Narjess Yazback

BMC-SBN
Discharge Planning Project
Discharge diagnosis
This is a 57 year old patient who came in on 2/5/14 with a chief complaint of altered mental
status and chest pain with a cough. Patient lives in a skilled nursing care facility and after a visit
from her husband, he noticed that she was not acting like herself. Patient has no prior history
of altered mental status, but has a past medical history of multiple strokes, bipolar disorder, and
depression. A chest X-ray was done for the patient, an EKG, and a CBC to check for the white
blood cell count. A nasal canula was also placed on the patient because their oxygen saturation
was low. After pneumonia was diagnosed with a chest x-ray, a blood culture was done, and
Levaquin and albuterol were prescribed for the patient. She is now ready to be discharged on
2/7/14.

Does the patient understand why they were hospitalized? Yes the patient was aware of the
cause of their hospitalization by verbalizing it. They know that they had pneumonia.
Pneumonia teaching for the adult patient was provided, along with health maintenance in
the adult female.

Patient Teaching on pneumonia

Pneumonia is an infection of the lungs. It can be caused by a bacteria or a virus. These
infections are usually caused by breathing infectious particles into the airway and into the
lungs. Some symptoms you may see are coughing, fever, chest pain, an increased rate of
breathing, wheezing, mucus production, and in some patients you may see confusion.
Pneumonia is diagnosed with a chest X-ray which would show pulmonary infiltrate
which is an abnormality in the lungs. Other tests include blood testing, urine and sputum
samples to find the specific cause of the pneumonia, and blood gases to check how well
the lungs are working. Pneumonia can be contagious because it can be spread by
coughing and sneezing, this would be a reason you may be asked to wear a mask before
and during an examination. As far as treatment goes, if the pneumonia is caused by a
bacteria it will be treated with an antibiotic medicine, if it is caused by the influenza virus
it will be treated with an antiviral medicine. Most other viral infections will usually run
their course and something that can be done at home is obtaining plenty of rest and stay
well hydrated. For prevention of pneumonia, a pneumococcal vaccine is available to
prevent a bacterial pneumonia infection, and it is usually suggested for people over the
age of 65, for patients on chemotherapy, for people with immune system problems, and
for people with chronic lung diseases. If you smoke, it is time to quit, if interested you
may receive instructions and counseling on how to stop smoking. For home care, cough

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suppressants may be used; however coughing protects you by clearing your lungs of the
excess mucus. If you are prescribed with an antibiotic or antiviral, always finish the
medicine even if you start to feel better. An expectorant may be provided to loosen up
mucus and allow it to be cleared with coughing. Before taking over the counter medicines
for pain and discomfort, always check with your provider. Avoid smoking because it can
contribute to pneumonia. Coughing is often worse at night, therefore sleeping in a semiupright position in a recliner or using a few pillows under the head can help. Make sure to
get rest as your body needs it. Seek immediate medical help if you begin coughing up
blood, have a fever, develop shortness of breath, illness becomes worse or your pain is
uncontrolled with medicines.
Patient teaching on health maintenance
A healthy lifestyle and preventative care can promote health and wellness. Maintain
routine health, dental and eye exams. Eat a healthy diet with foods like vegetables, fruits,
whole grains, low fat dairy products, and lean proteins. Decrease intake of foods high in
solid fats, added sugars, and salt. You may obtain more information about a proper diet
from your caregiver if necessary.
Regular physical exercise is a very important thing to do for your health. Most adults
should get at least 30 minutes of moderate intensity exercise a day, and muscle
strengthening exercises 2 or more days a week. Maintain a healthy weight. This can be
identified with a BMI (body mass index) which is a tool that helps identify possible
weight issues. A normal BMI for an adult should be between 18.5-24.9. Maintain normal
blood lipids and cholesterol levels by exercising and minimizing your intake of saturated
fat. Blood tests for lipids should be done every 5 years unless you are over 50 or already
have a known high cholesterol level.
If you are pregnant, do not drink alcohol. Avoid the use of street drugs and do not share
needles with anyone.
High blood pressure can cause heart disease and increase the risk of a stroke. Blood
pressure should be checked at least every 1 to 2 years medically. If you have ongoing
high blood pressure that does not go away with dietary and exercise changes, it needs to
be treated medically. If you are 55-79 years old, ask your caregiver if you should be
taking aspirin to prevent strokes. Diabetes screening should be done every 3 years. Breast
cancer screening is an essential preventative care for women, and a simple breast self
examination can be done at home which requires understanding the normal appearance
and feel of your breasts. After age 40, women should consider having a yearly
mammogram. A pap smear should be done for women every 3 years after age 30. After
the age of 50 a colonoscopy is another preventative screening tool for colorectal cancer.

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Practice safe sex, use condoms and avoid high risk sexual practices to reduce the spread
of sexually transmitted infections. When exposure to the sun occurs sunscreen should
always be used, an SPF of 30 or higher is recommended. Make sure to notify your
caregiver for any changes in moles on your skin, especially if it involves color or shape.
Always stay current with your immunizations.
Handouts were provided for the patient to keep.

Are there any associated core measures and, if so, have they been met? Yes the patient
had core measures for Pneumonia which included 1) blood culture within 24 hours prior
to or 24 hours after hospital arrival for ICU patients. (2/5/14) 2) Appropriate initial
antibiotics for CAP in immunocompetent ICU and non- ICU patient. (2/6/14)These core
measures have been met by the hospital.

