Running head: DISCHARGE PLANNING

Discharge Planning Project Paper

Liza McGill SN, SMH
University of South Florida

DISCHARGE PLANNING

Discharge Planning Project

History of Present Illness (HPI)
Patient is a 59 year old white female who lives at home with her husband. In November
of 2014, patient developed some light post-menopausal spotting, which led her to go see her
primary care doctor. The patient had no prior medical problems. However, patient has family
history of cancer on both sides of her family. The patient has never drink or smoke. Patient
exercises regularly and is in good health. Her doctor ordered a pelvic ultrasound and the results
showed that her uterus had leiomyomata and some lesions that was unable to be clarified by the
ultrasound. Patient was then ordered to do a magnetic resonance imaging (MRI) to get a clearer
picture of the uterus. The MRI showed a uterine fibroid 6.8cm by 6.2 cm with degeneration.
Patient was then sent to see an oncologist for further evaluation. The doctor performed an
endometrial biopsy and an endocervical curetting which confirmed a high grade adenocarcinoma
with papillary serous feature.
The patient was admitted to the hospital after a planned scheduled surgery on February
12, 2015 for endometrial cancer. Patient underwent a robotic assisted laparoscopic hysterectomy
with bilateral salpingo-oophorectomy, a bilateral pelvic and periaortic lymphadenectomy, a
omentectomy and a cystoscopy with mini laparotomy. On February 12, 2015, patient was
transferred to 3NW, in room 331-B a short stay post surgery unit for observation. Patient was
ordered pain medications for pain. Patient was alert and oriented and sitting up in bed. Her
abdomen was soft and non tender. Her incisions areas were dry, clean and intact. Patient was
pleasant and was awaiting discharge.
Medical History
Endometrial cancer 2015

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Surgical History
Nasal surgery 1993, rhinoplasty 1993, lip repair 2015, tubal ligation and cesarean section.
Discharge diagnosis
Base on my assessment the patient understood why she was hospitalized as she relayed
her interpretation back to me. It is important to teach the patient to avoid heavy lifting, sexual
intercourse for at least 6 weeks , to notify surgeon of any wound drainage or odor. Also, about
the types of food to eat, to keep her follow up appointment, to avoid driving while on pain
medication, to use a stool softeners and how to prevent infections. Patient discharge diet and
activity was as tolerated. The associated core measures were the removal of the urinary catheter
and the removal of the intravenous line. Both of these were met.
Medications
There was a reconciled list of medications which includes both new and refill
prescriptions. The list included information on the last dose taken and on the next expected dose
to be taken. The patient showed understanding of the medications she takes. She understood
what she takes them for, the directions of how to take them and their side effects. The patient
mostly takes vitamins and mineral supplements to offset what she might be missing in her diet as
she is a lacto-vegetarian.
1. Norco 5/325 (hydrocodone 5mg + acetaminophen 325mg): This medication is use
to manage moderate to severe pain. The medication was giving to the patient as a discharge
home mediation. Patient takes one tablet by mouth every 4 hours as needed for pain. Some side
effects of this medication includes but not limited to constipation, nausea and vomiting,
dizziness, sedation, hypotension, Steven-Johnson syndrome etc. Advise patient to take
medication as directed and not to take more than recommended dose. Instruct patient how and

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when to take medication. Advise patient that this medication is known to for its potential abuse.
Advise patient never to share her medication with anyone other than who its prescribe for.
Caution patient to avoid driving while taking this medication as may cause drowsiness. Advise
patient to ask for help when ambulation as medication can cause dizziness. Encourage patient to
turn, cough and breathe deeply every 2 hours to prevent atelectasis. Advise patient to notify
provider if pain is not controlled. Advise patient of ways to prevent constipation from this
medication. Advise patient to rinse mouth frequently or chew sugarless gum to decrease dry
mouth. Advise patient to avoid or decrease intake of alcohol to no more than 3 glasses a day as
increases the risk of liver disease.
2. Calcium 400mg: This medication is a mineral supplement. Patient takes 1200mg by
mouth once a day. This medication is the patient home medication. This medication is use to
increase serum calcium levels. The patient was told to stop this medication per the order of her
physician. Some side effects of this medications are headache, bradycardia, constipation,
hypercalciuria, nausea and vomiting. Advise patient not to administer concurrently with foods
containing large amounts of oxalic acid such as spinach or rhubarb or dairy products. Advise
patient that medication may cause constipation and should increase fluid intake or use a laxative.
Advise patient to avoid excessive use of tobacco or beverages containing alcohol or caffeine.
Encourage patient to maintain a diet adequate in vitamin D.
3. Vitamin E 400 international units: This medication is a vitamin supplement. It is
used a dietary supplement use to prevent vitamin E deficiency. Some side effects associated with
this medication is fatigue, headache, weakness, blurred vision and rash etc. Instruct patient to
take medication as directed and that missed dose can be omitted as this vitamin is stored in the

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body for a long periods. Advise patient to report any side effects promptly to health care
professional.
Home Assessment
Patient resides at home with her spouse. Patient states her living situation is safe as she
has no stairs or throw rug. Patient states her reliable mechanism for self care is herself and her
husband. Patient fills her prescription at Walgreens pharmacy. Her husband will drive her to her
follow up appointments, get her medications and anything she is unable to do for herself. At
present patient has no financial concerns for any treatment or required care that she may need.
Follow up
The patient has no need for home health services or any durable medical equipment at
this time. The patient will need follow up appointment. However, none has been scheduled as
the physician office will call her to scheduled. Patient also, has to follow up with the oncologist
gynecologist but they too will call patient with appointment date. At this time patient does not
need any physical therapy, social worker or occupational therapy in her discharge planning.
Summary
Patient was admitted to unit post surgery for observation and care. Patient was educated
on how to prevent readmission. Patient was told to check her temperature regularly as a fever of
101degrees or greater is an indication of an infection. Patient teaching on new medication is
highly important to prevent readmission. The importance of keeping follow up appointments. It
is also important to prevent constipation and avoid strenuous activity. All these are important
considerations to help prevent readmission.

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References
Van Leeuwen, A., Poelhuis-Leth, D., & Bladh, M. (2014). Unbound Medicine, Inc.
[Software].Daviss Drug Guide. Nursing Central. Retrieved
from http://www.unboundmedicine.com/products/nursing_central.
Van Leeuwen, A., Poelhuis-Leth, D., & Bladh, M. (2014). Unbound Medicine, Inc.
[Software].Diseases and disorders: A Nursing Therapeutics Manual. Nursing Central.
Retrieved from http://www.unboundmedicine.com/products/nursing_central.