NRS-460 Benchmark – Case Study: Timothy Smith – Discharge Planning
NRS-460 Benchmark – Case Study: Timothy Smith – Discharge Planning
An RN-BSN-prepared nurse needs to demonstrate an enhanced understanding of the complex management of disease during patient discharge, as well as the additional aspects of communication and safety in the work environment. The purpose of this assignment is to participate in discharge planning for a patient, utilizing communication and information technology, in a scenario where patient and provider safety are a concern.
PART I: Health History and Medical Information
Evaluate the health history and medical information for Timothy Smith, presented below.
Mr. Smith is ready to be discharged from the hospital. Timothy has been weaned off oxygen. His tube feedings have been discontinued, and he is tolerating a pureed diet. To facilitate safe discharge, the hospital case manager has set up services with a transitional care manager from a Home Health agency. The goal is for Mr. Smith to attain safe recovery and rehabilitation.
- Broken left leg status
- Weight bearing status: non-weight bearing, stand pivot with right leg only
- Assistive devices: wheelchair
- PICC line present for discharge
- Left upper leg wound care: dressing changes as needed for open reduction internal fixation (ORIF) on the leg
- Psychiatrist telehealth follow-up scheduled for a Zoom call upon discharge
- Telehealth follow-up visit scheduled two weeks after discharge with Primary Care Physician (PCP)
Lab Tests and Vitals
- Room air, respiratory rate 16 breaths per minute
- Vital signs are within normal limits
PART II: Critical Thinking Activity
Use the findings from your evaluation to complete the following:
| Home Health Care and Rehabilitation Therapy
During care coordination and transition of care planning, it is essential to consider the type and level of care a patient might need. |
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| You are the transitional care manager assigned to Mr. Smith before discharge. Based on Mr. Smith’s assessment findings, develop a discharge plan that encompasses his care needs following discharge. Your response should be a minimum of 200 words. | As the transitional care manager for Mr. Smith, it is imperative to establish a comprehensive discharge plan to facilitate a safe recovery and mitigate the risk of rehospitalization. Mr. Smith’s care requirements are intricate owing to his non-weight-bearing condition on the left leg, dependence on a wheelchair, existence of a PICC line, recent orthopedic surgery (ORIF), and a background of mental health disorders, including PTSD. Upon discharge, Mr. Smith will necessitate integrated treatments to address his physical and psychological well-being (Lobchuk et al., 2020).
A proficient home health nurse must be arranged for regular visits to provide PICC line care, administer IV antibiotics, and conduct wound assessments with dressing changes as needed. A physical therapist will be essential to commence strength and mobility training aimed at preserving function in the unaffected limbs and averting deconditioning (Lobchuk et al., 2020). A home safety assessment is essential to ensure that the living environment facilitates wheelchair access and reduces fall hazards. Telehealth psychiatric follow-up must be guaranteed, alongside medication reconciliation and adherence instruction. The strategy must incorporate collaboration with a dietitian to evaluate his nutritional requirements, including his recent shift from tube feeding to a pureed meal. Education for families about mobility assistance, infection prevention, and emergency response is essential to ensure comprehensive care within the home setting (Mohamed et al., 2021). |
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| Discuss three to five interdisciplinary roles that will be essential in supporting Mr. Smith’s home health and rehabilitative care needs. Your response should be a minimum of 150 words. | Multiple interdisciplinary responsibilities are essential for facilitating Mr. Smith’s recovery and maintaining continuity of care post-discharge. The home health nurse will act as the primary caregiver, overseeing the management of his PICC line, delivering intravenous antibiotics, and conducting routine wound care and dressing changes for his ORIF site. The nurse will check for infection indicators and educate the patient and caregiver on medication adherence and self-care measures (Mohamed et al., 2021).
A physical therapist (PT) is essential for establishing and supervising a rehabilitation program aimed at strengthening unaffected limbs, preserving joint mobility, and instructing safe wheelchair transfers to avert additional injuries. Third, an occupational therapist (OT) can evaluate Mr. Smith’s capacity to execute activities of daily living (ADLs) and provide adaptive techniques or instruments to enhance autonomy in the home environment (Lobchuk et al., 2020). A nutritionist can assist with meeting his nutritional requirements during recuperation, particularly regarding the transition from tube feeding to a pureed meal. Finally, a mental health professional, such as a psychiatric nurse practitioner or counselor, will offer telemedicine assistance for his PTSD and emotional well-being, aiding in stress reduction and mitigating potential psychiatric crises during his recovery (Mohamed et al., 2021). |
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| You are the home health nurse assigned to treat Mr. Smith. Identify two areas of concern that you might prioritize during your initial visit with him following discharge. Your response should be a minimum of 150 words. | As the home health nurse assigned to Mr. Smith, the two principal areas of concern to focus on during the initial home visit are the management of the PICC line and ensuring mobility safety. The PICC line requires prompt attention to ensure optimal operation, prevent infection, and verify that Mr. Smith and his caregivers understand the protocol for maintaining line hygiene and administering IV antibiotics. Signs of erythema, edema, or exudate at the insertion site must be evaluated, and the record of antibiotic administration should be examined to confirm compliance (Lobchuk et al., 2020).
