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GNT 1 – 724. 2. 4-01-07 Contemporary Nursing Issues Mary Purvis Healthcare Issues In order to determine the safest and most appropriate discharge plan for this patient the case manager will work closely with the interdisciplinary team who is directly caring for the patient; together they will come up with the most effective, appropriate, and safest discharge plan. In this case study, there are several important healthcare issues the case manager needs to address with the team prior to Mr. Trosack’s discharge from the hospital.

The first issue that needs to be addressed is the issue of the patient’s safety. There are many concerns regarding Mr. Trosack’s living environment. The case manager would want to inform the team, that the patient lives alone in a two-story apartment, and the only access to the apartment is up two flights of stairs. It should be discussed that it would be unsafe to send him back home under these conditions, and take the risk that he might fall down again, especially now that his functional ability is compromised.

Secondly, there is the issue of the family, and their inability and lack of understanding to adequately care for the patient at this time. The team would discuss the concerns regarding the patient’s family support, and their understanding of what Mr. Trosack’s discharge needs would be. As the patient and his son have been distant and unable to really unite, a social worker referral may be needed to help bring the family together. And the third issue the team needs to discuss is whether the patient has the ability to manage and care himself.

The patient has just had a major surgery on his hip one month ago, and has just been newly diagnosed with diabetes and high blood pressure. This raises the concern that the patient may not have the physical or cognitive ability at this time to care for his newly diagnosed illnesses when he gets home. Sending Mr. Trosack home may cause a major decline in his health and healing process. This may result in frailty, which could lead the patient to go down hill rapidly. Finally, the case manager would discuss the patient’s new loss of independence.

The case manager will share her findings from the patients interview with the team regarding the patient’s prior level of functioning. Up until this injury and hospitalization the patient was very independent, active, healthy, and a productive member of society. He was working everyday, still managing a bakery with his brother and making major life decisions. He was in control of his life, and now he has very little control of his life. This is a big change in the patient’s usual lifestyle. He is going through a role change and new life transition. Importance of Issues

When planning a patient’s discharge it is important to identify and address any safety concerns there might be. In learning the patient would need to return to his second level apartment alone, would then alert the team that this patient is at high risk for a fall if he returns to his current residence. Falls are a serious health risk as the result of a fall can lead to injury, loss of independence, reduced quality of life, and death (Mauk, 2009). If Mr. Trosack falls again, it could cause his health to decline rapidly and he may never recover. Mr.

Trosack will require more help in order to complete the healing progress and stay well when he returns home. It is important to make sure the patient has adequate support and help in place prior to sending the patient home. The lack of family support and understanding of the care the patient will need regarding the patient’s disease management and his physical ability to care for himself, when he returns home, is worrisome. Mr. Trosack would be left alone most of the time, as the son and his wife are at work and are not available to physically be with him, and take care of him.

It will be important for the case manager to facilitate communication with the patient and his family in order to have a successful post hospital discharge. In my studies on successful aging, I learned that if a patient goes into a negative living situation it could impact his over all health (Mauk, 2009). The patient has just been newly diagnosed with some very complex medical problems and he has had a lot of life changes in a very short time. He has never had surgery before; previously he has not taken prescription medications before now.

He will have a lot to learn in order to take care of himself and treat his diseases. The patient is just recovering from a major surgery and is newly diagnosed with both high blood pressure and diabetes and is still weak and deconditioned. The patient is not able to care for himself at home, so it would be unsafe to send him home alone. This would be a set up for disaster, as he doesn’t have help at home and will be unable to get around his apartment safely. He will also be unable to get his meals and groceries. It is important to make sure the patient goes somewhere he will be safe and get the care he needs.

Mr. Trosack has suffered a great loss of independence due to his injury and new medical problems. The patient had never had prior surgery, or never had diseases of this nature before. Now, he is totally dependent on others to survive. He will need care to get around, to get his groceries, to care for himself. There have been some huge changes in a short period of time in Mr. Trosack’s life, and the way he will look and mange his life has totally changed. It may be hard for him to accept and it may lead to social isolation and depression.

The goal of the team is to formulate a safe and appropriate discharge plan for the patient’s continuing recovery process, so the patient can be able to maximize his functional independence. Interdisciplinary Team Members The interdisciplinary team should consist of the following members: a case manager, the patients attending Physician, the patients bedside nurse, a Physical Therapist who is evaluating and treating the patient, Occupational Therapy evaluating and caring for the patient. A case manager may also work with a medical social worker. Expected role of Team Members

Each member of the interdisciplinary team plays a very important part in planning a safe discharge for the patient. The role of the case manager is to facilitate a safe and appropriate discharge plan. The case manager will determine the patient’s needs by assessing risk and in collaboration with the physician and members of the healthcare team the case manager will lead in the development and implementation of a safe discharge plan. The case manager will do a case management interview with the patient and family to discuss the patients living situation and home environment.

