Please help with Discharge Plan!

  1. Mrs. Jefferson is a 76 year old admitted to the hospital with gangrene of her left foot. She is an insulin-dependent diabetic who has not been compliant with her diet, medicines and insulin. She has only Social Security for income, which pays about $400 per month. She lives in a second floor apartment in government subsidized senior housing. She says she cannot afford the foods for her diabetic diet and is unable to pay for her medications, insulin, and syringes as soon as she needs them.

    Her left leg has been amputated below the knee during her hospital stay. She will need sterile dressing changes twice daily for several weeks because her incision line became infected and is slow to heal. She has difficulty transferring to the wheelchair balancing on her right leg only. She tends to fall to the left during pivot transfers.

    Mrs. Jefferson has two daughters that live out of state. They are both concerned about her, but they are unable to take time off work and away from their own families to be with her. She has several friends who live in the senior apartment. The physician has written orders to make arrangements for Mrs. Jefferson to be discharged in two days.


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    When writing out the plan, should I just include referrals that have been made along with goals? Or am I supposed to ensure beforehand that the pt has appropriate care after being discharged and just document that? I know that she would need help purchasing meds, food, appropriate care at home (home health nurse),physical therapy,social services, and possibly a support group of some kind to help her cope with the loss of a limb. Am I on the right track? I think I might be lost...
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    2 Comments

  3. by   Daytonite
    a discharge plan includes reviewing pretty much the same general orders you would have expected the doctor to write when a patient is admitted:
    • their diet
    • allowed physical activity
    • medications they need to take
    • any treatments and tests they need to be doing after discharge
    • referrals to any outside agencies or support groups
    • follow up appointments with doctors have been made and patient understands
    • teaching materials and/or contact with outpatient professionals for continued care and teaching have been provided to the patient
    you know:
    • has not been compliant with her diet, medicines and insulin
    • has only social security for income, which pays about $400 per month\
    • she says she cannot afford the foods for her diabetic diet and is unable to pay for her medications, insulin, and syringes
    • need sterile dressing changes twice daily for several weeks
    • has difficulty transferring to the wheelchair balancing on her right leg only
    • tends to fall to the left during pivot transfers
    • has two daughters that live out of state, but they cannot come to be with her
    • she lives in a senior apartment where she has several friends
    it would be appropriate to make referrals to outside agencies, probably a home health agency, to go to her home after she has been discharged home to make an assessment of her needs. as a diabetic requiring sterile dressing changes that should qualify her for skilled nursing services by a home health agency under part a of her medicare coverage. you can double-check that this qualifies her on the medicare website. you should also check what community services for the elderly are provided in your area and how to get access to them for someone. as a new amputee she will need to know how to navigate around her community and use public transportation to get to and from doctor's appointments. by the way, how will she get to her follow up appointments with her doctors? you need to make sure those are arranged. you need to make sure she has or will have a way to get her prescriptions filled. you also need to make sure she has been provided with all the teaching that she needs with regard to her diet, medicines, insulin, wound care and mobility. it doesn't have to be you specifically, but it needs to be put into her current care plan so all the nurses caring for are on the same page and helping prepare her for the discharge in 2 days. most hospitals these days have either a social service person or a discharge department who will also assist. since she is claiming she cannot afford to pay for her food or medicine you better get the social service person involved. she needs financial assistance and social services are the best at assessing that situation.

    when we did these kinds of things for school we got our hands smacked pretty badly if we didn't show we had looked into our own community services to see what they provided. our profs didn't want generic answers. they wanted to know we got down and really checked out our local resources.
  4. by   Student4Now
    Thank you so much!!!!

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