Discharge Plan

The patient is an 89 year old Chinese female. About two years ago she had a small bowel
resection to treat stage 3 rectal cancer. Ever since, the patient has lived with a colostomy. Other
diagnoses include hypertension and chronic constipation. The patient has been hospitalized
several times due to recurring small bowel obstruction, which is one of the complications of
small bowel resection and constipation. As a retired physician and through the experiences of
several episodes of small bowel obstruction, the patient is expected to have sufficient knowledge
about colostomy care and the symptoms of small bowel obstruction. But further investigation
about her awareness and experience about other complications of small bowel resection
including celiac disease, Crohn's disease, short gut syndrome, malabsorption, is needed.
(Medscape, 2015) Currently the patient's weight is 58 kg, which is within normal range for a
female of her age. This indicates that the patient is not having a nutrition absorption issue. But
since her constipation persists and presumably contributes to small bowel obstruction
(Medscape, 2015), the assessments about her diet should include monitoring the patient's usual
diet to see if it includes food items that exacerbate blockage in a patient with a colostomy.
Education should be provided if needed to minimize the chances of recurrence of small bowel
obstruction. The foods that should be avoided include whole grains, carbonated drinks, nuts, hard
vegetables and fruits, and fatty food. And soft food low in fat and fiber is recommended in
general (University of Pittsburgh of the Health Science, 2015).
In addition, hypertension is one of the major medical issues for the patient. Sodium
restriction should be included in the hypertension management education. (Gulanick & Myers,
2014, p.340). For a thorough assessment and education on diet, a referral to a registered dietician

will be a valuable intervention. (ATI Nursing, 2013, p.413-415). Because the patient has chronic
hypertension and bradycardia, patient education should include regular blood pressure and heart
rate monitoring at home, signs and symptoms of hypertension (chest pain, blurred vision,
dizziness, nausea and vomiting) and bradycardia (fatigue, dizziness, lightheadedness) and their
complications including stroke and MI, and prevention and early interventions of the
complications, the importance of regular exercise to effectively manage hypertension, and
increase the mobility of the bowel and perfusion to peripheral tissues, and proper administration
of antihypertensive medications that can lower her heart rate, which is already low. For stroke,
the administration of low-dose aspirin within 24-48 hours after the onset of the symptoms such
as sudden headache, immobility on one side of the body, blurred vision in one or both eyes,
slurred speech, etc. should be included in the teaching to prevent further clot formation. (ATI
Nursing, p.159) For MI, education should stress that a nitroglycerine tablet should be placed
under the tongue and 911 should be called immediately. (ATI Nursing, p.345)
Also, the patient is at risk for anemia and infection due to low WBC counts presumably
caused by rectal cancer. The treatment options for anemia like taking iron supplements should be
discussed, and precautions for infection should be reinforced emphasizing hand-washing,
vaccination, personal hygiene, diet high in protein, and adequate rest (Gulanick & Myers, 2014,
p.106).
The patient should be informed when to call her physician in regards to abnormal
findings on her stoma. The abnormalities that need immediate medical attention include that the
stoma is more than a half inch larger than normal, is pulling in, below the skin level, is bleeding
more than normal, has turned purple, black, or white, is leaking often or draining fluid, does not
seem to fit as well as it did before, has a discharge from the stoma that smells bad, and has no

stool output longer than 3 days. (University of Pittsburgh of the Health Science, 2015) Even
though the patient seems to have proper skills for colostomy management, a reinforcement of
education and a referral to enterostomal therapy nurse (ET) would minimize the chance of
potential complications for ostomy (Gulanick & Myers, 2014, p.594).
In regards to learning, the patient has a language barrier for English health care providers.
Her primary language is Mandarin. Therefore, if the dietician and ET are Mandarin speaking
persons or is accompanied by a translator, the communication will be much smoother. Otherwise,
the patient doesn't exhibit any other barrier to learning. Her cognitive, emotional, and
developmental levels seem proper for adult-level learning and communication. The patient
currently resides at home with her daughter, and will be going home. The daughter is the one
who will pick up the patient when discharging. Most likely the daughter is the person who will
help the patient if needed. However, since the patient is physically independent, there appears to
be no need for personal assistance or assistive device for daily activities such as walking,
cooking, bathing, grooming, ostomy changes, etc. But to include the daughter in the education
on how to monitor hypertension regularly, safely administer antihypertensive meds, recognize
the early signs and symptoms of stroke and MI and implement prompt interventions, and
recognize abnormal findings on the ostomy will enhance the viability of the education.

References
American Heart Association. (2014). Bradycardia. Retrieved from www.heart.org
ATI Nursing (2013). RN adult medical surgical nursing (9th ed.).
Gulanick, M., & Myers, J. L., (2014).Nursing care plans: Diagnoses, intervention, and
outcomes. (8th ed.). Philadelphia, PA: Mosby.
Medscape. (2015). Small bowel obstruction. Retrieved from
www.emedicine.mediscape.com
University of Pittsburgh of the health science. (2015). Colostomy care. Retrieved by
www.upmc.com