sure the number works -- trying to find the number to call when there was a concern (below), that actually went through to an real life human on a Friday evening, was about a 30 minute task (and this is for me, not some 80 year old lady who isn't familiar with this stuff).....in short: highlight phone numbers to call for medical questions that are not obvious 911-type things...also my dad had some urinary retention in the hospital and they wanted him to follow up with a urologist "1-2 days after discharge"...when I called the number for the doctor on the discharge papers, the receptionist told me this doctor didn't take new patients. I was surprised! I called and got him appointment with a different urologist I know of, but a lot of patients and family may get seriously stressed and upset about this, or worse, fail to follow up on an important issue.


    4. Make sure you tell your patients about possible side effects...especially with unfamiliar meds --- this sounds obvious, but still. My dad was prescribed nucynta, which I had never heard of. It's a newer narcotic and helps prevent constipation (it totally did by the way). Anyway, my mom was saying how my dad was having these horrible nightmares, and was acting "weird" - I come over and hang out with him to notice he's not "drowsy" or just a little loopy, like on some narcotics, he is having increased anxiety, restlessness, and occasionally twitching - and then he's saying things like "I was thinking about driving down to visit nan" (aka his grandma who's been dead for 20 years) - he immediately realized and laughed about it, but that was odd. my mom said he had been out of it and was occasionally talking to himself - she just thought he was on heavy duty pain meds because he just had a joint replaced --I first got kind of pissed at my mom, like "how didn't you think this was something to tell me" but she said he was talking to himself not in this obvious, how-can-you-miss-it way, but just kind of mumbling to himself before and after sleeping. I asked him if he heard anyone talking to him that wasn't there, saying it could be a potential side effect - and he said yeah, but I thought it was just the nightmare thing (he was awake and on meds, so yes this sounds ridiculous but I got my answer - he was having audible hallucinations!) -- there was no information given to them on this drug. I looked it up and sure enough "call your doctor if you experience" and under that there was "twitching or muscle spasms, hallucinations" - it also had sleep disturbances/nightmares.[/font]

finding the phone number for the correct person to contact was ridiculous. Finally calling back the hospital, they said to call his visiting nurse and to also get his blood work to see if possible electrolyte imbalances. I find the folder the visiting nurse left, but the front that had a line where your RN's name is suppose to be was empty. I asked my mom if the nurse left a phone number and she said she didn't know. I sort through the paperwork and just call the agency and it takes me forever to actually get the RN on the phone.

To sum this all up... My dad is not an elderly man, he was discharged to home, where he has my mom, who works from home and can be with him all the time, and to top it all off he has a daughter who lives 10 minutes away that is an RN! He isn't what comes to mind when you think of the patient that will have any issues related to confusion after discharge. Yes, dealing with it was a pain for me, but for someone who doesn't know how to google the number for the visiting nurse, or doesn't know what is not a "normal" side effect, this whole thing would have been really overwhelming and could have had a bad outcome.

It's easy to forget how things that seem obvious to people who work in the healthcare setting can be completely foreign to all types of patients. I just wanted to share!

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On our end, in home health, these are things that the admitting nurse should be instructing and then be available for clarification. And unfortunately we can't admit the same day of discharge.

Joint replacements are actually the most clear cut routine admissions for us but when you consider how much time it takes to obtain insurance info, consent forms, 21 page assessment form, complete medication reconciliation, then completing enough teaching on meds, wound care, symptom management, precautions and safety to set them up until the next visit can be very challenging for the non seasoned home health nurse trying to accomplish all of that in 1 - 1 1/2 hrs. (You can imagine how it goes for a complex medical patient). Seasoned home health nurses are worth the weight in gold if you ask me and hard to come by. I wish schools would incorporate a real home health course.

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Specializes in Public Health.

I feel like this type of situation is an unfortunate and potentially very dangerous situation. But sadly, I don't see this problem getting any better. Unless there is a discharge nurse available to go through all of these things in depth, there isn't enough time to go through these things with three other discharges happening concurrently and 3-4 other patients that need care.

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Specializes in Critical care.

I'm cardiac and in my unit we don't deal with complex pain management often upon d/c, but I obviously know the common drugs people go home on. I don't know every little side effect and I'm not a pharmacist, so IMHO I don't think I should have to know every little detail about the drugs- it's just not possible. I think pharmacists are a good resource that are under utilized. If a patient were to have a lot of concerns about a new drug I would tell them to speak with their doctor and/or pharmacist. It's also good to point out the info packets that come with new prescriptions and that they should look it over.

I do make sure I thoroughly go over more complicated prescription instructions at least a couple of times. When patients are going home with a new prescription of nitro I even quiz them after I go over it, that way I know they understand what to do. We also make sure our unit phone number is highlighted in the d/c paperwork and emphasize that they can call and reach someone at any time with questions.

