In this assignment the author will discuss a discharge plan with rationale for an older person with a long term condition. Included will be potential and actual problems presenting from the patient profile on discharge from an acute care setting. Reference to the Nursing and Midwifery Council’s (NMC) professional code of conduct (2008) shall be made throughout the assignment along with a discussion of legislation in the latter part that is relevant to the plan of care arranged. Moreover any copies of documentation used in the appendix will remain anonymous maintaining confidentiality.
The theoretical model used to formulate this plan of care is Roper et al (1990) activities of daily living which concentrates on twelve elements essential for daily living skills and the level of dependence required for them. The elements’ of the theoretical model chosen will be those applicable to the patients discharge care for example, mobility and breathing.
The patient profile referred to is that of an elder gentleman in his late seventies admitted to hospital following weakness on waking to the left side of his body which had mainly affected his mobility. There also appeared to be some facial drooping with dysarthria. For the purpose of this assignment when referring to the patient he will be named as Mr Smith as to personalise the plan of care.
Mr Smith has a past medical history of chronic obstructive pulmonary disease (COPD) and asthma for which he receives drug therapy of salbutamol and becotide inhalers. He is also the main carer for his wife whom suffers severe Alzheimer’s disease.
Liaise with the discharge co-ordinator as to the impending discharge of Mr Smith. This will ensure the continuity of his care on discharge.
The discharge co-ordinator provides valuable assistance and is able to amplify the experience of a patient’s venture from hospital to the community Day et al (2009). They are highly skilled nurses in this specialist area and mediate between the multidisciplines’s involved in the care needs of Mr Smith.
- Possible changes to Mr Smith’s movement, function and orientation.
- Complete a falls risk assessment using an identified tool and follow advisory notes on completion.
- With consent liaise with occupational therapy and physiotherapy departments for a discharge assessment and continued rehabilitation within the community.
- Make certain a home visit with therapy teams has been undertaken before discharge.
A falls risk assessment tool (FRAT) is a way to establish risk and manage falls prevention. Its use is advocated in the National institute for clinical excellence (NICE) guidelines in falls prevention document (2004).
Following the use of FRAT (appendix 2) it is decided that Mr Smith is at moderate risk of falling and advices of therapy team input.
Mr Smith requires an assessment by the occupational therapy team in his home environment prior to his discharge. This ensures his safety and well being for day to day living and maintains his independence. The visit presents an opportunity for the occupational therapist to evaluate the need for adjustment in the home. For example it is recorded that Mr Smith has some difficulty in rising out of the bath he would therefore need modification in his bathroom to enable him to do this, promoting independence and maintaining his dignity.
Mobility doesn’t just include the physical aspect of movement it involves fine motor activity, personal assertion, feeling and communicative function also. Having a stroke can cause dysfunction, having a dramatic causatum on the person’s life Barnet et al (2009). Making adjustments in the home can be an upsetting experience.
An assessment by the physiotherapist will maximise rehabilitation in physical movement and allow instruction on the use of equipment that may be required in doing so, this ascertains safety and accuracy during use.
Physiotherapists have superior kinetic knowledge and can introduce advice in falls prevention minimising the occurrence. NMC (2008) requires you as a nurse to refer to another practitioner when it is in the best interests of a person’s care.
Both therapists will be able to initiate communication with day hospitals for continued rehabilitation therapy sessions within the community.
Maintain a safe environment and communication.
- Mr Smith is to administer daily medication and understand the information provision.
- Ensure the prescription with 7 days’ supply is provided and sent to pharmacy in time for discharge.
- Guarantee Mr Smith and his relatives receive relevant information regarding medication. Explain in an accessible manner.
- Arrange an out patients appointment. Present written and verbal information regarding the appointment.
- Inform the GP of Mr Smith discharge.
Mr Smith has been prescribed aspirin 75mg following an ischaemic cerebral vascular accident (CVA). The aspirin is given prophylactically and inhibits platelet aggregation which could otherwise result in a thrombus formation British national formulary (BNF) (2009).