After discussing the available and appropriate care options and obtaining input from the patient and the family, the case manager assesses the patient’s functional status with the healthcare team. The case manager will go to the physician and the team to formulate the safest and appropriate discharge plan. The case manager must use her clinical assessment and critical thinking skills to work closely with the patient and his family to formulate a discharge plan for this patient with complex medical, emotional, and social needs.

The attending physician will assess the medical stability of the patient, and appropriate level of care for post hospital care. The patient’s bedside nurse will inform the team on the medical progress of the patient. The nurse performs and documents her assessment of the patient body systems every shift. The nurse is a good resource for the case manager to check with to find out about the patients cognitive abilities, regarding how well the patient is able to understand his disease process, the patient capability of checking his own blood sugars and understanding when to take his new medications.

Is he understanding his new diet, is he eating, and so on. This information is valuable for the case manager in order for her to recognize when the patient is stable for discharge. The physical therapist will evaluate the patient’s functional status for balance and gait. The physical therapist will recommend if they think it is safe for the patient to return home or if he needs to have more physical therapy, either at a skilled nursing rehab or acute care rehab facility. The occupational therapist assesses the patient’s to see how well the patient is functioning.

One way the occupational therapist measures functional status is by assessing how the patient is able to perform instrumental activities of daily living and activities of daily living. Instrumental activities of daily living (IADL) are things like the patients ability to manage his own medications and the patient’s ability to prepare meals. Activities of daily living (ADL’S) are things like are like bathing, toileting, and eating. This information will be valuable in planning for discharge, in order to determine if the patient is progressing and is able to function independently.

The case manager will work closely with the physical therapist and the occupational therapist who have been evaluating and treating Mr. Trosack. Both therapies have been assessing the patient’s functional abilities for both instrumental activities of daily living and activities of daily living and have great insight on how well the patient will do at home. Also the case manager will work with a social worker to assist with the patient’s family dynamics, to see if the patient and his family can be brought closer together to help Mr. Trosacks get the care he needs. Safety Assessment

By analyzing the safety issues of the safety assessment, it will help the case manager in determining the most appropriate discharge placement. This patient only has access to his apartment by two flights of stairs. This is a major problem in that, the patient just had a total hip replacement one month ago, and has only had two weeks of physical therapy in the acute care setting. After a Total Hip Replacement surgery it is important to continue total hip precautions as to not displace the new hip. The case manager would be concerned that the patient’s does not have the functional ability to climb stairs.

The patient must use a walker to ambulate and is still struggling climbing stairs. The patient has verbalized his concerns about experiencing pain and continued difficulty climbing stairs. As well as, this patient being unable to go down to his basement for supplies that he will need to live. These are all red flags for the case manager and the team; it would be unsafe to have a patient return to his apartment under these conditions. Furthermore, the patients apartment is small, cluttered with furniture, and has multiple small throw rugs throughout the space.

This raises another concern for the risk of falls. If the patient’s groceries needed to be brought up two flights of stairs, it would be hard to ensure that delivery of groceries could be arranged. As mentioned earlier, it is important for the patients healing process to stay on a healthy diabetic diet. It is also important for the patient’s diabetic management to eat on regular time schedule. In the findings the patient’s medicine cabinet was filled with old prescriptions this could pose a problem in that, the patient could get his medications mixed up.

He may have difficulty remembering to stay on his new medication and take them on a timely basis. The patient may need more help understanding how to manage his new illnesses. Medication adherence is very important in the treatment of both hypertension and diabetes. Discharge Plan Needs This patient continues to have trouble walking, balancing, and performing activities of daily living. Healing a hip fracture will take time; Mr. Trosack needs more physical rehabilitation therapy and professional nursing care in order to continue to gain strength and to heal.

The patient is still in a fragile state physiologically and he needs more time to heal. The patient will need to continue to learn how to care for himself, so he can gain some of his independence back. The patient needs a living place that supports recovery. In this case, it is apparent that the patient’s family has a lack the understanding about the care their father will need when he returns home. The case manager needs to have a discussion with the family to make sure they are aware that they will have to continue some of the medical and personal needs for the patient when he returns home.

During this family meeting the case manager will need to educate the family on several issues regarding what is needed to care for the patient. The family needs to understand that the patient will need to have a caregiver with him to make sure that he is safe, and doesn’t fall again. It would be pointed out to the family that sending the patient home alone with two flights of stairs to climb would be very unsafe. It would need to be stressed that preventing another fall is paramount for Mr. Trosack.

The case manager would discuss the importance of the patient getting more physical therapy to gain the strength he will need in order to return home. The case manager will need to educate the family on some of physiological changes and psychological changes associated with the aging process of an elderly person. It appears the patient’s son and wife do not quite grasp the seriousness of Mr. Trosacks injury and disease process. It will be Important to let them know that the patient will need assistance with ambulation, meal prep, proper diet, taking medications for DM and HTN, bathing and grooming, and driving to follow up appointments.

