DischargePlanningProject

TiffanyTran
UniversityofSouthFlorida
NUR4216L
EdithaCustodio,MSN
October20,2016

Thepatientwasan82yearoldCaucasianmalewhowasadmittedonOctober16,2016
withseverechestpainanddyspnea.Hereceivedafullcardiacworkupcardiacenzymes,EKG,
andcardiacechoallofwhichwerenegative,exceptfortachycardiaseenontheEKG.The
patientalsoreceivedaVQscan(negativeforpulmonaryembolism)andultrasoundDopplerfor
bilateralupperandlowerextremities(negativeforvenousthromboembolismsVTE).Patient
beganpresentingwithlowgradetemperatures(e.g.in99F),resultinginaworkupforinfectious
disease.UsingCTChestwithoutcontrast,patientwasfoundtohaveatelectasisandairspace
consolidationspredominantlyinthelowerlobesbilaterally(notvisibleontheoriginalCXR),
whichweresuspiciousofpneumoniaoraspiration.PatientwasplacedonIVclindamycin,a
broadspectrumantibiotic,(600mg/50mLevery8hours)andwasawaitingaspeechtherapy
consultforaswallowstudyonthedaycarewasprovided.
Thepatientunderstoodhisoriginaldiagnosis(unexplainedchestpain),buttheresultsof
hisCTChestwerefinalizedthedayofcare.Hedidnotunderstandhisdischargediagnosisand
howhisrecentdifficultiesswallowingthinliquidsathomecouldpotentiallyhaveledtohis
condition.Theprocessofaspiratingfoodintothealveoliandhavingitdevelopintoatelectasis
(alveolarcollapse)orpneumoniawasexplainedtothepatientindetail.Patientlearningwas
confirmedusingtheteachbackmethodofevaluation.AccordingtotheJointCommission,there
arenolongercoremeasuresdefinedforpneumonia,however,therearecoremeasuresforVTE,
whichareaconcernformosthospitalizedpatients(JointCommission,2016).Theapplicable
coremeasureVTE1(VTEProphylaxis)wasmetduringthispatientshospitalstay(Joint
Commission,2016).AfterhisscreeningtoruleoutVTE(theVQscanandultrasoundDopplerof

hisupperandlowerextremities),patientwasplacedondailyenoxaparin(Lovenox)30mg
subcutaneousinjectionsandsequentialcompressiondevices(SCDs)prophylactically.
Additionally,ambulationwithassistancewasencouraged.
AshisdischargewasdelayedduetotheresultsofhisCTChest,therewasnotyeta
reconciledlistofanynewprescriptionsorrefills.Upondischarge,however,theproviderwould
reconcilethemedicationlistandthenursewouldinclude,andexplicitlyexplain,informationlike
thelastdoseandnextexpecteddosetothepatient.Asmedications,suchasclindamycinand
enoxaparin,wereaddedtohisregimen,thepatientwaseducatedontheindicationsandpotential
sideeffects.Forinstance,thepatientwaseducatedtotaketheentireprescriptionofantibiotics,
nomatterhissymptoms,toavoidconcurrentuseofalcoholandthatGIupsetwascommon,but
tomonitorforandreportanyhypersensitivityreactions.Forenoxaparin,patientwaseducatedto
becautiousoffallrisksandtomonitorforandreportunusualbruisingorbleeding.
Duringthehomeassessment,thepatientconfirmedthathelivesindependentlyinahouse
withseveralanimals(4catsandadog).Thepatientagreedthathewasafallriskandconfirmed
thathehadaccessibilityfeaturesinhissinglelevelhomeforhissafety,e.g.ashowerchairand
handle,andanelevatedtoiletseat.Patientconfirmedthathedoesnothavearearugsandthathe
usesacaneorawalkerwithaseat,dependingonhisstabilityeachday.Themainconcernabout
homewasthatpatientdidnothaveanemergencyalertsystem.Patientinsistedthathedidnot
requirethis,however,hisnursewasinformedandagreedshewouldfollowupwiththepatients
socialworkertoaddressthisconcern.Patientadvisedthat,duetohisdiabeticneuropathy,hehad
givenupdrivingabout6yearsago,butthatheutilizestaxisorhashisdaughter(whoresidesin
thehousebehindhis)drivehimandhelphimcompletehisinstrumentalactivitiesofdailyliving

(IADLs).Hedeniedanyfinancialconcernsregardingmedicationsorfollowupappointments.
Patientwasnotinneedofhomehealthservicesordurablemedicalequipment,butdid
haveseveralfollowupappointmentsalreadyscheduled.Twoofhisfollowupappointmentswere
scheduledforDecember2016attheUSFHealthFloridaCardiovascularInstituteofSouth
TampaforafollowupechoandvisitwithJoelFernandez,MD.Hewasalsoaskedtofollowup
withhisnephrologist,GermanRamirez,MD.,asaprecautionduetohisPMHofchronickidney
diseaserelatedtohisliverissuesandtransplant.Inregardstoothermembersofthe
interdisciplinaryteam,thepatientwasawaitingconsultfromspeechtherapyregardinghis
swallowevaluation.Thepatientsneedforservicesathomewasminimal,ashewas
independent.If,however,thepatientwereprescribedIVantibioticsathomeforlongterm
treatment,thesocialworkerwouldbeconsultedtosetuphomehealthcare.Further,hecould
benefitfromthesocialworkerarrangingforhimtohaveanemergencyalertsystem,butthe
patientdidnotseemreceptivetothissuggestion.
Inthispatientscase,themostimportantconsiderationtopreventhisreadmissionforthe
samesituationwouldhingeupontheresultshisswallowevaluation.Itseemedlikelythatthe
patientwasatriskforaspirationpneumonia,asheconfirmedhisswallowingdifficultiesoflate.
Thus,itwouldbepertinenttoeducatethepatientaboutthickeninghisliquidsandaboutsafe
swallowingtechniques,whichspeechtherapywouldbeabletoevaluateandaddress.Although
thepatienthadacomplexPMH,includingdiabetesmellitus,prostatecancer,livertransplant,
chronickidneydiseaserelatedtoliverfailure,andanemiarelatedtoliverinsufficiency,hewas
overseeinghisothercomorbiditiesrelativelywell.Hewasmanaginghisbloodglucoselevelsat
homewithinsulin,seeinganoncologistattheTGHCancerCenter,anephrologistforhis

kidneys,andhavinghislabsdrawnperiodicallyinordertodeterminewhetherornotherequired
injectionsofepoetinalfa(Procrit)forlowhemoglobin.Thereby,themainfocusforpreventing
readmissionwouldberegardingpreventionofaspiration.

References
Epocrates,Inc.(2016).Epocrates(Version16.6)[Mobileapplicationsoftware].Retrievedfrom
http://itunes.apple.com
JointCommission.(2016,June17).Coremeasuresets:Venousthromboembolism.Retrieved
fromhttps://www.jointcommission.org/core_measure_sets.aspx