Discharge Plan for Patient Who Underwent Total Hip Replacement

1 January 2017

This paper focuses on the discharge plan for patient who underwent the Total Hip Replacement (THR). The nurse, as a case manager, works with the multidisciplinary team to determine the appropriate discharge plan for the patient. The roles and responsibilities of each member are elaborated. The healthcare issues, the safety assessment are discussed. In this case study the patient lives alone during the recovery from the surgery, so the effects of social isolation and psychological factors on the recovery process are also explained.

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Assessment of the Situation: After the assessment of Mr. Trosack medical conditions, the three healthcare issues that present are identified as (1) high fall risk, (2)the insufficient family support, (3) the pain issues that are resulted from the hip fracture and the total hip replacement (THR), and (4) the impaired mobility. There are many factors that will put Mr. Trosack at risk for future falls. First, the physiological changes associated with ageing that affect mobility.

These factors may include hearing loss, visual impairment, decreased muscle mass, decreased muscle strength; especially in lower extremities, as well as a decrease in endurance. These conditions make the older adults vulnerable and contributing falls. Second, some of the medications that are prescribed for Mr. Trosack such as Percocet, Glucophage, and Lopressor have adverse side effects that may increase the risk of future falls. Percocet was prescribed for his postoperative pain, Glucophage was prescribed as an anti diabetic agent, and Lopressor used to treat hypertension.

Some of the side effects of Percocet associated with falls include orthostatic hypotension and sedation which can make him dizzy or drowsy. Hypoglycemia is a side effect of Glucophage and it is also risk factor for falls. Lopressor may cause fatigue, weakness, and hypotension and these symptoms could also easily increase the incidence of falls. In addition to the medications, other complications that develop after hip surgery are pain and impaired mobility which are also added risk factors of falls. Upon further assessment using the Morse fall scale it was found that Mr.Trosack scored 65.

A patient who scores more than 25 is at high risk and should have fall prevention strategies in place (Mauk, 2010). Because of the several high risk fall factors that present Mr. Trosack ,it should be recommended that he not be discharged to his home where he has to mostly mange his own care and risk future injury. His family also refuses any outside nursing assistance and it will be extremely difficult for Mr. Trosack to perform the basic activities of daily living. Another healthcare issue is the insufficient family support Mr. Trosack receives.

He currently lives alone in his own apartment on the second floor of a three story apartment building. He has a son, Peter who is 44 years old and married. Peter and his wife are very busy with their careers and both work about sixty hours a week. They are also trying to conceive their first child. Living this type of life and having their own family commitments will not allow them to offer much help to Mr. Trosack. It also has been shown that in the past Peter has had minimal contact with his father. The other family member that Mr. Trosack could look to is his brother, Karl.

However, most of Karl’s time is occupied with working schedules at the family-owned bakery store. This limitation prevents him to assist with Mr. Trosack’s daily care. Furthermore, the results of the family interview show that the family members have inadequate knowledge about the needs of taking medications. They also do not believe that Mr. Trosack has Diabetes and assume that a modification to his diet is enough to cure the disease. Since it appears that family members cannot provide sufficient care along with their lack of knowledge about his illness and treatments, Mr. Trosack is not safe to be discharged to his home.

The nurse must reevaluate and find placement where he can have adequate and effective care in a long-term care and rehabilitation facility. This will provide him the nursing care, wound care, physical therapy, ambulation assistance, dietary consultation to control Diabetes, teaching, and other services needed to facilitate his recovery and prepare him to care for himself at home. The third healthcare concern is the pain issues that can affect the recovery process and quality of life. The incision pain from the surgery may interfere with his mobility and activity of daily living.

Mr. Trosack potentially needs help for some asic daily functions such as preparing meals, getting dressed, taking showers, and getting out of bed. Although he has been prescribed Percocet to manage his pain he has a history of medication non -compliance as evidenced by the many old prescriptions that fill his bathroom medicine cabinet. Therefore, it is believed that he may not take his medications as prescribed, so pain may continue to affect his mobility, self care, and daily functions. Pain may also cause sleep disturbance, such as sleep deprivation, which can lead to fatigue and decreased immune functions. This potentially will slow down the recovery process after the surgery.

