Running head: DISCHARGE PLANNING PROJECT

Discharge Planning Project

Patricia Korovich
University of South Florida: College of Nursing

DISCHARGE PLANNING PROJECT

Discharge Planning Project

Patient education is a major factor of the nursing process that sometimes can be
glossed over during an individuals stay in a medical facility. A nurse may quickly
describe the effects of a new medication, or she may demonstrate how to use a complex
piece of medical equipment; ultimately, while the patient is still in the hospital setting,
there is a constant availability of staff to help explain what is happening during the course
of his or her care. When it comes to discharge planning, however, since there is less
access to assistance, it is profoundly important for a nurse thoroughly educate his or her
patients on what to expect when they leave the facility, how to care for themselves, and
when to seek further medical attention. This project seeks to detail the discharge planning
process for D. S., a patient with Guillain-Barre syndrome.
History of Present Illness
D. S. is an 18 year old female with a history of hypertension and morbid obesity
who was transferred to Bayfront Medical Center from St. Cloud Regional Medical Center
on 10/22/15. In July of 2015, the patient underwent gastric bypass surgery at St. Cloud
and was released several days after, as planned. A week or two following the procedure
she began to experience profound nausea and vomiting upon attempting to progress her
diet as directed by her physician; she sought medical attention and was admitted to St.
Cloud. During that admission a lumbar puncture was performed and the patient was
diagnosed with Pseudotumor Cerebri, treated, and was discharged. After several days the
patient began to experience parathesia and weakness in her feet, bilaterally, and became
unable to walk. She was admitted back to St. Cloud on 9/25/15. Several CT scans were
done of the head, lumbar and cervical spine, which were negative. During this admission,

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she began to experience bilateral hand weakness and parathesia, as well. It was decided
that the patient may have Guillain-Barre syndrome, and was transferred to Bayfront
Medical Center for further neurological assessment and care on 10/22/15.
The patient claims the lower limb weakness she is experiencing began three
weeks before her admission to St. Cloud on 9/25/15. She is now experiencing the
weakness, parathesiasa and flaccid paralysis in both the upper and lower limbs, below the
knees and elbows, which is constant. She describes the sensation as numbness and
tingling with sharp pains during movement. A nerve conduction test was completed and
confirmed absent motor and sensory responses in the arms and legs. She also has
occasional positional aching pain in the hips when left in one position for a prolonged
period of time; she is unable to reposition herself, however. During the course of her stay
at the hospital, she has been tachycardic and tachypnic; Symptomatically, she has
experienced anxiety, possibly related to the tachycardia, but is not claiming any shortness
of breath. Her treatment has involved extensive physical therapy, dietary consultation,
frequent position changes and administration of IV immunoglobulin, as well as digoxin.
Discharge Diagnosis
Patient Understanding
The patient understands that she has been hospitalized due to Guillain-Barre
syndrome (GBS) and that it was potentially caused by a viral infection she acquired after
her gastric bypass surgery. The disease process was explained to her, that it involves an
immune response in which the body attacks its own nerves, which causes tingling and
paralysis in the limbs. She recognized the symptomatic progression of GBS as her own
while it was being explained; the patient was informed that in GBS there is weakness and
possibly paralysis in the lower limbs, then the upper limbs, which can ascend to the trunk
of the body over time. She also understood that the recent changes in her heart and

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respiratory rates could potentially be due to the disease. What the patient did not know at
the point that her understanding was being evaluated, is that the prognosis for her
recovery is generally considered good, and that she will likely make a significant
recovery (Osborn, Wraa, Watson, & Holleran, 2014). Until that point she had been very
anxious and teary when talking about GBS and her hospitalization. After learning this,
she became less anxious and more enthusiastic about sessions with physical therapy.
Patient Education
Specific to this disease process, patient education needs to involve physical
therapy. This is because possibly the most helpful instruction will encompass exercises to
help regain movement and instruction on how the patient can ambulate to the best of her
ability safely. Physical therapy has been working with the patient five times a week since
her admission and has begun to see improvement from the state she was in upon arrival.
Still, they find more progress and practice is needed before she can be discharged home;
because of this, case management has suggested that S. D. be transferred to a
rehabilitation facility when she is medically stable and also be considered for a motorized
wheelchair, until she regains full walking ability.
S.D. understands that the added medical issue of being morbidly obese
complicates her recovery in terms of her mobility. Her appetite and eating habits have
been poor since the bariatric surgery, as well, and she understands this may be
contributing to her overall weakness. Her poor nutritional intake and decreased activity
put her at risk for skin breakdown, and she was taught the need for frequent repositioning
and to notify staff if she became damp. Additionally, she was taught how to use an
incentive spirometer correctly, every hour or so, since she is at high risk for respiratory
complications due to poor nutritional intake, and limited mobility. Initially, she was

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unable to hold the spirometer; however, later in her hospital stay she managed to find a
way to balance it for use, and states that she does so after every vital check.
Core Measures
The patient, due to her immobility, is at high risk for venous thromboembolism
(VTE), so she was placed on VTE core measures. In compliance with the core measures,
she was ordered Lovenox injections and SCD sleeves. Due to physical therapy placing an
anti-foot drop boot on the patient, which required rotation every few hours, the patient
consented to placement of one SCD sleeve that was rotated, as well. Also by direction of
the core measures, CBC labs were drawn daily, monitored and the patient was assessed
for signs and symptoms of bleeding and/or deep vein thromboembolisms.
Medications
At the time I was providing education to the patient, there was a reconciliation
begun upon admission but not completed for discharge since plans were still being
established for transfer to the rehabilitation facility. The patient will continue the
medications she was prescribed before entering the facility including:
1.
2.
3.
4.
5.
6.
7.