Also education is needed regarding the disease process and management associated with high blood pressure and diabetes. The family will need to know the importance of making sure the patient gets the care he needs to manage his diabetes and hypertension. The family does not even believe the patient has diabetes, so importance must be stressed that the patient needs to get his medications on time, and that he will need help with meal preparation for a healthy diet in order to control his diabetes and high blood pressure. The family has clearly refused outside nursing assistance, so it should be addressed to the amily that due to the patients failing health, he will not be capable of caring for himself right now and he will need assistance with activities of daily living. There was also some lack of understanding on the family’s part regarding leaving the patient alone. It should be discussed with the family that prior to this hospitalization their father was healthy, independent and fully capable of caring for himself, but due to the changes in his medical condition, he will no longer be capable of caring for himself when he discharges from the hospital.

By letting the family know that without proper care there dad’s health may decline and it could result in a poor recovery. It must be stressed to the family the importance of the patient getting the proper support and care he needs to make a full recovery. The case manager must also let the family know the reasons and the importance of why the patient should not be left alone, for both the safety concerns and the consequences of social isolation. There is a clear indication that the family is very stressed with their own work demands.

This education and discussion might give the family a little better insight and understanding of what the patient is going through and what the patient will need post hospital stay. The case manager can talk with the patient and the family to discuss different discharge options. She will give the patients family resources for skilled nursing facilities, assisted living facilities, hiring of private pay caregivers, and senior center phone numbers. In order for the patient to make a smooth transition to home he must have the support and help he needs at home (“Hospitalmedicne. rg”). Assessing the patients needs of care for after discharge from the hospital is important, to ensure that he gets the necessary services in place prior to discharge. Health, quality of life, and family relationships can have and impact on how a person lives there later years (Mauk, 2009). Social Isolation By sending Mr. Tosack’s home where he will stay in his apartment alone all day would be doing him a great disservice. Staying by himself could cause his health problems to be exacerbated, and it may cause his health to decline rapidly.

The patient is at high risk for isolation. Social isolation can lead the patient to become depressed, which is very common, especially in older men. Mr. Trosack has been a healthy, independent man, in control of his life and making all of his own decisions. He went from being a functional independent man to a functional dependent person. The patient will not be as mobile and active as he was before, and he will not be able to socialize and be involved in social activities as before if he goes to his apartment alone. Mr.

Trosack had been interacting with his customers daily at the bakery, so he really needs to go to a place where he can continue to socialize with others. Mr. Trosack has just experienced a huge role change and will need time to transition. It will be hard for Mr. Trosack to change to a dependent role. Mr. Trosack may feel that he would not want to bother other people in order to get the help he will need at home to properly care for himself. In order to prevent social isolation Mr. Trosack should not go home alone. Psychological Factors

One of the psychological changes associated with the aging process is that an elderly person may experience cognitive changes. These changes can affect a person’s response time and coordination. Various changes in cognition can have an effect on intelligence. It can affect the ability to comprehend and process information. One of these abilities of intelligence is known as fluid intelligence, this is the ability to think abstractly. Another intellectual ability is known as crystallized intelligence, this will reflect the knowledge and skills a person has gained over time.

It is due to these cognitive changes Mr. Trosack might have difficulty with response time and coordination and being able to comprehend and process all the new information regarding his new diagnosis and new drug regime. Therefore, when an elderly person experiences cognitive changes such as these it will play a major role in how well and how fast a person will recover from an injury or an illness. Recommendations The case manager along with the interdisciplinary team would recommend that the patient go to a skilled nursing facility, short term for more rehab therapy.

This would be the most beneficial, and safest discharge plan for the patient. This patient’s family is not prepared at this time to care for Mr. Trosack healthcare needs. Furthermore, the family refuses outside services such as nursing assistance to help care for the patient. This will give the patient more time to heal and get stronger before he returns home. It will also give the patient time to understand and learn how to control his diabetes and high blood pressure and to care for himself. This patient needs to go to a place with professional staff trained to care for his needs.

Ongoing physical rehabilitation is the most important part of recovery for the first few months following surgery for a Total Hip Replacement. The patient has just been newly diagnosed with some very complex medical problems and he has had a lot of life changes in a very short time. He has never had surgery before; previously he has not taken prescription medications before now. He will have to a lot to learn in order to take care of himself and to be able to treat his diabetes and hypertension.

The patient needs a place that supports continuing recovery. It would be suggested to the family to get involved with Mr. Trosacks discharge plan; with the patients permission the case manger can have the patients family tour skilled nursing facilities in the area to choose one of their choice. The case manager and the social worker would work closely with the family to see if the family can start working with their father to start thinking about making arrangements for the patient after he is discharged from the skilled nursing facility.

Discharge planning begins early on in the patient’s hospitalization. It involves the patient, family, physician, nursing, case manager, social worker, and rehabilitation staff. The whole purpose is to continue the patient’s improvement outside the hospital setting. References “Getting Ready to Go Home”. (2011, Nov). Retrieved from Hospitalmedicine. org. N. p. , n. d. Web. 20 Nov 2011. Mauk, K. L. (2009). Gerontological Nursing: Competencies for Care. Jones & Bartlett. ISBN 13:9780763755805.

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