Eighty percent of strokes result from ischemia, caused by a thrombus blocking the cerebral circulation therefore, preventative medication such as aspirin reduces the risk of a reoccurrence Greenstein and Gould (2009a).
It is important to provide Mr Smith with written and verbal information with regard to instruction on how and when to take his medication, along with the dosage and possible side-effects he may encounter.
Educating Mr Smith on the need for medication and possible consequence of non compliance present him with an informed choice and reduces the risk of a drug induced re-admission. Reports suggest that fifty percent of older people may not take medicines prescribed for them as they have not received valued information about the benefits and risks involved Department of health (DOH) (2001).
The NMC (2008) say’s that you must share information about people’s health and regime’s in a way they can understand. This facilitates informed choices and compliance.
Nurses have a responsibility to continue assessment of their patient’s suitability for self-administration; the NMC’s standards for medicines management (2008) standard 9 require you to acknowledge changes to a patient’s condition and safety with regard to self-administration.
Assessing Mr Smiths understanding and capability of remembering to take his medication is of great importance as if he is likely to encounter difficulty, provision for pre-dispensed medicine or help from a carer can be arranged Wade (2007). Indirect questioning will provide some indication as to how much Mr Smith understands and will not make him feel inadequate, maintaining his dignity and respect.
An outpatient’s appointment with a neurologist will maintain consistent specialist monitoring of Mr Smith’s condition even though once discharged the GP is responsible for care in the community and continued prescribing. It is therefore vital that the GP has documentation on this hospital admission and any follow up appointments to be attended.
- Change to Mr Smith’s social and home environmental needs.
- Inform Mr Smith as to the importance of social services’ participation and gain his consent.
- Liaise with social services for an assessment of needs completing the relevant documentation (section’s 2 & 5) in acceptable time ready for Mr Smith’s discharge.
Consent must be given by Mr Smith prior to the involvement of social services, even though it is documented that they have had previous input with Mrs Smith’s care. It is the individual’s right to confidentiality and as a nurse you must respect this NMC (2008).
Mr Smith has indicated that he has concerns with regard to coping and caring for his wife whom has severe Alzheimer’s disease when he is discharged. Social services must assess the need for a care support package and provide financial advice for the services required as Mr Smith is a home owner. With Mr Smith’s consent social services may even consider the possibility of Mrs Smith remaining in the nursing home until Mr Smith is more able bodied.
The need fulfilment of the dependent can generate emotional stress in the carer and burden their physical well-being with the high level of physical exertion needed to provide endowed care Mackenzie and Lee (2006).
When Mr Smith returns home it is the expectation that he will be allowing himself time to recover and not put his self under duress which could result in a relapse in his health. Anecdotally, caring for his wife at this stage would not be beneficial to his rehabilitation.
- Transportation home on discharge from hospital.
- Liaise with relatives regarding transport home and if necessary arrange hospital transportation.
- Verify Mr Smith has keys to his property, that someone will be there to receive him or that the key safe number is available.
It is of upmost importance that Mr Smith and his relatives are fully aware of the date of discharge and the preparations for his arrival. Where possible, Mr Smith and his relatives should contribute to the discharge plan. The expectation of you as a nurse is that you uphold peoples’ rights to be involved in decisions about their care NMC (2008).
Working and playing.
- Possible isolation and lack of social contact.
- With consent refer Mr Smith to the community stroke liaison services and complete the relevant referral documentation. Provide the services contact details.
The community stroke liaison nurse is there to provide support with initial changes to Mr Smith’s life. She is a specialist in stroke rehabilitation and can present him with coping strategies. These will help Mr Smith focus on problem solving approaches and heighten his sense of control Carpenito-Moyet (2008a).
The nurse specialist may also be able to provide Mr Smith with mini health checks and details of support groups, clubs and give advice regarding enrolling on an expert patient programme if it is available within the local authority.
The expert patient programme is a self management course for people with long term conditions. It was launched in 2002 as a pilot programme but is now national. The course is delivered over a six week period by a trained tutor who is either a volunteer or a previous programme attendee and is vastly beneficial. The service reduces isolation, promotes confidence and empowers those living with deficits or complex needs DOH (2001).