Medications
Discharge medications
1) Levofloxacin (Levaquin) - last dose: 2/7/14
-750 MG, by mouth, every 24 hours, 4 days
-Indicated for community acquired pneumonia.
Levaquin by mouth has a rapid onset.
Side effects: Elevated intracranial pressure, seizures, torsades de pointes, hepatotoxicity, colitis,
Stevens-Johnson syndrome
Patient teaching

Always provide a list of medications when seeing a new doctor to prevent drug to drug
interactions. For instance concurrent use of Levaquin with amiodarone can increase risk
for torsades de pointes.
Take medication as directed at evenly spaced times and finish the drug completely even if
you are feeling better.
Maintain a fluid intake of at least 1500-2000 ml/day to prevent crystalluria.
Avoid taking antacids or medications with calcium, magnesium, aluminum or iron 4
hours before or 2 hours after taking this medication because it will decrease absorption.
May cause dizziness or drowsiness, so avoid driving while on the medication.
Notify healthcare provider of any history of QT prolongation (hypokalemia), slow heart
rate, or recent MI.
Use sunscreen to prevent photo toxicity during and 5 days after therapy.
Report signs of super-infections such as furry growth on the tongue or vaginal itching or
discharge.
Notify healthcare provider if diarrhea occurs or stool contains blood or pus.

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 Notify healthcare provider for any hypersensitivity or abnormal reactions.

2) Acetaminophen (Tylenol) - last dose: 2/7/14 at 10:00 AM
-650 MG, every 4 hours
- Indicated as needed for pain and fever
Side effects: agitation, anxiety, hypertension, hepatotoxicity, hypokalemia, renal failure in
chronic use, muscle spasms, rash.
Patient teaching
Do not exceed 4g in 24 hours.
Take medication as directed and do not take more than the recommended dose.
Do not continue use after 10 days.
Avoid alcohol because it increases the risk of liver damage.
Avoid concurrent use of NSAIDS unless directed by healthcare professional.
Check labels on all OTC medications. Avoid taking more than one product containing
acetaminophen.
Consult provider if discomfort occurs or pain/fever is not relieved by routine doses.
3) Albuterol (Ventolin HFA) - last dose: 2/7/14 at 10:00 AM
-2 puffs, inhalation, twice daily
- An adrenergic used as a quick relief agent for acute bronchospasm.
Side effects: nervousness, restlessness, chest pain, palpitations, nausea, vomiting,
tremors.
Patient teaching
Avoid use with beta blockers because it may negate therapeutic effect.
Avoid use with caffeine containing products because it may increase stimulant
effect.
Take as directed. If missed dose, take as soon as remembered. Do not double dose
or increase the dose prescribed.
Contact healthcare professional if shortness of breath or symptoms are not
relieved, or if palpitations, chest pain and dizziness occur.
Prime unit with 4 sprays before use and discard canister after 200 sprays
Avoid smoking
Notify healthcare provider of all OTC medications or prescribed medications
currently being taken. Provide a list if available.
Albuterol may cause an unusual or bad taste in the mouth.
Instruct patient in proper use of inhaler.

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Rinse mouth with water after each inhalation to minimize dry mouth and clean
the mouthpiece with water at least once a week.
Notify healthcare provider of any abnormalities or complications with treatment.

Patients new medications were fully explained including their indication, side effects and
important patient teaching. Patient also understood the importance of continuing medication
therapy for the full prescribed period even if the signs and symptoms of the disease are resolved.
A medication reconciliation list (15 medications) including old medications that the patient was
already on, and new prescribed medications was provided for the patient to visualize and keep.
Teaching was not provided on old medication because the patient verbalized understanding and
knowledge.
Home assessment

Who does the patient live with? Is this a safe living situation? The patient resides at the
Boca Ciega skilled nursing facility, and receives visits from her husband there. Patient
explained that she has been there for over a year.

What are the reliable mechanisms for self care including transportation to get
medications, food, follow up appointments, etc.? Examples can include neighbors or
family members that assist. Patient is taken care of at the nursing facility, and she also has
her husband as an outside source because he does not live too far. If patient needs to go
outside the facility, her husband is her primary method of transportation and support
source.

Are there any financial concerns regarding medications or access to follow-up

appointments or required care (i.e. dialysis)? Patient has no financial concerns regarding
medications; she is covered under her insurance Humana Pro, and is financially stable.
Her husband provides transportation in the case of follow up appointments or any care
needed.

Follow up

Any need for home health services or durable medical equipment at the home? Patient
needs to remain on 2 L oxygen with nasal canula at the skilled nursing facility. No other
durable medical equipment is needed at the facility and for patient discharge.

Follow up: Patient has a CT scan scheduled in 8 weeks. She also needs to follow up with
her primary care doctor, but the appointment date and time have not yet been arranged. A
psych consult is needed in order to further address patients depression and anxiety.

Summary

Revised 8/2012

Patient was admitted with Pneumonia and they live in a close quarter community
(nursing care facility), so teaching on the disease prevention is very important. Oxygen
level maintenance for the patient is also very important to prevent her readmission to the
hospital. Patient teaching on finishing the course of her prescribed medications even if
she feels better is vital for her health and can decrease her chances of readmission.

Patient has signed a document stating that education material, new prescriptions and
follow up instructions were received.

Revised 8/2012