NRS 460 Benchmark – Case Study: Timothy Smith – Discharge Planning Assignment

NRS 460 Benchmark – Case Study: Timothy Smith – Discharge Planning Assignment

NRS-460 Benchmark – Case Study: Timothy Smith – Discharge Planning
PART II: Critical Thinking Activity
Use the findings from your evaluation to complete the following:
Home Health Care and Rehabilitation Therapy
During care coordination and transition of care planning, it is important to consider the type and level of care a patient might need.
You are the transitional care manager assigned to Mr. Smith before discharge. Based on Mr. Smith’s assessment findings, develop a discharge plan that encompasses his care needs following discharge. Your response should be a minimum of 200 words. A patient-centered discharge plan should be developed for Mr. Smith. The discharge plan should encompass a range of care services to address his needs. Firstly, the nurse should provide health education to Mr. Smith. Health education should focus on care aspects such as treatment adherence, dietary and lifestyle modification, and approaches to achieve optimum outcomes in his care (Provencher et al., 2021). The nurse should also educate Mr. Smith on the care coordination plan, including the incorporation of telehealth into his care.

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Mr. Smith’s discharge plan should also encompass interdisciplinary teams that would be involved in his care post-discharge. It is evident from the assessment findings that Mr. Smith will require rehabilitative care from a physical therapist and an occupational therapist. He will also require care from a wound care nurse and a psychiatric nurse to ensure his optimal health (Sivasundaram et al., 2020). The transitional care manager should ensure that these professionals are involved in developing a care plan for Mr. Smith.
Mr. Smith’s functional changes and the impact of the accident on his health have considerable psychological implications. The transitional care manager must also ensure that post-discharge care promotes his psychological, emotional, and spiritual care. The manager should ensure the ready availability of support from Mr. Smith’s significant others such as family and friends. Mr. Smith should also be linked with social support groups to facilitate his coping with his changes in functioning. The manager should also ensure that Mr. Smith accesses counseling services to promote his psychological well-being (Provencher et al., 2021). These strategies will ensure holistic care for Mr. Smith after his hospital discharge.
Discuss three to five interdisciplinary roles that will be essential in supporting Mr. Smith’s home health and rehabilitative care needs. Your response should be a minimum of 150 words. Mr. Smith’s care requires different interdisciplinary roles to ensure his safe recovery and optimal functioning. One of the interdisciplinary roles that is needed for Mr. Smith’s care is the nurse. Nurses should be involved in Mr. Smith’s post-discharge care for his recovery. Nurses will perform different aspects of care such as wound dressing, medication administration, vital signs monitoring, patient education, and assessment of his treatment response (Pfeufer et al., 2020). They will also coordinate the interprofessional care being offered to Mr. Smith.
The other interprofessional role required for Mr. Smith’s care is physical therapy. Physical therapists should be involved in Mr. Smith’s care. They will provide the needed services such as assessing his strength, functional abilities, and mobility. The therapists will also help develop a patient-centered rehabilitation program that will help restore Mr. Smith’s functioning. Mr. Smith also requires occupational therapy post-discharge. An occupational therapist should be involved in his discharge planning. The therapist will assist Mr. Smith develop competencies in performing his activities of daily living (Donohoe et al., 2020). Mr. Smith also requires an occupational therapist to assess his functional status and recommend interventions he should embrace to regain his independence in performing activities of daily living.
You are the home health nurse assigned to treat Mr. Smith. Identify two areas of concern that you might prioritize during your initial visit with him following discharge. Your response should be a minimum of 150 words. One of the areas of concern that I would prioritize during the initial visit following Mr. Smith’s discharge will be infection prevention and control. I will assess Mr. Smith’s wounds for healing and any signs of infection. I will also clean and dress his wounds to prevent infections. The other aspect of infection prevention and control that I will consider is medication administration and determining his adherence to the prescribed medications. I will administer the prescribed intravenous medications to facilitate wound healing (Foster et al., 2020). I will also educate Mr. Smith and his family about infection prevention and control practices such as hand hygiene.