Eating and drinking.
- Nutritional support and secondary prevention
- With consent refer Mr Smith to a community dietician completing the documentation.
- Highlight the importance of lifestyle and dietary changes with regard to his condition.
- Outline the need to attend to any future difficulty in swallowing or further dysarthria.
Following his stroke Mr Smith may have a reduced appetite. Carpentino-Moyet (2008b) suggests this may be due to fatigue, being less mobile or even because of some pain from limb limitation. Carpentino-Moyet (2008c) also discuss that during Illness or convalesce a good nutritional consumption can reduce the risk of further complications and aid faster recovery. Referring to the community dietician ensures that a diet plan optimal in calories and nutrition is received.
Making certain that Mr Smith has some understanding about his condition will endeavour compliance with diet and life style changes. The reoccurrence of a CVA is much higher during the first year of rehabilitation, therefore regular checks and life style conversions need to be initiated DOH (2001).
Mr Smith’s awareness and detection of further difficulties with speech and swallowing is a desired outcome as this could most definitely interfere with his nutritional intake in the future and would incorporate further change to his diet and lifestyle they would also warrant a referral to a speech and language therapist for a swallow assessment.
- Mr Smith has COPD and asthma and requires respiratory maintenance and secondary prevention advice.
- Ensure Mr Smith is aware of how to use his inhalers with the correct technique. Inform him of the importance to have regular visits to the GP or respiratory nurse in order to maintain adequate respiration.
- Provide cessation of smoking advice.
Belamy and Booker (2000) suggest that the recommended maintenance appointment for patients with mild to moderate COPD should be annually within the primary care setting, they also indicate the monitoring session should involve a full assessment of the patients smoking status, symptom control, and medication efficiency with inhaler technique. Furthermore it allows the health care professional to perform spirometry.
It appears that Mr Smith’s therapeutic intervention of becotide and salbutamol inhalers have symptomatic control of his COPD at present however, he is now also prescribed aspirin which could contraindicate his condition. Occasionally aspirin causes bronchospasm Greenstein and Gould (2009b) therefore close monitoring is essential.
In practice we can promote smoking cessation and provide advice to Mr Smith with regard to the health risks involved following his stroke and COPD. It is his individual choice as to whether he will participate.
Many people given smoking cessation advice will continue smoking disregarding concern for their health. The NMC (2008) stipulates that as a nurse you must not discriminate against those in your care, treating people as individuals regardless of whether their choice exacerbates their illnesses.
Key issues in older adults and long term conditions care provision:
Extensive change has been underway with regard to the care standards and expectations of health and social care services for older people.
The force for change has happened due to demographic analysis, which indicates that people are living much longer with an increase in those above the age of eighty. According to the DOH (2001) this figure is expected to have doubled between 1995 and 2025. Such longevity influences the amount of people living with long term conditions.
Research and reports from extensive consultation with older people, their carer’s, healthcare professionals and from media coverage, discuss services declining to meet the needs of older people with age discrimination and depletion of dignity and respect being a major domination as clinical area’s lacked evidence based practice DOH (2001).
The introduction of clinical governance has helped develop effectiveness of evidence based practice assuring the quality of care is of a high standard.
Zwanenberg and Edwards (2004) describe clinical governance as a system to advance the quality of care in which healthcare managers are responsible for policy compliance. They explain that primary care trusts are accountable for providing evidence of their effectiveness and quality of clinical practice and further acknowledge the level of need for accountability since public interest in cases of malpractice.
Care plans are aspects of clinical governance policies Lugon and Secker-Walker (1999) as is the essence of care document developed by the DOH in 2001.
The essence of care document is a guidance tool specific in enabling healthcare professionals to deliver a structured and patient focused practice within eight areas of care. Some of the areas include food and nutrition, self-care and privacy and dignity. The document also enables professionals to distinguish areas of poor practice allowing for remediation DOH (2001).
