Discharge Planning Project

Shannon OShea
University of South Florida

My patient is a 61-year-old female who presents with headache, fever and

chills for the last week. She says that approximately one week ago she started

having headaches, and since then she developed some chills and fevers. She saw
her primary care physician and they prescribed her Augmentin. After five days
however, this did not help her and she continued to become worse with headaches
and fevers. Her chills became so bad she began to violently shake so she came in to
the emergency room. She says her head hurts all over, and she has had some
stiffness in her neck. She did deny any nausea or vomiting. In the emergency
department the patient had a fever of 100.2 and her labs were within normal limits.
The patient had a lumbar puncture which was abnormal showing an elevated white
blood cell count and noticeable red blood cells. She was admitted to the hospital for
further monitoring and evaluation, and was diagnosed with viral meningitis.
The patient is alert and oriented times four. Her headaches, fevers and chills
have decreased. She is ambulating independently in her room, and to the restroom.
She is resting comfortably and doesnt seem to be in any distress. The patient is
currently receiving pain medication for headaches. The plan is for the patient to be
discharged this afternoon. She will be going home independently.
Discharge Diagnosis
The patient is aware of why she was admitted to the hospital. At first she did
not understand what could be causing her problems, but after the doctor explained
viral meningitis and how it works it became clearer to her. Now that she has been
diagnosed with viral meningitis there is some education that she was provided. The
patient was made aware that viral meningitis has a treatment process which
generally consists of pain management, rest and monitoring. Following viral
meningitis that patient has a risk of developing symptoms such as exhaustion,
headaches, dizziness, and hearing difficulties (Viral Meningitis, 2014). The patient

has also been advised not to do any straining, or any heavy lifting that could strain
the neck muscles. My patient does not have any core measures at this time.
Medications
The patient does have a reconciled medication list with her discharge packet.
She has three new prescriptions that have been explained to her and the education
material has been provided. She has two new medications for pain which are Norco
and Ibuprofen, and she has a new prescription for Immitrex for her headaches. In
her discharge packet she has a complete list of when her last doses were given, and
when she needs to take her next doses of medication. The patient has been
educated on all her new prescriptions, and is aware of how to take the medication,
when to take them, and any side effects that may occur.
Home Assessment
The patient currently lives in a one story home with her husband. The patient
states her husband takes great care of her when she is ill, and he will assist her with
anything she may need. The patients living situation is safe, and there are currently
no barriers for her to be discharged home independently. Following discharge, the
patient is to refrain from driving for one week. Her husband will be driving to pick up
any prescriptions and accompany her to follow up appointments. The patient has
not expressed any concerns of financial difficulties, and she states she will have no
problems picking up her prescriptions or attending follow-up appointments.
Follow-Up
The patient does not have any need for home health care services, or any
durable medical equipment at this time. The patient has a follow up appointment

scheduled with her primary care physician three days from now at his office. The
patient does not have any need to consult a specialist. and no other team members
were included in her discharge planning.
Summary
The most important considerations to prevent readmission for my patient is
education on signs and symptoms of bacterial meningitis and keeping up with her
follow-up appointments. Viral meningitis can sometimes turn out to be early
bacterial meningitis which can be much more dangerous. The patient has been
provided education that consists of home care tips such as proper hand hygiene,
staying hydrated and resting and refraining for activities for one week. The patient
has also received information on identifying signs of her meningitis worsening, and
when to seek medical attention. With adequate rest and proper pain management
the patient should feel better in two to seven days (Viral Meningitis, 2014).

References
Viral Meningitis. (2014, November 26). Retrieved November 23, 2015, from
http://www.cdc.gov/meningitis/viral.html