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Within this assignment I will be looking at effective discharge planning to include all members of the Multi Disciplinary Team in order to meet all needs of the individual

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´╗┐The Department of Health 2010 suggests ?Discharge or care transfer is an essential part of care management in any setting. It ensures that health and social care systems are proactive in supporting individuals and their families and carers to either return home or transfer to another setting. It also ensures that systems are using resources efficiently. This practical resource provides practitioners and organisations with advice to support improvements in how they manage the discharge of individuals and transfer of care between settings.? Within this assignment I will be looking at effective discharge planning to include all members of the Multi Disciplinary Team in order to meet all needs of the individual in question. I will look at problems which may arise once the patient has been discharged and provide nursing interventions and the rationale behind these interventions. In this instance I will be providing a discharge plan for a gentleman, who for confidentiality reasons in accordance to the NMC code of Conduct 2008 which states ?You must respect people's right to confidentiality? I will refer to as Mr S. Mr S is 87 years of age, lives in a flat and is mainly house bound, although he does go out occasionally with his family. ...read more.


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 ...read more.


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. ...read more.

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