The national institute of clinical excellence formulated guidelines for practice in assessment and prevention of falls, declaring that falls are a major cause of disability or mortality in the elder population and impact on their quality of health and life NICE (2004). NICE (2004) also report that falling can have a devastating repercussion to an individual causing psychological distress, lack of confidence and poor self esteem, dependency and even pressure injury. The guidelines provide strategies for assessment (FRAT appendix 2) of those at risk of falling, including individuals following a stroke and suggest setting provision for interventions such as physical therapy, home adjustment and the revisal of visual deficit NICE (2004).
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The development of the national service framework (NSF) for older people by the DOH (2001) delivers policies as to the standard of healthcare that older people should receive. The NSF endeavoured to set strategies over a 10 year programme looking for improvements within specific areas of health promoting independence and providing treatment with respect and dignity. The document lists the quality of care that is required on the best available evidence and provides one standard for all, achieving consistency within healthcare DOH (2001).
The focus of the NSF for older people was to abolish age discrimination and provide a patient centred approach to care DOH (2001). The document defines stroke and falls prevention, promotion of health and introduces standards of care for hospital and intermediate settings and for mental health illness in older people.
The DOH in connection with the NSF for older people also developed the NSF for long term conditions in 2005. The document expresses the need for the promotion of ‘quality of life’ with autonomy based around the individual’s specific need for their condition. Implementation of this policy includes provision of support for housing, benefits, education and pension schemes helping those suffering with long term conditions to live as independently as possible with access to services as required DOH (2005).
A stroke (CVA) is classified as a long term condition and the DOH (2007) stroke strategy document identifies the need for health promotion and management of risk. The plan of action firstly focuses on awareness and prevention, treatment and services available for those whose lives have been affected by stroke. Secondly, it identifies that all needs, health and social of the individual, should be contemplated in a plan of care not just medical ones DOH (2007).
The stroke strategy guidelines allow for individuals following a minor event to be given an MRI scan within 24 hours, as evidence suggest eighty percent will follow on to have a severe stroke DOH (2007). Clinical area’s can therefore reduce deaths in practice if they adhere to this policy. Promotion of healthy weight, physical exercise and smoking cessation along with regular blood pressure checks and advice on alcohol consumption further reduce risks DOH (2007).
The stroke strategy also expresses the need for a multidisciplinary approach, all health and social care workers collaborating together cultivating a stroke care community that will provide the best possible service for those affected returning home DOH (2007).
Continued assessment by the multidiscipline’s’ following a hospital admission is essential to ensure an individual’s suitability for discharge. The DOH (2004) suggests that consideration be made for the individual’s physiological, functional and psycho-social wellbeing during the assessments. Being ‘fit for discharge’ means that receiving care in an acute setting is no longer needed and continued care can be provided between the GP, community services and outpatients appointments DOH (2004).
One professional included in the multidiscipline approach within the community is a pharmacist with initiatives developed to increase their involvement in care, such as repeat dispensing, medication reviews and independent prescribing especially for those with long term illness DOH (2005). The pharmacist’s involvement within the multidisciplinary team is very beneficial to patient care as it decreases medication errors, discovering discrepancies and many contra-indications before the medication reaches the patient.
All legislation and government policies have influence on the way healthcare professionals practice. They provide guidelines as to accommodate continuity of healthcare in general. They set standards for quality of care that service user’s can expect when accessing healthcare provision and project how they will receive this provision.
Legislation is an important aspect of healthcare and individual’s have the right to life without discrimination, being treated equally with dignity and respect regardless of their condition, disability or age.
The writer concludes that Mr Smith is awaiting discharge from hospital following a stroke. Evident from the patient profile he has achieved a satisfactory level of independence and he appears to be making good progress. The discharge plan documented for Mr Smith incorporates many of the NHS and social care policy initiatives to deliver continuity of care from hospital to home using elements from the Roper et al (1990) theoretical nursing model.
The discharge plan supports the inclusion of multidiscipline’s’, health promotion, prevention strategies and patient participation. It also up holds the NMC code of professional conduct (2008) whilst focusing on independence and maintenance of one’s dignity, providing community support and rehabilitation.
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