Case Study: Timothy Smith - Discharge Planning

Evaluate the information and formulate a conclusion based on your evaluation. Complete the critical thinking table and submit the completed template to the assignment dropbox.
It is necessary for an RN-BSN-prepared nurse to demonstrate an enhanced understanding of the complex management of disease during the discharge of a patient, and the additional aspects of communication and safety in the work environment. The purpose of this assignment is to participate in discharge planning for a patient utilizing communication and information technology, and in a scenario where patient and provider safety is a concern.
PART I: Health History and Medical Information
Evaluate the health history and medical information for Timothy Smith, presented below.
Mr. Smith is ready to be discharged from the hospital. Timothy has been weaned off of oxygen. His tube feedings have been discontinued and he is tolerating a pureed diet. To facilitate safe discharge, the hospital case manager has set up services with a transitional care manager from a Home Health agency. The goal is for Mr. Smith to attain safe recovery and rehabilitation.

  1. Broken left leg status
  2. Weight bearing status: non-weight bearing, stand pivot with right leg only
    a. Assistive devices: wheelchair
    b. PICC line present for discharge
  3. Left upper leg wound care: dressing changes as needed for open reduction internal fixation (ORIF) on leg
  4. Psychiatrist telehealth follow-up scheduled for a Zoom call upon discharge
  5. Telehealth follow-up visit scheduled two weeks after discharge with Primary Care Physician (PCP)
    Lab Tests and Vitals
  6. Room air, respiratory rate 16 breaths per minute
  7. Vital signs are within normal limits

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 prior to 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.
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.
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.
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.

Full Answer Section

Sample Answer

         

Evaluation and Critical Thinking for Timothy Smith's Discharge

   

Part I: Health History and Medical Information Evaluation

  Mr. Timothy Smith presents as a patient requiring comprehensive discharge planning due to his complex medical status. The key aspects to note from his health history and medical information are:
  • Left Leg Injury & Mobility Impairment: The "broken left leg status" and "non-weight bearing, stand pivot with right leg only" indicate significant mobility limitations. This directly impacts his ability to perform activities of daily living (ADLs) and safely navigate his home environment. The prescribed "wheelchair" as an assistive device confirms this need.
  • PICC Line: The presence of a PICC line for discharge suggests ongoing need for intravenous medication administration (e.g., antibiotics, pain management, nutritional support if not fully tolerating diet), which requires specialized care and monitoring to prevent complications like infection or occlusion.