Read the case study below. Evaluate the information and formulate a conclusion based on your evaluation. Complete the critical thinking table and submit the completed template to the assignment dropbox.
It is necessary for an RN-BSN-prepared nurse to demonstrate an enhanced understanding of the complex management of disease during the discharge of a patient, and 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, and in a scenario where patient and provider safety is 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 of 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.
1. Broken left leg status
2. Weight bearing status: non-weight bearing, stand pivot with right leg only
a. Assistive devices: wheelchair
b. PICC line present for discharge
3. Left upper leg wound care: dressing changes as needed for open reduction internal fixation (ORIF) on leg
Sample Answer
Evaluation of Health History and Medical Information for Timothy Smith
Patient: Timothy Smith
Current Status for Discharge:
Weaned off oxygen.
Tube feedings discontinued, tolerating pureed diet.
Transitional care manager from Home Health agency secured.
Goal: Safe recovery and rehabilitation.
Key Medical Information:
Broken Left Leg Status: This is the primary acute issue that led to hospitalization. The specific nature of the fracture (e.g., tibia, femur, fibula) is not detailed, but the context of "left upper leg wound care: dressing changes as needed for open reduction internal fixation (ORIF) on leg" strongly suggests a significant long bone fracture, likely of the femur or tibia, requiring surgical repair.
Weight-Bearing Status: Non-weight-bearing (NWB) on the left leg, stand pivot with the right leg only. This is critical for mobility and safety.
Assistive Device: Wheelchair. This indicates his primary mode of ambulation will be non-weight-bearing, requiring significant upper body strength and/or assistance.
PICC Line Present for Discharge: A Peripherally Inserted Central Catheter (PICC) line indicates ongoing intravenous therapy is required post-discharge. This could be for long-term antibiotics (common for ORIF to prevent/treat infection), pain management, or other medications. This is a complex medical device requiring specialized care and monitoring.
Left Upper Leg Wound Care: Dressing changes are needed for the ORIF site, implying an open wound or incision that requires regular assessment for signs of infection, healing progress, and proper wound management.