The second area of concern that I will prioritize is Mr. Smith’s psychosocial health. I will assess his psychosocial health and well-being. I will obtain information from him about the adequacy of support that he receives for his mental health and well-being, and rule out mental health problems such as major depression and anxiety disorders. I will also assess his adherence to the prescribed treatments for depression (Yeung et al., 2022). I will also assess his functional status and utilization of social support resources for his recovery.
Psychosocial and Spiritual Considerations
Providing holistic nursing care for patients with complex conditions requires that the nurse takes into account the patient’s psychosocial and spiritual needs.
Given the patient’s current situation, discuss ways in which the nurse can take into account and address the patient’s psychosocial and spiritual needs. Your response should be a minimum of 150 words. The nurse should provide care that considers and addresses Mr. Smith’s psychosocial and spiritual needs. The nurse should begin by assessing Mr. Smith’s spiritual and psychosocial needs during the first encounter. The assessment will enable the nurse to develop appropriate treatment plans that address Mr. Smith’s psychosocial and spiritual needs. The second strategy the nurse should consider is ensuring that he develops a positive relationship with Mr. Smith. Trust, honesty, accountability, and responsibility should characterize the relationship between Mr. Smith and the nurse. The nurse should aim at creating an environment where Mr. Smith is comfortable expressing his concerns, views, and preferences. The nurse can also promote the patient’s spiritual health by offering culturally competent care. The care should respect Mr. Smith’s cultural values, beliefs, and preferences that influence his experiences with his health problems (Ghorbani et al., 2021). Nurses can also provide emotional support by adopting strategies such as validating Mr. Smith’s feelings and concerns and offering reassurance.
Just Culture
The patient is due to receive his IV antibiotic before discharge. As the nurse reviews the electronic orders, she notices that the antibiotic dose seems incorrect. Upon discussion with the provider and pharmacy, it was determined the dose entered was incorrect.
Discuss how reporting this near miss will help contribute to a just culture reflecting civility and respect. Your response should be a minimum of 200 words. Reporting the near-miss event will contribute to a just culture that reflects civility and respect in some ways. Firstly, reporting the event will encourage transparency in the organization. It will encourage other healthcare providers to report near-miss events and other forms of errors committed in the provision of patient care services. Reporting also demonstrates that the organization is committed to transparency, safety, quality, and efficiency in the provision of patient care services. Reporting enables healthcare providers to learn from mistakes. The care team can analyze the events to identify the factors that might have contributed to them and the strategies that should be adopted to prevent future occurrences. This helps create a culture of patient safety in the organization. Lastly, reporting the event strengthens communication, respect, and trust among healthcare providers (Manias et al., 2020). Healthcare providers acknowledge the importance of open communication, respect for professional expertise, and the need for collaboration to prevent error occurrence in the future.
Discuss how clinical judgment and critical thinking should be applied despite the use of information and communication technologies. Your response should be a minimum of 150 words. Clinical judgment and critical thinking should be used in Mr. Smith’s care despite the use of information and communication technologies. Nurses should use their clinical judgment and critical thinking because health technologies cannot interpret in entirety the patient’s data. For example, the technologies can collect data such as Mr. Smith’s vital signs but not his psychosocial health and spiritual needs. Nurses should also use their critical thinking and clinical judgment to solve ethical dilemmas in Mr. Smith’s care. Despite their efficacy, health technologies cannot solve ethical and legal challenges that might be experienced in Mr. Smith’s care. Nurses also use their critical thinking and clinical judgment to determine the changes in Mr. Smith’s health. They compare data obtained at different times to determine the efficacy of the selected treatments (Clemett & Raleigh, 2021). Health technologies might lack the ability to determine such trends or patterns, hence, the need for clinical judgment and critical thinking.
