To ensure all medication is correctly dispensed as per prescription, and in the correct form.
To explain what each medication is for, to educate patient about medications and side effects.
To explain the importance of taking correct dosage of each medication and to complete each course of medication prescribed.
To advise family and carers on medications and details of the prescription.
The Rationale is: “Medication discharge education (MDE) is a major component of discharge planning and a requirement for hospital accreditation. It is essential for persons who are at high risk of re-hospitalization and need to rely on drug therapy to manage a chronic illness.” (Martens 1998) The patient should have knowledge of the medication he is taking and be aware of any unusual side effects of that medication, he should be made aware to seek medical attention if any adverse reactions occur, these could include swelling of the face, eyes, lips or tongue or breathing difficulties. Lindenburg 2010 suggests “Drug-related problems in the elderly may involve overuse, inappropriate drugs, and omission of drugs that are indicated. Rational use of drugs requires that patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements for an adequate period of time, and at the lowest cost to them and their community.” An explanation of how important it is to take the correct medication as per prescription is vital to the patients well being. Family and carers should be made aware of the details of the prescription in case Mr S has trouble comprehending, as it is easy to assume that the patient is cognitively intact and able to understand instruction. Medication should be on the ward ready to give to the patient at the point of discharge from hospital. Medication should always be checked by a registered Nurse against the prescription before handing it to the patient in order to avoid dispensary errors.
The Problem is: Patient is Type two diabetic, which is generally controlled by diet. Potentially could lead to long term complications associated with Diabetes, such as Nephropathy, Neuropathy, arthropathy or retinopathy.
The Goal is: For the patient to be able to manage their Diabetes effectively, maintaining blood glucose levels between 4mmol/l and 7mmol/l. NSF diabetes suggests that services should be “Person-centred: empowering the individual to adopt a healthy lifestyle and to manage their own diabetes, through education and support which recognises the importance of lifestyle, culture and religion, and which, where necessary, tackles the adverse impact of material disadvantage and social exclusion.”
The Nursing Interventions are:
Provide patient with information regarding Diabetes
Show patient how to carry out Capillery Blood Glucose Monitoring (CBGM) and advise on how often this needs to be checked.
To advise patient on correct foot care.
Refer to nutritionist regarding nutritional information and frozen ready meals.
Refer to community matron regarding Expert Patient Programme.
Involve family or significant others.
The Rationale is: Education about diabetes could be an extremely important factor in the psychological effects on the patient. The department of health 2005 suggests there are “emotional and psychological effects of living with a longterm condition generally on the individual, their carer and family. These can include stress, depression, loss of self image and cognitive/behavourial issues”, having greater knowledge and understanding of diabetes and how to live with the condition are likely to decrease the risk of psychological distress.
CBGM monitoring is an important factor in the control of diabetes, in order for early detection of a Hypo or Hyperglycaemic attack, educating the patient on the correct way to check his own sugar levels gives the patient autonomy, this however is under the assumption that the patient has sufficient dexterity.
Foot care is essential to diabetics due to lack of sensation, as Poretsky 2010 describes “Insensitivity coexists with diabetic foot wounds more than 80% of the time” enabling the patient to carry out the majority of his foot care himself involves him with his own care, assuming that Mr S has the physical capability to carry out his own foot care otherwise family/carers could assist with this.
Dunne (2008) states “Failure to assess, manage and prevent malnutrition ultimately leads to increased risk of development of malnutrition-related illnesses, increased risk of infection, increased likelihood of hospital admission, increased length of stay in hospital and can impact on prognosis.” With help from the nutritionist Mr S will be able to maintain an adequate nutritional intake and control his diabetes at the same time.
The Problem is: Mr S has a wound to his shin.
The Goal is: to encourage wound healing and to prevent any further infection. To maintain surrounding skin ensuring that it remains intact.
The Nursing Interventions are:
Refer Mr S to the district nursing team for wound care and to dress wound as required.
Educate Mr S and family/ carers regarding how to look out for clinical signs of infection.
Advise Mr S and family/ carers on how to care for the wound until district Nurses have visited.
Assess pain levels.
The Rationale is: educating the patient and family/carers to be aware of clinical signs of infection such as swelling, increased redness, pain, pus, is vital to catch the infection in early stages and to treat the infection early on, this enables patient autonomy as he is involved in his wound care.
Ensuring the patient/ family and carers have enough knowledge to care for the wound until the patient is seen by the district nursing team will reduce any risk of infection.
