Question

Please write a discharge plan for the following patient.

Make sure to Include:

-Explanation of diagnosis

-Follow-up plans after discharge

-Resources for questions, concerns or needs (i.e. Home health, physical therapy, counseling etc.)

-Medications

-Nutrition

-At least one other area of pertinent information for the patient to have a successful discharge from the unit, and prevent readmission (you get to choose this).

Ms. Kate a 76 year-old female who was admitted from the emergency department with a diagnosis of Right Cerebra Vascular Accident. Her Past Medical History includes: hyperlipidemia, hypertension, osteoarthritis, and osteoporosis.

Neurological: left-sided weakness for the past 2 days, awake, alert, and oriented to person, place, and time. Denied swallowing difficulties, no visual defects and denied pain. Medications: Aspirin 81mg per oral daily; Tylenol 650mg per oral when necessary for pain;

Cerebral vascular and pulmonary: Placed on a cardiac monitor, findings indicated normal sinus rhythm. Vital signs taken every 4 hours, pulse 82; blood pressure 168/64; respirations 20. Lung sounds were clear to auscultation bilaterally. Oxygen Saturation on room air 97%.

Gastrointestinal: Abdomen soft, non-tender, not distended, positive bowel sounds. Bowel movement present

Genitourinary: Voids freely, requiring assistance to the bathroom. Output approximately 1000ml/day. Brief episode of dysuria on admission. Integumentary: skin intact, no lesions noticed

Musculoskeletal: Active range of motion right side; limited range of motion on the left side; required assistant to get into a wheelchair. History of recent balance problems.

Psychosocial: lives with daughter in a two story home; occupation: retired teacher

Answer 1

Patient name : Ms.Kate

Medical record Number:

Admission date :

Discharge date:

Attending physician:

Admission Diagnosis: Right Cerebro Vascular accident

Final Diagnosis: Right cerebro vascular accident, Hyperlipedemia, Hypertension, Osteoarthritis, Osteoporosis.

Hospital course: 76 yr old female, brought to emergency department with the complains of left sided weakness for 2 days, and diagnosed to have right cerebro vascular accident.Physical findings revealed that, the presence of  left side weakness. She was conscious and oriented, swallowing ability intact. She reqiured assistance to meet bathroom needs and changing positions and having unsteady gait.Her BP was elevated 168/64 mm Hg.All other physical findings are with in normal limits.

Surgical procedure- None

Condtion on discharge : Patient sent home, in stable condition. Since, she needs minimal assistance to meet activites of daily living. Partially dependent.

Education : Follow- up : According to the physician's order .

Diet :Include plenty of vegetables and fruits in daily diet.Avoid deep fried foods and trans fat . Restrict salt (2gm/day), Small and frequent feed at 2 hrs interval. Drink 6-8 glasses of water per day. Have fat free milk every day.

Medications : Aspirin 81mg/day, po

Tynelol 650 mg, po, prn

Discharge instruction:for client and family,

Take aspirin after taking food to prevent gastric irritation.

Tynelol if pain present.

Take other routine medications

Use bed side commode.Use walking devices to gain balance, Floor and surroundngs must not be slippery. Use hand bars .

While raising from bed turn to unaffected side, then sit.

While standing, depend on unaffected side , maintain balance then walk.

Excercise: Change position every 2 hrly to prevent bedsore. Perform ROM exercises( ankle exercise) and muscle tightening exercises to enhance blood circulation and muscle strength.     

Seek help from physiotherapist- Excercises help to improve muscle strength, joint mobility and gait balance.

Use assistive devices as per the direcion.

Seek advice from family health nurse/ community health nurse if needed.

Counselling physician/Nurse: