Running head: DISCHARGE PRIORITIES 1

Discharge Priorities:

Education for the Hospitalized Patient

Rebecca Netjes

University of South Florida

 Discharge Priorities: Education for the Hospitalized Patient

The patient is a 40-year-old female that presented to the emergency department (ED) on

03/34/2017 for evaluation of bilateral pedal edema that had become more severe “over the last

four days”, per patient report. The edema was located solely in her lower extremities, had been

present for at least four days, was not painful, and was not relieved with any treatment. She

reported feeling insects crawling on her skin and a painful oral lesion. While in the ED, the

patient experienced a hypertensive crisis and worsening dyspnea. Her blood pressure was

229/141 mmHg with a heart rate of 141 beats per minute. The patient was started on a

nitroglycerin drip, was administered intravenous furosemide and morphine, and a BiPAP was

placed to assist in ventilation. The patient’s heart rate lowered to 97 beats per minute and her

systolic blood pressure decreased to 207 mmHg.

The patient has a past medical history of hypertension, arthritis, and illicit drug abuse. On

03/24/2017 a chest x-ray revealed no acute finding. However, an echocardiogram found the

patient to have a preserved ejection fraction of approximately 55%, left ventricular hypertrophy

with moderate mitral/tricuspid regurgitation, and diastolic dysfunction. The patient was then

admitted to the progressive care unit (PCU) for evaluation and treatment for acute, early-onset

congestive heart failure. The patient was to receive education regarding lifestyle modifications

associated with the new diagnosis, as well as creation of a pharmacologic management plan.

Since admission, the patient has not experienced another hypertensive crisis or episode of

dyspnea.

Discharge Diagnosis

During this hospitalization, the patient was diagnosed with “acute, early-onset congestive

heart failure”. She states that she understands the diagnosis and factors that may have contributed
to her diagnosis. Throughout her admission, the patient has been active in the education process

in that she requested information on how to manage her new condition and asked questions.

First, the patient was education on the pathophysiology of congestive heart failure and lifestyle

management. In addition, topics that the patient was provided education on include the

symptoms associated with congestive heart failure such as activity intolerance, decreased cardiac

output, fluid volume imbalance, and impaired gas exchange. She was provided a written

education, verbal instruction, and community resources that could assist her. The associated core

measures for this patient are those regarding congestive heart failure, and they have all been met.

The patient was weighed in the ED and daily on the PCU, discharge instructions regarding diet,

medications, and weight were provided, and the ejection fraction was documented. This patient

was started on an ACE inhibitor, but not a beta-blocker as they are contraindicated in patients

with a history of cocaine abuse. This patient has elected to admit herself into an inpatient

rehabilitation facility where she will follow up with the in-house physician.

Medications

The reconciled list of the patient’s new prescriptions includes amlodipine 10 mg TAB PO

daily, furosemide 40 mg TAB PO daily, hydralazine 25 mg TAB PO daily, and lisinopril 10 mg

TAB PO daily. A written copy of this list was provided to the patient, as well as the

rehabilitation facility she will be residing at, which included when she should take her

medications again (the next morning). She was instructed that amlodipine is a calcium channel

blocker used to regulate heart contraction and prevent arrhythmia; side effects of this medication

include fatigue, palpitations, dizziness, and flushing. Additionally, the patient was instructed that

furosemide is a diuretic used to reduce blood pressure by promoting diuresis, and that side

effects could include dizziness, electrolyte imbalances, diarrhea, and an increase in cholesterol.
Hydralazine is a nitrate that vasodilates peripheral vessels to decrease blood pressure, and side

effects include headache, tachycardia, and nausea. Finally, the patient was instructed that

lisinopril is an ACE inhibitor that aids in reducing blood pressure, and side effects include

dizziness, cough, and facial flushing. She was instructed to report any new symptoms to her

provider, seek medical attention for acute chest pain, and not to abruptly stop taking her

medications. The patient reported understanding of all medications.

Home Assessment

Currently, the patient lives with her boyfriend of ten years in a single story home. She

reports that this is a safe relationship, and he has “always wanted to help me”. However, this

patient has elected admission to a rehabilitation facility. She reported that “she has learned a lot

here”, but that she “wants more skills before [she] is on her own again”. The patient understands

that continued use of illicit drug abuse could contribute to damage to her heart or a decline in

functional status. The rehabilitation facility she selected is specialized in that they have on-site

social workers that assist individuals with identifying ways to abstain from illicit drug abuse (i.e.

Narcotics Anonymous (NA) meetings). At this time, the patient does not have concerns about

mechanisms for self-care or financial concerns as this facility accepts uninsured patients. She

stated that when she is home she will either have access to a car or the buses, that she will be

able to obtain prescriptions at a discounted rate at Publix, and that her boyfriend and godmother

will be available to assist her. Her only concern is finding a cardiologist she can afford, but will

be working with the social workers at the rehabilitation facility to identify one.

Follow Up

At this time, there is not a need for home health service or durable medical equipment.

There are follow-up appointments scheduled at the rehabilitation facility starting when she is
admitted, and then weekly after her first appointment. She should follow up with a cardiologist

and her primary care physician. The cardiologist attending to her during her admission

emphasized that it is critical for her to see a cardiologist as her medications will likely need to be

adjusted within the next month. Currently, the patient has a case manager that has been assisting

her in identifying resources in the community such as the rehabilitation facility, discount

prescriptions at Publix, and local NA meetings. It would be helpful for the patient to continue to

meet with a social worker or case manager as she develops coping strategies and appropriate

lifestyle changes for her new diagnosis.

Conclusion

For any patient that has been hospitalized, a primary goal should be prevention of

readmission. In this scenario, the three most important factors in decreasing the patient’s

likelihood of readmission include lifestyle modifications, effective management of her

pharmacologic regimen, and support. Examples of appropriate lifestyles modifications include

daily weight, a restricted fluid intake, a diet low in salt, and exercise. Adherence to her

pharmacologic plan will also be pivotal in her success. Her medications were selected because

they will decrease her cardiac workload and delay the progression of the disease process. Finally,

assistance from family, friends and appropriate healthcare professionals will aid in the patient’s

success.

Through therapeutic communication and effective education patients can begin to

understand that they have the ability to play an active role in the management of their health.

With this realization, quality patient care is provided and the ultimate goal of patient health can

be met – but it must begin with education and encouragement.