The secondary goal is to assess Mr. Smith’s mobility and residential surroundings. Given his non-weight-bearing condition and reliance on a wheelchair, it is essential to analyze fall hazards, examine the accessibility of essential areas (such as the toilet and bedroom), and ensure that the home is equipped with the requisite assistive devices (Mohamed et al., 2021). Instructing on safe transfer methods and verifying caregiver proficiency in facilitating mobility are crucial for preventing harm and fostering independence. |
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| Psychosocial and Spiritual Considerations
Providing holistic nursing care for patients with complex conditions requires that the nurse take into account the patient’s psychosocial and spiritual needs. |
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| Given the patient’s current situation, discuss ways in which the nurse can consider and address the patient’s psychosocial and spiritual needs. Your response should be a minimum of 150 words. | Meeting Mr. Smith’s psychosocial and spiritual needs is crucial for delivering comprehensive care, particularly in light of his recent hospitalization, restricted mobility, and PTSD history. During the preliminary assessment, the nurse should cultivate rapport and do a psychosocial examination to evaluate the patient’s emotional condition, coping strategies, support network, and indicators of anxiety or depression. Active listening and sympathetic communication are essential for establishing a secure environment in which Mr. Smith feels acknowledged and esteemed (Lobchuk et al., 2020). Engaging a mental health expert, such as a social worker or counselor, may assist in addressing underlying emotional or trauma-related issues.
The nurse should inquire with open-ended questions regarding any significant beliefs or practices of Mr. Smith and ascertain his interest in receiving assistance from a chaplain or spiritual counselor. Allocating time and space for prayer, meditation, or other spiritual practices can improve emotional well-being (Perpetua et al., 2023). Honoring Mr. Smith’s values, cultural heritage, and preferences enhances his agency and facilitates his holistic recovery. |
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| Just Culture
The patient is due to receive his IV antibiotic prior to discharge. As the nurse reviews the electronic orders, she notices that the antibiotic dose appears to be incorrect. Upon discussion with the provider and the pharmacy, it was determined that the entered dose was incorrect. |
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| Discuss how reporting this near miss will contribute to a just culture that reflects civility and respect. Your response should be a minimum of 200 words. | Documenting the erroneous antibiotic dosage as a near miss is essential for cultivating a just culture that encourages accountability, learning, and ongoing enhancement, while eschewing blame and retribution. In a just culture, healthcare professionals are motivated to report errors or potential errors without fear of retribution, thereby fostering a culture of safety and openness (Mohamed et al., 2021). By acknowledging and reporting this near miss, the nurse fulfills her professional obligation and aids in preventing harm not only to Mr. Smith but also to future patients who may be affected by similar paperwork errors.
This effort exemplifies civility and respect throughout the healthcare team by fostering open communication and collaboration among nurses, providers, and pharmacists. It illustrates reciprocal appreciation for each discipline’s contribution to maintaining safe and effective care, hence enhancing interprofessional trust. Reporting the near miss allows the facility to examine fundamental causes, assess systemic vulnerabilities, and enhance practices, including the integration of alarms in the electronic health record (EHR) system to identify dose differences (Vaismoradi et al., 2024). This technique fosters a culture that prioritizes learning from errors over attributing blame. It enables personnel to voice their concerns, enhances patient safety, and strengthens the nurse’s position as a patient advocate, ensuring that clinical precision, ethics, and respect consistently inform care decisions. |
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| Discuss how clinical judgement and critical thinking should be applied despite the use of information and communication technologies. Your response should be a minimum of 150 words. | Despite the extensive application of information and communication technologies (ICTs) in healthcare, clinical judgment and critical thinking remain vital elements of secure and efficient nursing care. Technologies including electronic health records (EHRs), drug administration systems, and telemedicine platforms are intended to improve efficiency and minimize errors; nonetheless, they cannot replace human judgment (Mohamed et al., 2021). Nurses must rigorously evaluate the precision and pertinence of information provided by these systems. For instance, if an order seems erroneous—such as an abnormally high drug dosage—the nurse must verify and confirm it, rather than relying unquestioningly on technology.