Keeping these indications in mind, the pain issues described here should be considered when planning for discharging the elderly patient. The fourth healthcare issue is impaired mobility. The mobility impairment affects patient both physical and psychological aspects. Due to the gait instability, poor balance, pain and, muscle weakness caused by the hip fracture and the surgery, Mr. Trosack has to use walker for ambulation. However, he lives in a small cluttered apartment, the bathroom is also small with no safety equipments installed, and there are many scatter rugs, this home environment highly put him at risk for falls.

Using walker as an assistive device for ambulation and not being able to independently perform daily activities like before, these are the adjustments to the lifestyle changes which can lead a psychological problem as he states “he is being disabled”. Due to the fact that he is living alone, if the discharge destination is home, the feeling of being disabled and the isolated living conditions, may lead to a psychological disorder such as depression. Therefore, the interdisciplinary team will need to consider the impaired mobility issues when planning for the discharge placement.

The interdisciplinary team works together to develop an appropriate discharge plan that meets patient’s goals, needs, and their medical conditions. The plan will also promote their independence in their activity of daily living as much as possible. Some of the healthcare professionals that make up the multidisciplinary team to establish the discharge plan for Mr. Trosack include the physician, nurse, physical therapist, and the registered dietitian. The members of the team have the specific roles and responsibilities. The physician assesses the patient’s medical conditions, summarizes the medications and the treatments.

Next, the physician then writes the discharge order, discusses the discharge plan of care, and the follow up visits with Mr. Trosack and family members. The nurse’s role, as a case manager, is involved in all aspects of the discharge planning. The nurse will inform Mr. Trosack and his family about the discharge process. In this scenario, after the evaluation of the patient’s clinical conditions and psychosocial issues, the patient is likely to be placed in a skilled nursing facility. The nurse will coordinate with the chosen facility and make arrangements for the transfer to ensure a smooth transition and for the continuity of care.

Teaching is an essential part of nursing care. Mr. Trosack and his family members will be taught how to manage the incision site, his pain, Diabetes, and hypertension. Teaching also involves dispensing medications along with the side effects, the appropriate diet to control blood sugar levels, diabetic foot care, prevention of fall risk, good nutrition to promote healing, signs and symptoms of hyperglycemia and hypoglycemia, and when to report to the healthcare provider. Another healthcare professional who will play an important role in the discharge plan is a Physical Therapist (PT).

Mr. Trosack will be assessed and evaluated about his mobility status, balance, and gait patterns. PT will make recommendations about assistive devices for ambulation such as a walker and arrangements for gait and balance training. PT also provides teaching to patients and their family members about exercise programs such as strengthening exercises to improve muscle strength around the hip joint and legs. Other types of the exercise may include range of motion exercise which can prevent joint stiffness and maintains joint flexibility.

Additional instruction includes the proper use of the devices, safe transferring, and positioning techniques. Other personnel who make up the interdisciplinary team is the registered dietitian (RD). An RD will work with the patient and perform an assessment using medical and social history, diet history and laboratory data to plan for the appropriate nutrition program. Individualized sample menus and meal plans based on patient conditions are provided to patient and family members. The RD also monitors the patient’s nutritional status and the response to the plan to improve the clinical outcomes.

With his current medical illnesses, Mr. Trosack needs adequate calories, vitamin c, and zinc to promote wound healing and recovery from the Total Hip Replacement. The meal plan should also include a diabetic diet to control blood sugar levels and the proper nutrition to manage hypertension. As for the discharge placement for Mr. Trosack, the results of the safety assessment are important and will be used to determine the post discharge site of care. The data from the interview of the patient and family members reveal that the patient’s goal is to be discharged home.

However, the assessment of the current living environment found that there were many factors not suitable for Mr. Trosack’s recovery at home. He lives in a three- story building, on a second floor, and there is no elevator, the post surgery conditions will make it difficult for him to take the stairs. Mr. Trosack also mentions in the interview that he cannot go to the basement. Furthermore, his apartment is small and cluttered, and there are many small rugs scatter throughout the apartment, this makes it difficult for him to get around and to manipulate the walker.

