Okay. This is one of the most important
things that a nurse does with the team.
It's ongoing discharge planning.
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.
This is something that should be
thoughtful and intentional,
involve lots of different professionals,
and it really should start on admit.
We're looking at the functional safety of the
patient. We want to promote their health
and reduce any modifiable risk factors.
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.
It would be fantastic if anyone was
smoking, they could completely stop.
If anyone was eating unhealthy, well, they
can completely change those habits.
If they are drinking way too much,
they would just stop.
That's not reality.
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.
So that involves conversation and assessment
with you as a professional
to ask them what's important to them.
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.
Now coping is another thing. We need to
provide support for that patient.
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
talk through that with them and help them
plan for how they will address that.
Now, discharge planning involves not
just the professionals and the patient,
but the family members or the people that
the patient identifies as their
or significant people in their life.
See, that's not for us to decide.
If it comes from making a legal decision,
the law defines who has
the ability to do that.
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.
So, if we're talking about Mr. Johnson,
one of our favorite case studies,
we're talking about his functional safety.
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.
We'll look at modifiable risk factors
and do just what we talked about.
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.
We're going to talk about coping.
We're going to validate him and acknowledge,
"Hey, what you're going through is tough.
We understand. And the things
that you're feeling
are natural and normal emotions
that go along with a life event like this.
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.
Now, hopefully, that support group will
involve people who are on the other side.
I don't mean death. But I mean, on
the other side of this event.
They've done it, they've worked
through the rehab,
and now they're living productive lives.
Those are key parts of a support group.
We need to really address his changes
in roles and responsibilities.
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.
And we're going to need to appropriately
educate him about his medication.
One of the most important things
Mr. Johnson can do
is control his blood pressure.
Activity will help with that,
diet will help with that,
but he's got to understand
the risks and benefits of his
that he'll be discharged on.