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. He has a carer who comes in twice daily to help him with his personal care. Mr S cooks his own frozen microwave meals for lunch and his family or carers’ help with other meals, his family do his shopping.

Mr S was admitted to hospital following a series of transient ischaemic attacks (TIA’s) , his most recent attack lead him to stumble from which he suffered a wound to his leg, the wound became infected and is not healing very quickly. He also has type two diabetes, “Type 2 diabetes occurs when not enough insulin is produced by the body for it to function properly, or when the body’s cells do not react to insulin. This is called insulin resistance.....it  is sometimes referred to as maturity-onset diabetes because it is more common in older people” (NHS Choices) which is generally controlled by his diet although on admission to hospital it was raised at 10mmol/l.  He has had hypertensive episodes in the past, but this seems to be controlled by Bendroflumethiazide which he takes 2.5mg once per day. He does have a mild case of osteo-arthritis, although this seems stable.

The Problem is: Mr S is taking 4 Medications including Simvastatin, which he takes 20mg at night time. Aspirin, 75mg once per day, in order to prevent blood clots and reducing the risk of further TIA’s, he also takes paracetamol 500mg up to four times per day when he needs it for pain management.

The Goal is: For Patient to receive all medication as per prescription, in order to gain maximum benefit from the medication. To take medication safely and to reduce risks of complications.

The Nursing Interventions are:

To order all medication from the pharmacy prior to discharge.

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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 ...

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