Also, the bathroom is small and there are no safety tools, such as a raised toilet seat installed for patient who just underwent the hip surgery. The further assessment found many expired old prescriptions in the medicine cabinet; this reflects his noncompliance with medications in the past. Other factors that need to take into the considerations when the patient is discharged home are the transportations to the follow up visits, the support of the family, and the ability of the patient to manage the activity of daily living (ADLs).

Mr. Trosack’s family members are too busy with work and unlikely to provide the adequate support. Therefore, Mr. Trosack will have a difficulty getting the medications, and going to the follow up visits. As for the capability to manage basic ADLs, the incision pain and the unsteady gait can interfere with the ability to perform some basic functions, for instance, getting dress, getting in and out of bed, and using the toilet.

Based on the safety assessment and the interview data, Mr.Trosack should be discharged to the skilled nursing facility where he can receive the skilled nursing care and rehabilitation services, while working towards the goal to go home. If Mr. Trosack and the family members decided to be discharged home, the nurse will need to explain the plan of care and provide the extensive teaching to the patient and family members. This is to ensure that the patient will receive a safe and effective care at home. The teaching must be emphasized on the patient safety which includes home modification and fall preventions.

The additional information includes diabetic care, medication and side effects, the ability of the family to provide supports on both physical and psychosocial needs. The nurse also may provide the necessary information about the community resources that helps to support the patient’s care. As for the safety measure, if possible, Mr. Trosack should move to the ground floor apartment. The living environment inside the apartment needs to be modified for an easy ambulation to decrease fall risks. The adequate lighting, removing the clutter and make the clean pathways are essential.

He also needs some safety equipment installed in the bathroom. These may consist of the bath seat, high toilet seat, grab bars, a tub transfer bench, and the assistive devices to help with the low body dressing and bathing (http://www. texashealth. org/body. cfm? id=1619). During the recovery period, the family members have to consider the ability to manage their time in order provide Mr. Trosack the sufficient and effective care. Mr. Trosack will not be able to take the stairs, therefore he will need the assistance from the family to deliver meals or groceries, and remove the trash.

The family members can also assist in removing the spoilage food in the refrigerator, and the old medications in the bathroom cabinet. The current prescribed medications, the walker, and the telephone should be located within reach. The family members may take turn to help patient with the dressing changes, bathing, dressing, and toileting. In addition, due to the medical diagnoses of Diabetes and hypertension, the family and Mr. Trosack also will receive the teaching on the diabetic care, the appropriate nutrition to control blood sugar and blood pressure.

The diabetic care teaching involves the monitoring of the incision site for signs and symptoms of infections, any skin breakdown, and the daily inspections of the feet. Moreover, the nurse will also teach the patient the proper use of the glucometer, the signs and symptoms of hypoglycemia and hyperglycemia, and the proper response to these conditions. The nurse will also educate patient and the family members about weight reduction and the health benefits. Mr. Trosack weights 210 lbs; losing weight will help him improve the medical conditions of Diabetes and hypertension.

Weight loss helps promote cell’s sensitivity to insulin. It also has a positive effect on lowering blood pressure. Teaching also includes medications and the side effects, and when to report to the healthcare provider. The nurse will explain the importance of taking medications to manage the current illnesses. The negatives effects of medication non compliance also should be addressed. Besides nursing care, PT also provide teaching about the proper use of walker, the safe positioning and transferring, and the exercise program to promote the joint movements and muscle strengths.

Taking care of Mr. Trosack requires a great amount of time and commitment. Since Mr. Trosack has medical issues from the surgery, his brother, Karl has to manage the bakery business alone. Karl will struggle with work and managing time to adequately take care of his brother. Similarly, Mr. Trosack’s son, Peter and his wife also have high pressure from work. They both work in the average of sixty hours per week. Besides they plan to conceive a child. So their situations may not allow them to provide Mr. Trosack a competent care.

