Ongoing Discharge Planning – Stroke Nursing Care in Med-Surg

00:01 Okay. This is one of the most important things that a nurse does with the team.

00:06 It's ongoing discharge planning.

00:09 So, it's interdisciplinary collaboration to make sure we know what is the next best step for our patients? So, this is not something that should be rushed through.

00:19 This is something that should be thoughtful and intentional, involve lots of different professionals, and it really should start on admit.

00:27 We're looking at the functional safety of the patient. We want to promote their health and reduce any modifiable risk factors.

00:34 Aye, aye there's the rub. This is where it gets a little personal, right? This is where we're going to have to approach professionally and calmly helping our patient identify how changing some of their modifiable risk factors will help them reach a level of health that they think is important.

00:54 It would be fantastic if anyone was smoking, they could completely stop.

00:58 If anyone was eating unhealthy, well, they can completely change those habits.

01:01 If they are drinking way too much, they would just stop.

01:04 That's not reality.

01:06 So what we want to do is work with the patient to help them identify how making small changes, taking the next step, will help them be able to do things that are important to them.

01:18 So that involves conversation and assessment with you as a professional to ask them what's important to them.

01:24 Watch them in their interactions. Who is important to them? Do they have younger people in their lives? Do they have children? Are there big life or family events coming up that they want to be able to attend? Weddings, graduations, whatever the event is, find out what the patient feels is important, and connect what's important to them to making those small changes in their health.

01:46 Now coping is another thing. We need to provide support for that patient.

01:50 Do they need to be with a counselor, or do we need to help them line up some of those resources? And we want to help them acknowledge that there could be some changes in their roles and their responsibilities, talk through that with them and help them plan for how they will address that.

02:05 Now, discharge planning involves not just the professionals and the patient, but the family members or the people that the patient identifies as their family members or significant people in their life.

02:18 See, that's not for us to decide.

02:21 If it comes from making a legal decision, the law defines who has the ability to do that.

02:25 But when it comes to caring for the patient, the patient determines who are the significant people in their lives, and who will be involved and affected by those changes in their roles and responsibilities.

02:37 So, if we're talking about Mr. Johnson, one of our favorite case studies, we're talking about his functional safety.

02:43 What are we going to be watching for with him? How is he doing walking? What are the times that are most at risk for him? How does he do with dressing, with eating, with moving? Those are the things we'll be talking about in functional safety.

02:56 We'll look at modifiable risk factors and do just what we talked about.

02:59 Find out what's important to him and make the connection between what's important to him and modifying those risk factors that he can.

03:08 We're going to talk about coping.

03:09 We're going to validate him and acknowledge, "Hey, what you're going through is tough.

03:14 We understand. And the things that you're feeling are natural and normal emotions that go along with a life event like this.

03:22 Here are some resources we have for you to help." This might be a great place for a counselor or for a support group, other patients that have gone through similar things.

03:31 Now, hopefully, that support group will involve people who are on the other side.

03:36 I don't mean death. But I mean, on the other side of this event.

03:40 They've done it, they've worked through the rehab, and now they're living productive lives.

03:45 Those are key parts of a support group.

03:48 We need to really address his changes in roles and responsibilities.

03:51 Is he going to be able to go back to work? How soon can he? What adaptations might need to happen at his workplace? We'll help work through that with him.

03:59 And we're going to need to appropriately educate him about his medication.

04:06 One of the most important things Mr. Johnson can do is control his blood pressure.

04:11 Activity will help with that, diet will help with that, but he's got to understand the risks and benefits of his anti-hypertensive medication that he'll be discharged on.