Metoprolol 50 MG PO BID
Pantoprazole 40 MG PO Daily
Carafate 1G PO ACHS
Alprazolam 0.25 MG PO PRN Q6H
Ondansetron 4 MG PO PRN Q6H
Acetaminophen 650 MG PO PRN Q6H
Supplements: Folic acid (1MG PO Daily), Ergocalciferol (50,000 iu PO Daily)
and a multivitamin

Along with these orders the patient will likely be discharged with an anticoagulant, a
medication to manage her tachycardia, and a stool softener. The patient will potentially
continue the Digoxin and Lovenox she was prescribed during her admission and add a
medication such as Colace to the list.

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Because I both gave and observed my preceptor give the patient her medications, I
can verify that the patient was given information regarding side effects. This and
additional medication education that would include:
1. Digoxin (0.125 MG, by mouth, daily) is a cardiac glycoside that is typically used to
treat atrial fibrillation, a cardiac dysrhythmia. It also improves the strength and
ability of the heart or to control the rate and rhythm of the heartbeat. When taking at
home, it is important not to miss any doses and to continue taking the medication
even when feeling better. Go to the doctor for routine blood tests and/or if there are
signs of overdose (confusion, visual disturbances, slow heartbeat, etc.). Side effects
may include dizziness, fainting, slow heart rate and unusual bleeding. Also do not
drive until the effects of the medication are known.
2. Lovenox (50 MG injection daily) is an anticoagulant (or a blood thinner) used to
prevent blood clots, especially in the legs, due to limited activity. If this medication
were to be prescribed upon discharge, the mother would have to demonstrate the
ability to give the injection since the patient does not have fine-motor use of her
hands. This injection needs to be given in the abdomen, 1-2 inches away from the
belly button, rotating the sites each time. There is a risk for bleeding with this
medication, so care needs to be taken to avoid injury, even small ones like shaving.
Any unusual bleeding needs to be reported to a doctor.
3. Colace (100 mg, by mouth, twice a day) is a stool softener that would be given to
this patient for several reasons: immobility, poor eating habits and fluid intake,
generalized weakness and prescription of medications that may cause constipation.
This medication will not cause a bowel movement, but make it easier to go. It is

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important to increase fluid intake to have normal bowel movements. The effect of
the medication may take several days.
Home Assessment
The patient lives at home with her two parents, her two older siblings and one
younger sister, 3 years old. They live in a single-story home in St. Cloud Florida, with no
stairs and no pets. Her mother is able and willing to assist the patient with all of her needs
at home with the help of her husband, and maintains she has the help of the patients
older siblings when the father is at work. The patients mother states that the house was
already been rearranged after the patients gastric bypass surgery to better allow her
mobility, with a wheelchair if necessary. There are no rugs in the house, at all, and the
patients bathroom is equipped with handlebars and a shower seat. The doorways are
wide enough to permit a wheelchair, which they own. Case management is working with
the patients medical insurance to see if a motorized wheelchair may be covered. The
patient was advised to ask for help whenever she is feeling weak or tired to prevent falls.
Follow-up
It is possible that a home health aid may be necessary in the home to assist the
mother care for the patient. This decision may be made after evaluating her progress in
the rehabilitation facility. As stated before, the patient may have a need for a motorized
wheelchair. There will be a need for frequent follow-up appointments with the patients
general practitioner to check digoxin levels, as well as a follow-up with a neurologist to
assess the status of her GBS. Additionally, the patient will require physical therapy
sessions, the frequency of which will depend on her progress in the rehabilitation facility.
If deemed necessary, the patient may also have a follow-up with occupational therapy.
These appointments have not yet been made, but the patient and her mother are aware of

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the need for them. It was reinforced that the patient still needs to maintain her scheduled
appointments with her gastroenterologist and dietitian to address the progress of her
bariatric surgery.
Summary
The patient is aware that while she is likely to make a significant recovery from
her illness, it is possible that it can take years or months to do so. She states, I get that
this is a marathon, not a sprint. I know I have to put the work in to get better. It is
important that she improve her dietary intake (especially protein) to improve her strength
and energy for physical therapy sessions. Both improved nutrition and mobility will help
prevent skin breakdown, blood clots and respiratory issues. Gaining strength and learning
proper body mechanics with physical therapy may also help prevent falls. It was
reinforced to the patient, though, that it is best to take things one step at a time and not to
over do it; exhausting herself would not be conducive to getting better.
References
Kee, J. L., Hayes, E. R. & McCuistion, L. E. (2015). Pharmacology: a
Patient-centered nursing process approach (8th ed.). St. Louis,
MO: Mosby Elsevier.
Osborn, K., Wraa, C., Watson, A., Holleran, R. (Eds.). (2014). Medical-surgical nursing:
Preparation for practice (2nd ed.). Upper Saddle River, New Jersey: Pearson.