Discharge Planning
The nursing process is dynamic and cyclical. Problems may resolve or change. Resolved problems are noted on the care plan or care path as “resolved.” As clients meet their goals, new goals are set. If goals remain unmet, you must consider the reasons these goals are not being achieved and suggest revisions to the nursing care plan.
For the woman with pneumonia described,one goal is to acknowledge the need for follow-up to prevent a recurrence of problems. By the time of discharge, both the client and her daughter are able to identify signs and symptoms that would indicate a recurrence. However, if this evidence was lacking, the plan of care would need to be modified to address additional teaching for the client and her daughter.
Key Concept Nursing evaluation is the measurement of the effectiveness of assessing, diagnosing, planning, and implementing. Evaluation includes the following steps:
• Analyzing the client’s responses
• Identifying factors that contributed to the success or failure of the care plan
• Planning for future nursing care
Discharge planning is the process by which the client is prepared for continued care outside the healthcare facility or for independent living at home. Clients, family, or other healthcare workers may provide continuing care. Planning for discharge begins when a client is admitted to the healthcare system and is ongoing throughout the client’s plan of care. Because clients achieve different levels of care at different times, the discharge plan must be individualized. Some facilities incorporate the discharge plan into the nursing care plan or clinical care path.
Before the client is ready for discharge from the facility, the healthcare team usually holds a conference with the client (and family, if possible). The purpose of this conference is to identify long-term goals that are still unresolved and to plan for continued assistance to the client.
Working together, the healthcare team and client may set new goals at the discharge conference. The family learns to help the client to meet new—and also former—goals. The primary nurse, or team leader, is responsible for seeing that the client or family has the necessary discharge instructions. All instructions (verbal, and written or printed out) that are given to the client or family must be carefully documented. Discharge plans also include plans for follow-up. Box 36-1 lists components of discharge planning.
BOX 36-1.
Examples of Components of Discharge Planning
A discharge plan includes specific components of client teaching, with documentation of exactly what was taught, who did the teaching and when, who was present (members of the healthcare team, client and/or family), and the client’s reaction or expressed level of understanding. Examples of specific components include the following:
Equipment needed at home
• Documentation that the family has obtained equipment or knows where to get it
• Documentation of instruction and return demonstration in the use of any special equipment
• Documentation of ability to understand instructions
Dietary needs: Special diet
• Documentation by the dietitian as to teaching the client and family
• Document their level of expressed understanding
Medications to be taken at home
• Documentation of instructions and special precautions
• Procedures, such as a dressing change or injection of medication
• Demonstration and return demonstration must have been given several times
• Documentation of ability of client or significant other to do procedure
Resources
• Written contact numbers and addresses of resources
• Referral to public health or home care services
• Documentation of expected first date of service
• Documentation of contact numbers
• Documentation for follow-up care
Emergency response: Danger signs
• Documentation of specific urgent problems that may develop
• Documentation of emergency numbers and physician’s numbers
Activity
• Documentation that instructions were given and understood
• Examples of activities allowed or not allowed
Summary
• Documentation of verbal teaching, demonstrations, and return demonstrations
• Documentation that a copy of the written instruction sheet was given to client and/or significant others
• Description of each specific concept or task that was taught
• Documentation ability of the client or significant other to comprehend instruction
• Documentation of planned follow-up by facility or physician
Key Concept Discharge teaching begins on admission and continues throughout the client’s care.The client and family cannot be expected to remember a large amount of teaching at one time, especially just as the client is leaving the facility
NCLEX Alert Discharge planning may include written instruction, skills demonstration, and/or verbal teaching. The client, the family and one or more significant persons may be included in the discharge planning. Always consider the uniqueness of the client and the client’s situation when providing an NCLEX answer
KEY POINTS
• Implementation involves dependent, interdependent, and independent actions.
• Nurses use intellectual, interpersonal, and technical skills to implement care plans.
• During implementation, nurses collect further data and communicate information with other members of the healthcare team.
• During evaluation, client responses are analyzed, factors contributing to the success or failure of the plan are identified, and planning for future care occurs.
• Discharge planning and future planning are based on nursing care plans.