Because the family declines the outside nursing care, the nurse can provide the community resource lists to assist the family in provide the adequate care. For instance, the local senior center offers the different services to serve the elderly in the community such as senior transportation program; this can help Mr. Trosack to go to the scheduled follow up visits. Some of the other services are the meals on wheels which delivers the nutritious meal to the patient’s home. Also the respite care, this helps the family to have a temporary relief from providing care to the patient.

Besides the physical care, the older adults also need psychological supports to promote the recovery. Social isolation and psychological factors can impact patient’s recovery from the illness. The causes of social isolation may be due to the lack of supports from family and friends, the financial difficulty, the illnesses, cognitive impairment, and lack of transportations. Also, the physiological changes associated with ageing, for instance, the impaired sensory functions, such as poor vision and hearing loss, can decrease the ability of the elderly to interact with other people which can result in social isolation.

Being isolated from the society, it can lead to the loneliness. The lonely patients tend to have no interest in self care and physical activity. They also usually don’t comply with medications and medical treatments; this may cause the negative clinical outcomes. Furthermore, the elderly who lives alone with no supports commonly has poor appetite. A good nutrition is needed for wound healing and the recovery from the surgery and diseases. In contrast, poor nutrition will slow down the healing and recovery process.

In addition, dealing with the illnesses is a great challenge in life; the patients will experience the emotional difficulty and need some supports to get through the situation. Lastly, social isolation is usually associated with poor mental health. This may further cause psychological dysfunctions such as depression and suicide. Apart from social isolation, psychological factors such as personal’s beliefs, optimisms, and the ability to cope with stress and the challenges in life, also play important role in the recovery process.

The elder patients, who are optimistic about their care, and the possibility of the recovery, normally have a better a capability to cope with stress and the illnesses better than the pessimistic patients. They believe in the healthcare providers and the positive outcomes of the treatments, therefore these patients are likely to corporate with the plan of care, the necessary life style changes to improve the medical conditions, and doctor appointments. The optimists generally maintain good social supports and participate in social activities.

They are also mostly in a good emotional state and happy with their lives. The happiness is linked to better immune functions, which lead to positive recovery outcomes. Besides optimism, the ability to cope with stresses also an essential element in the recovery process. The older patients who are capable of applying the coping skills to reduce stress may have better clinical outcomes that those who lack of stress management skills. The high level of chronic stress affects the physiological functions of the body. In response to stress, our body releases the cortisol hormone.

One of cortisol functions is to suppress immune system. When the immune system is weak, it decreases the ability of the body to recover from diseases and fight infections. Based on Mr. Trosack medical’s condition, the results of safety assessment, and the information from patient and the family’s interview, he should be discharged to the skilled nursing facility and work towards the goal to be discharged home. At the skilled nursing facility, he will receive the care needed for the recovery. Mr. Trosack will have nursing assistant to assist with some ADLs such as toileting and dressing.

He will received nursing care to monitor the incision site, manage the incision pain, monitor blood sugar levels to prevent the complications of diabetes. Also he will be provided proper nutrition and pharmacological interventions to manage diabetes and hypertension. Furthermore, he will be monitored for future falls and injury. Besides nursing care, Mr. Trosack will receive physical therapy treatments and the exercise program to improve balance and muscle strengths. He will also learn about the proper positioning to prevent the dislocation of the hip joint.

Moreover, he will receive the adequate supports from the medical professionals and the staff. Also, he will have the opportunity to participate in group activities which will give him a sense of social connectedness. This helps promote mental health and facilitate the recovery. In conclusion, the nurse as a case manager works with patient, family members, and the interdisciplinary team to plan for the appropriate discharge for the patient. The discharge destination is chosen based on patient’s goal and needs.

The results of the safety assessment and the interview of the family and patient along with patient’ medical conditions are used to determine the discharge placement. If the patient’s goal is to be discharged home, the nurse must provide the family the information about the needs of home modifications, the safety equipments installation to prevent future falls. Also, the nurse will discuss with the family members regarding the supports patient will receive at home during the recovery period. The nurse will also explain the family about the effects of social isolation and the psychological factors in the recovery process.

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