Levels of Risk
As Mr. Smith is waiting for the nurse, he becomes impatient and starts to verbally attack the patient care technician as she obtains his vital signs.
Identify actual and potential levels of risk to the care team within this situation given the patient’s history of PTSD. Your response should be a minimum of 150 words. The patient has a high risk of causing harm to the care team because of his history of post-traumatic stress disorder. The patient might be aggressive and irritable when being cared for by other healthcare providers after his discharge. This is likely to lower the quality of care that he will receive, hence, his recovery. Mr. Smith is also at risk of self-harm. Behaviors such as verbal and physical attacks will increase his risk of injuries such as falls since he currently uses assistive devices. There is an increased potential for Mr. Smith’s poor treatment adherence. Changes in functional status and poor mental health imply that the possibility of Mr. Smith being non-adherent is high. Poor treatment adherence will also worsen his mental health, and delay healing and recovery from his injuries. Mr. Smith is also at risk of receiving suboptimal support from his family and significant others because of his aggression and irritability (Pfeufer et al., 2020). Therefore, modalities to ensure his optimum mental health should be considered.
What can the nurse do to diffuse this situation? What steps can be put in place to ensure safety for both patients and providers in the future? Your response should be a minimum of 150 words. The nurse should respond calmly to diffuse the situation. In doing this, the nurse should prioritize staff and patient safety. Being calm will help the nurse to de-escalate the situation and prevent it from worsening to physical aggression. The nurse should ensure that the patient, patient care technician, and other healthcare providers in the environment are safe from any form of harm. The nurse should then adopt strategies such as validating Mr. Smith’s feelings and redirecting his conversation with the patient care technician to shift the focus from the situation. Some strategies can be put in place to ensure safety for both patients and providers in the future. Firstly, nurses and other healthcare providers must set boundaries with their patients to ensure that they demonstrate the right behaviors. Secondly, all patients should be assessed for violence and aggression. Healthcare providers should be informed of the risks to ensure that they incorporate effective approaches to caring for such patients (Caruso et al., 2021). Lastly, healthcare providers should be trained in effective management of undesired patient behaviors such as verbal aggression. This will ensure that they are competent in addressing these issues in their practice.
Patient Portal
The nurse is helping Mr. Smith log in to the Patient Portal (i.e. MyChart) before discharge.
Explain the considerations for ensuring the patient would be able to use this resource at home. In your discussion include considerations related to the patient’s condition and cognitive status based on his assessment findings and history of injury reviewed in previous topics. Your response should be a minimum of 200 words. Mr. Smith should be able to use MyChart at home. One of the considerations for the nurse is to ensure that Mr. Smith understands the reasons for telehealth in his care and its impacts on health outcomes. Mr. Smith’s understanding and motivation are crucial for effective telehealth use in managing his health. The nurse should also assess Mr. Smith’s ability to operate and interpret data generated by the system. Mr. Smith should be able to log in to the system and initiate different aspects of care such as contacting his primary care provider and monitoring his health status. The nurse should also assess Mr. Smith’s ability to make sound decisions (Gusdorf et al., 2023). Information about Mr. Smith’s decision-making abilities will inform his ability to ensure the safe use of telehealth post-discharge.