An aseptic technique is preferential when cleansing and dressing the wound, however “the decision to use aseptic or clean technique should be made on the basis of risk of infection to the patient...and the environment in which they are cared for” (Vuolo 2009:64). The district Nurses should continuously assess the wound and use dressings appropriate to encourage wound healing during each stage in order “to obtain a clean, warm, moist granular wound bed while protecting the periwound and intact skin” (Myers 2008:146). The wound is likely to be slower to heal as Mr S is a diabetic, “the inflammatory response is delayed in hyperglycaemia, adversely affecting granulation tissue formation” (Dealey & Cameron 2008:33)
The patients pains levels should always be measured as “increased pain may be an indicator of infection” (Dealey 2005), Mr S should be advised to seek medical attention if the pain within the wound worsens.
The Problem is: Mr S suffers with Hypertension.
The Goal is: for the patient to remain in control of his Hypertension, for blood pressure to remain within the normal range, 100/60 – 140/90, and to reduce the risk of further hypertensive episodes.
The Nursing interventions are:
Educate patient on hypertension
Instruct patient and family/carers to self measure Blood Pressure.
Suggest lifestyle changes which may help reduce the risk of further hypertensive episodes.
Suggest the Dietary Approaches to stop Hypertension (DASH) diet.
Advise patient of signs and symptoms to be aware of which need to be reported to a health care provider, including headaches and dizziness, shortness of breath, chest pain, nose bleeds or changes in vision.
Involve family or significant others.
The Rationale is:
Knowledge of a condition involves the patient in his own care, giving the patient autonomy; NICE 2011 informs us “People with hypertension should have the opportunity to make informed decisions about their care and treatment.” This autonomy is enhanced by educating the patient on how to self measure his BP giving him a sense of control, and by educating him on signs and symptoms to be aware of which may indicate a rise in blood pressure.
NICE 2011 state “High blood pressure (hypertension) is one of the most important preventable causes of premature morbidity and mortality in the UK. Hypertension is a major risk factor for ischaemic and haemorrhagic stroke, myocardial infarction, heart failure, chronic kidney disease, cognitive decline and premature death” therefore, it is important to inform the patient of any lifestyle changes which are likely to help control his hypertension. These changes include; reducing sodium intake “dietary sodium contributes to fluid retention and elevated BP” (Gulanick and Myers 2007:303), smoking cessation as smoking causes vasoconstriction, if the patient is overweight, weight loss should be encouraged “of all lifestyle changes, weight reduction has most consistently demonstrated BP- lowering effects” (Gulanick and Myers 2007:302). NICE 2004 suggest Lifestyle advice should be offered initially and then periodically to people undergoing assessment or treatment for hypertension.
“The DASH diet is grounded in healthy eating principles that, in addition to lowering blood pressure, are associated with lower risk of heart disease, stroke and cancer. (Heller
2007:13) this may be an ideal diet for Mr S to follow, however as his Diabetes is usually diet controlled this is an important factor to consider.
The Department of Health (2003) suggest “It is increasingly evident that effective hospital discharges can only be achieved when there is good joint working between the NHS, local authorities, housing organisations, primary care and the independent and voluntary sectors in the commissioning and delivery of services including a clear understanding of respective services. Without this the diverse needs of local communities and individuals cannot be met.”
From this assignment I can clearly see effective discharge planning is essential to ensure the patients well being and to refrain from re-hospitalization. All members of the Multi Disciplinary team must be taken into consideration so that ongoing well being can be provided to the patient once he has been discharged.
References
British Journal of nursing 2008, vol 17 no 20
BMJ. 21 FEBRUARY 2009. VOLUME 338
Dealey.C (2005) The Care of Wounds; a Guide for Nurses. 3rd Edition. Blackwell Publishing. Oxford
Dealey C. and Cameron J. (2008) Wound Management; essential clinical skills for Nurses. Wiley Blackwell. Chichester
Department of Health (2003) Health & Social Care Joint Unit and Change Agents Team. Discharge from hospital: pathway, process and practice
Department of Health (2005) National Service Frameworks for Long Term conditions
Department of Health (2007) National Service Frameworks for Diabetes
Gulanick. M and Myers. J.L (2007) Nursing Care Plans; Nursing Diagnosis and Intervention. 6th Edition. Mosby Elsevier. Missouri.
(6/02/12 11.39am)
Lindenburg, J.A (2010) Medication Safety in the Elderly: Translating Research Into Practice
Martens K.H. (1998) Journal of Advanced Nursing 27, 341–348
Myers B.A (2008) Wound Management; Principles and Practice. 2nd Edition. Pearson. New Jersey
NMC code of conduct.
Poretsky L. (2010) Principles of Diabetes Mellitus 2nd Edition. Springer. New York
Vuolo J. (2009) Wound care made incredibly easy. 1st edition. Lippincott Williams and Wilkins. London
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