Clinical judgment informs decision-making in complex scenarios, such as reading patients’ nonverbal cues during virtual consultations or assessing when a patient’s condition is worsening despite “normal” digital vital signs (Vaismoradi et al., 2024). Nurses must leverage their experience, assessment abilities, and ethical judgment to enhance technology and champion patient safety. In doing so, they preserve the integrity and humanity of care within a technology-driven context. |
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| Levels of Risk
As Mr. Smith waits for the nurse, he becomes impatient and starts to verbally attack the patient care technician as she takes his vital signs. |
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| Identify actual and potential levels of risk to the care team within this situation, given the patient’s history of PTSD. Your response should be a minimum of 150 words. | Mr. Smith’s vocal hostility towards the patient care technician poses both immediate and potential hazards to the care team, especially given his history of post-traumatic stress disorder (PTSD). The inherent danger encompasses immediate emotional distress and psychological impairment to the technician, potentially impacting job performance and team morale. There exists a risk of escalation from verbal to physical violence, potentially jeopardizing the safety of adjacent staff and patients. Due to Mr. Smith’s PTSD, stimuli such as delays or perceived threats may provoke impulsive responses or episodes of intensified anxiety and fury (Vaismoradi et al., 2024).
Potential concerns include the emergence of a hostile work environment, increased employee turnover, and a decreased willingness among workers to interact directly with Mr. Smith due to apprehension or unease. If inadequately managed, these risks can jeopardize therapeutic relationships, diminish service quality, and lead to liability issues for the facility (Vaismoradi et al., 2024). Comprehending PTSD-related behaviors and proactively mitigating associated hazards is crucial for ensuring a secure and courteous environment for both personnel and patients. |
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| What can the nurse do to diffuse this situation? What steps can be taken to ensure the safety of both patients and providers in the future? Your response should be a minimum of 150 words. | To de-escalate the situation, the nurse should maintain composure, approach Mr. Smith in a non-threatening manner, and employ therapeutic communication strategies, including active listening, maintaining sustained eye contact, and using a soft, respectful tone. Recognizing Mr. Smith’s frustration without bias, such as by stating, “I comprehend that you are currently feeling distressed,” can help alleviate tension. The nurse must ensure that the patient care technician withdraws safely and allows Mr. Smith a brief period to restore his calm before continuing with care. A qualified staff member or mental health professional should be consulted if necessary (Zhang et al., 2024).
The facility should institute de-escalation training for all personnel, emphasizing trauma-informed care, particularly for patients with PTSD, to avert future instances. A customized behavioral care plan for Mr. Smith must be established, delineating triggers and suitable interventions. Moreover, identifying patients with a history of behavioral issues in the EHR, designating consistent caregivers, and employing a team-oriented strategy can improve safety for both patients and staff (Vaismoradi et al., 2024). |
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| Patient Portal
The nurse is helping Mr. Smith log in to the Patient Portal (i.e., MyChart) before discharge. |
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| Explain the considerations for ensuring the patient will be able to use this resource at home. In your discussion, include considerations related to the patient’s condition and cognitive status based on his assessment findings and history of injury reviewed in previous topics. Your response should be a minimum of 200 words. | Prior to discharge, the nurse must confirm that Mr. Smith can independently access and navigate the Patient Portal (such as MyChart) from home (Zhang et al., 2024). Multiple criteria about his present state and cognitive status must be considered. Mr. Smith has had a substantial injury—a fractured left leg necessitating open reduction and internal fixation—and is in the initial phases of physical rehabilitation, dependent on a wheelchair and managing a peripherally inserted central catheter. Despite steady vital signs and respiratory condition, his physical limitations may hinder comfortable device usage; thus, adaptations such as voice-to-text or larger font options could be beneficial.
Furthermore, Mr. Smith possesses a documented history of PTSD, which may impair concentration, memory, and emotional regulation. The nurse must evaluate if the employee exhibits the cognitive acuity required to perform tasks such as logging in, accessing the portal, and interpreting medical information. A concise demonstration followed by a return demonstration can validate his comprehension (Vaismoradi et al., 2024). It is essential to ensure his access to a compatible device and a reliable internet connection at home. Issuing written directives, establishing automated reminders, and outlining methods for contacting technical assistance might enhance his success. Should issues persist, incorporating a caregiver throughout the educational process may enhance portal utilization and compliance. |
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| Discuss the benefits for both the patient and the care team in using information and communication technology to support the patient-provider relationship. Your response should be a minimum of 150 words. | The utilization of information and communication technology (ICT), including patient portals and telehealth platforms, offers substantial advantages to both patients and healthcare teams in enhancing patient-provider interaction, for patients like Mr. Smith, information and communication technology enhances healthcare accessibility by enabling real-time access to laboratory results, prescription inventories, upcoming appointments, and provider communications. This accessibility enables patients to actively engage in their care, fosters transparency, and bolsters trust in the healthcare system (Perpetua et al., 2023).