The nurse should educate Mr. Smith on MyChart use. The education and training should equip him with the knowledge and skills needed to navigate the portal. Clarity in instructions is also important in ensuring that Mr. Smith can use the portal effectively. This includes simplifying the instructions related to the system use and performing common tasks that would be needed for efficient virtual delivery of care services. The nurse might also consider incorporating the use of visual aids to enhance Mr. Smith’s understanding. Patients often have different levels of understanding when being taught the use of health information technologies. As a result, the nurse should ensure tailored education for Mr. Smith (Gusdorf et al., 2023). The nurse should educate Mr. Smith based on his technology literacy, preferences, and needs.
Discuss the benefits for both the patient and the care team in using information and communication technology to support the patient-provider relationship. Your response should be a minimum of 150 words. Information and communication technology benefits patients and the care team in many ways. Firstly, patients benefit from timely access to the healthcare services they need. Patients can communicate with their healthcare providers virtually, which ensures timely access to healthcare information and services. Health technologies also reduce healthcare costs. They eliminate unnecessary hospital visits since healthcare providers can assess their patients virtually and make treatment decisions. Healthcare technologies also increase engagement in healthcare. Patients play a proactive role in the management of their health problems, hence, their empowerment. Healthcare providers also benefit from health technologies. The benefits include increased efficiency in the provision of healthcare services, enhanced communication with their patients, and timely monitoring of patient’s health status. Healthcare technologies such as telehealth provide real-time data about patient’s health status such as heart rate for patients with cardiovascular problems. Healthcare providers can use the information to make timely decisions about patient care and needs. Telehealth also improves efficiency in healthcare. It reduces workload and costs to health organizations and patients (Gajarawala & Pelkowski, 2021). Therefore, patients and healthcare providers benefit from information and communication technologies that support patient-provider relationships.
What obstacles might hinder his use of the Patient Portal? Your response should be a minimum of 150 words. Some obstacles might hinder Mr. Smith’s use of the Patient Portal. One of the obstacles is limited internet access. The use of the Patient Portal requires patients to have access to the Internet. Patient and provider interaction occurs virtually, which translates into the need for reliable internet access. The other obstacle that might be experienced is Mr. Smith’s unwillingness to use the Patient Portal. His unwillingness will imply that the desired care outcomes with the use of the technology will not be realized. The other barrier that might be encountered is a lack of technology literacy. Patients should be competent in navigating the system for efficient interaction with healthcare providers. Limited technology literacy will imply that Mr. Smith will not benefit from the Patient Portal, hence, a barrier. The last obstacle that might hinder Mr. Smith’s use of the Patient Portal is the shortage of healthcare providers (Gajarawala & Pelkowski, 2021). Provider shortages will imply a high workload for the available staff, which will limit the provision of care through the Patient Portal.
Telehealth
Mr. Smith is scheduled for a telehealth appointment with the psychiatrist upon discharge.
Discuss the information and resources that the nurse should ensure the patient has available in preparation for his visit. Your response should be a minimum of 150 words. The nurse should ensure Mr. Smith has a range of information and resources for the telehealth appointment. One of the resources is internet access. A reliable internet connection is needed for effective interaction between Mr. Smith and the psychiatrist. Mr. Smith should also have the device for telehealth. The devices can be a laptop, tablet, or a smartphone, which can enable virtual interaction between the psychiatrist and the patient. The devices should also be compatible with those being used by the psychiatrist. The devices should have functioning cameras, microphones, video, and audio capabilities to ensure that the psychiatrist can interact face-to-face virtually with Mr. Smith. The nurse should also ensure that Mr. Smith can access the telehealth platform. This includes ensuring that his credentials have been registered with the service provider and login details provided to him. Mr. Smith might encounter challenges in using telehealth technology (Gajarawala & Pelkowski, 2021). Therefore, a support person should be there to offer him the assistance he might need in using the system.