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I agree that its a bigger issue and there would need to be more of a system wide or hospital wide change, but I will approach discharges with more perspective now. Unfortunately I don't have the time I want (or often need) when discharging patients, but from now on I'm definitely going to make sure the patient or caregiver can tell me what number they're going to call if they have any problems. (I'm going to highlight it). We go over all meds with patients on the med rec, but I'm going to try and make sure the OTC drugs are in generic and trade names, and make more of an effort to do discharge teaching as I work with the patient during their admission.

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I absolutely agree we shouldn't and couldn't know every side effect of every drug. My dad happened to get the side effect that happens to 1% of people. I know in my hospital, we try and give education on a least one medication and one "problem". Yes it would have been ideal, but I don't blame them for not having the time to educate my mom and dad on every med or discharge instruction.

I think my post was more of just a wake up call (to myself and others) not to assume a patient knows something, or that they know how to navigate the system like we do. I think doing everything you listed in the second paragraph is an awesome way to do everything we can reasonably do as individual nurses to minimize problems post discharge.

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I agree that its a bigger issue and there would need to be more of a system wide or hospital wide change, but I will approach discharges with more perspective now. Unfortunately I don't have the time I want (or often need) when discharging patients, but from now on I'm definitely going to make sure the patient or caregiver can tell me what number they're going to call if they have any problems. (I'm going to highlight it). We go over all meds with patients on the med rec, but I'm going to try and make sure the OTC drugs are in generic and trade names, and make more of an effort to do discharge teaching as I work with the patient during their admission.

You will have positive impact on every patient you touch with this attitude, even if you don't accomplish all that you would like every time.

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Somebody else who is both on /r/nursing and allnurses!

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I think the biggest hurdle in this goal is time. Most Nurses do not have the time to spend 1+ hrs going through a complete d/c with everything the OP listed.

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Specializes in LTC,Hospice/palliative care,acute care.

I'm your dad's age and I just had a total hip,anterior approach.I could have been discharged the next day but that scared me so I stayed two nights and am glad I did,I needed to be there.

Here are some tips I'd like to pass on-

ASK QUESTIONS before you leave the hospital.Review the discharge instructions while you are still in your room and call your nurse back in if anything is unclear.Don't let them rush you out the door

take you discharge instructions and scripts to the pharmacy,review them with the pharmacist.You'll get exactly what you need.My husband did this on his own when he went to get my scripts...Smart guy .Also READ the print out from the pharmacy-this includes ALL side effects

Use a pill box or an empty egg carton for your routine meds and WRITE DOWN the time you take your PRN's.I kept a tablet and pen in my bag full of meds (and my make-up) I don't handle narcs well and my husband was working himself to death so I tried to make things as easy as possible.

Put the important phone numbers IN the phone and USE them.The only dumb question is the one you don't ask.

Keep all pertinent paperwork together in an easily accessible place.Home care agency provides a folder,phone number is on the front.

That tablet and pen you are keeping beside you? Make a note of questions you may have for your follow up appointments.

Most of this is common sense ,even for people with no medical background.Every one of us would spend hours at the vet,pepper him with questions if our dog or cat was sick yet for ourselves we want someone else to be responsble for us and to 'fix thing's.We have to be responsible for ourselves.

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Specializes in Med/Surg/ICU/Stepdown.

My former employer had a system whereby dedicated 'discharge nurses' followed patients from admission to discharge and assessed, reassessed, and educated the patient on their discharge needs throughout their entire stay. They were also responsible for coordinating any in-home services needed after discharge, e-scribing, transportation, and follow-up appointments. They were also the persons performing the physical discharge since they had been working with the patient throughout their stay. This system worked tremendously well as it was beneficial for the patient to have one "go to" person that was constantly thinking about life after the hospital. It also was helpful to those of us working at the bedside as it allowed us to focus more on the inpatient care side of things and saved us precious time in both not rushing a discharge and not missing any important information. The day of discharge, we'd simply notify the discharge nurse, and then our care for the patient essentially ended there, and they took over until the patient physically left the hospital.

The employer I currently work for has no such system. They have 'CCCs.' These individuals don't get involved until maybe 1 to 2 days prior to discharge, and 99% of their information comes from the bedside nurse. In a large system, that's potentially dangerous, as we are all often caring for 4-5 high acuity patients, and may not always have all the pertinent information.

I agree the way that we make the transition from hospital to home has to change in order to avoid readmissions and exacerbation of chronic health care issues. Patient compliance does have a lot to do with it but there's much to be said for having the time to actually do comprehensive education with patients.

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Be especially careful educating when there is a language barrier. I learned this in home health when I had a patient taking metoprolol 50mg AND lopressor 100mg, among others. She had gotten the lopressor from the ED and they failed to tell her to stop taking the metoprolol. Couldn't figure out why her heart rate was running in the 40's.

When English isn't someone's first language its never safe to assume they understand everything you're telling them, even if they can communicate some what in English.

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