The ICT enhances communication for the care team, minimizing delays in follow-up, prescription modifications, and appointment scheduling. Providers can monitor patient progress more effectively and address inquiries or concerns without necessitating in-person visits, which is especially advantageous for patients with mobility limitations or transportation difficulties. Information and Communication Technology (ICT) enhances documentation precision and facilitates continuity of care by providing all healthcare team members with access to current patient information, thereby improving collaboration and patient outcomes (Vaismoradi et al., 2024). |
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| What obstacles might hinder his use of the Patient Portal? Your response should be a minimum of 150 words. | Multiple impediments may hinder Mr. Smith’s ability to utilize the Patient Portal effectively after discharge. Initially, his restricted mobility and recent surgery may render it physically challenging to manipulate a device, particularly in the absence of ergonomic equipment or assistive technology at home (Zhang et al., 2024). He may encounter technological obstacles, such as insufficient access to a dependable internet connection, a smartphone, or a computer. If Mr. Smith lacks familiarity with digital technologies, he may encounter difficulties with navigation, password management, or comprehending the medical terminology displayed in the portal.
A significant component is his history of PTSD, which may influence his attention span, memory, and emotional regulation. Cognitive and emotional issues may diminish his capacity or willingness to continuously participate in the portal (Perpetua et al., 2023). Furthermore, if Mr. Smith resides independently or without familial support, he may have no assistance available to help him utilize the portal. To overcome these challenges, it is essential to engage caregivers in training, streamline instructions, and offer alternative communication methods when necessary. |
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| Telehealth
Mr. Smith is scheduled for a telehealth appointment with the psychiatrist upon discharge. |
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| Discuss the information and resources that the nurse should ensure the patient has available prior to their visit. Your response should be a minimum of 150 words. | The nurse must verify that Mr. Smith has access to the necessary technology and understands its use in preparation for his upcoming telemedicine meeting with the psychiatrist. This entails verifying that Mr. Smith possesses a dependable internet connection, a functional smartphone, tablet, or computer equipped with a camera and microphone, and access to the telehealth platform (such as Zoom or a patient site with video functionality). The nurse should assist him in logging in, joining the virtual meeting, and confirming the audio and video settings (Vaismoradi et al., 2024). A printed or digital sequential guide can facilitate this approach.
The nurse must confirm that Mr. Smith possesses a private, tranquil environment for the appointment to ensure confidentiality and reduce distractions. Furthermore, it is beneficial to examine his medication list, current symptoms, and any mental health issues he may like to address (Vaismoradi et al., 2024). The nurse may enlist a caregiver to assist in the session if necessary. Ensuring the presence of all these aspects will facilitate Mr. Smith’s preparedness, alleviate anxiety, and promote a productive and meaningful psychiatric consultation. |
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| References (Please include working hyperlinks.)
Lobchuk, M., Bell, A., Hoplock, L., & Lemoine, J. (2020). Interprofessional discharge team communication and empathy in discharge planning activities: A narrative review. Journal of Interprofessional Education & Practice, 23, 100393. https://doi.org/10.1016/j.xjep.2020.100393 Mohamed, N., Mohamed, H., & Hafez, S. (2021). Tele Nursing to Optimize Discharge Planning for Elderly Patients and Ensure Continuity of Home Care during the COVID-19 Pandemic. NILES Journal For Geriatric and Gerontology/NILES Journal for Geriatric and Gerontology, 5(1), 92–109. https://doi.org/10.21608/niles.2022.197285 Perpetua, Z., Seitz, S., Schunk, J., Rogers, D., Gala, J., Sherwood, P., Mikulis, A., Santucci, N., Ankney, D., Bryan-Morris, L., & DePasquale, K. (2023). Virtual discharge. Journal of Nursing Care Quality, 38(3), 234–242. https://doi.org/10.1097/ncq.0000000000000689 Vaismoradi, M., Rae, J., Turunen, H., & Logan, P. A. (2024). Specialized nurses’ role in ensuring patient safety within the context of telehealth in home care: A scoping review. Digital Health, 10. https://doi.org/10.1177/20552076241287272 Zhang, Y., Stayt, L., Sutherland, S., & Greenway, K. (2024). How clinicians make decisions for patient management plans in telehealth. Journal of Advanced Nursing, 80(9), 3516–3532. https://doi.org/10.1111/jan.16104 |
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Assessment Traits
Benchmark
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Assessment Description
Use the “Case Study: Timothy Smith – Discharge Planning” template to complete the assignment.
This case study has indirect care experience requirements. The “NRS-460 – Case Studies: Indirect Care Experience Hours” form, found in the Topic 1 Resources, will be used to document the indirect care experience hours completed in the case study. As progress is made on the case study, update this form indicating the date(s) each section is completed. This form will be submitted in Topic 5.
You are required to cite a minimum of three sources to complete this assignment. Sources must be published within the past 5 years and appropriate for the assignment criteria and relevant to nursing practice.
While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center. This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance.
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