References
Caruso, R., Antenora, F., Riba, M., Belvederi Murri, M., Biancosino, B., Zerbinati, L., & Grassi, L. (2021). Aggressive Behavior and Psychiatric Inpatients: A Narrative Review of the Literature with a Focus on the European Experience. Current Psychiatry Reports, 23(5), 29. https://doi.org/10.1007/s11920-021-01233-z
Clemett, V. J., & Raleigh, M. (2021). The validity and reliability of clinical judgement and decision-making skills assessment in nursing: A systematic literature review. Nurse Education Today, 102, 104885. https://doi.org/10.1016/j.nedt.2021.104885
Donohoe, E., Roberts, H. J., Miclau, T., & Kreder, H. (2020). Management of Lower Extremity Fractures in the Elderly: A Focus on Post-Operative Rehabilitation. Injury, 51, S118–S122. https://doi.org/10.1016/j.injury.2020.04.050
Foster, A. L., Moriarty, T. F., Trampuz, A., Jaiprakash, A., Burch, M. A., Crawford, R., Paterson, D. L., Metsemakers, W.-J., Schuetz, M., & Richards, R. G. (2020). Fracture-related infection: Current methods for prevention and treatment. Expert Review of Anti-Infective Therapy, 18(4), 307–321. https://doi.org/10.1080/14787210.2020.1729740
Gajarawala, S. N., & Pelkowski, J. N. (2021). Telehealth Benefits and Barriers. The Journal for Nurse Practitioners, 17(2), 218–221. https://doi.org/10.1016/j.nurpra.2020.09.013
Ghorbani, M., Mohammadi, E., Aghabozorgi, R., & Ramezani, M. (2021). Spiritual care interventions in nursing: An integrative literature review. Supportive Care in Cancer, 29(3), 1165–1181. https://doi.org/10.1007/s00520-020-05747-9
Gusdorf, R. E., Shah, K. P., Triana, A. J., McCoy, A. B., Pabla, B., Scoville, E., Dalal, R., Beaulieu, D. B., Schwartz, D. A., Horst, S. N., & Griffith, M. L. (2023). A patient education intervention improved rates of successful video visits during rapid implementation of telehealth. Journal of Telemedicine and Telecare, 29(8), 607–612. https://doi.org/10.1177/1357633X211008786
Manias, E., Kusljic, S., & Wu, A. (2020). Interventions to reduce medication errors in adult medical and surgical settings: A systematic review. Therapeutic Advances in Drug Safety, 11, 2042098620968309. https://doi.org/10.1177/2042098620968309
Pfeufer, D., Kammerlander, C., Stadler, C., Roth, T., Blauth, M., Neuerburg, C., Böcker, W., Zeckey, C., Lechleitner, M., & Gosch, M. (2020). Multidisciplinary inpatient rehabilitation improves the long-term functional status of geriatric hip-fracture patients. European Journal of Medical Research, 25(1), 31. https://doi.org/10.1186/s40001-020-00433-2
Provencher, V., D’Amours, M., Menear, M., Obradovic, N., Veillette, N., Sirois, M.-J., & Kergoat, M.-J. (2021). Understanding the positive outcomes of discharge planning interventions for older adults hospitalized following a fall: A realist synthesis. BMC Geriatrics, 21(1), 84. https://doi.org/10.1186/s12877-020-01980-3
Sivasundaram, L., Tanenbaum, J. E., Mengers, S. R., Trivedi, N. N., Su, C. A., Salata, M. J., Ochenjele, G., Voos, J. E., & Wetzel, R. J. (2020). Identifying a clinical decision tool to predict discharge disposition following operative treatment of hip fractures in the United States. Injury, 51(4), 1015–1020. https://doi.org/10.1016/j.injury.2020.02.108
Yeung, P., Severinsen, C., Good, G., & O’Donoghue, K. (2022). Social environment and quality of life among older people with diabetes and multiple chronic illnesses in New Zealand: Intermediary effects of psychosocial support and constraints. Disability and Rehabilitation, 44(5), 768–780. https://doi.org/10.1080/09638288.2020.1783375

 

Use the “Case Study: Timothy Smith – Discharge Planning” template to complete the assignment.

This case study has indirect care experience requirements. The “NRS-460 – Case Studies: Indirect Care Experience Hours” form, found in the Topic 1 Resources, will be used to document the indirect care experience hours completed in the case study. As progress is made on the case study, update this form indicating the date(s) each section is completed. This form will be submitted in Topic 5.

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Benchmark Information

This benchmark assignment assesses the following programmatic competencies and professional standards:

RN-BSN

5.3: Contribute to a culture of provider and work environment safety.

American Association of Colleges of Nursing Core Competencies for Professional Nursing Education

This assignment aligns to AACN Core Competencies 5.3, 8.2, 8.3, 8.4, and 8.5.