Mr. G is a patient that has been hospitalized for an exacerbation of Congestive Heart Failure (CHF) twice in the last two months. He is not complying with his medication regimen, dietary restrictions or doctor visits. Clients with CHF have potentially reversible causes including, a poor understanding of CHF, poor compliance with medication and diet, poorly controlled hypertension, inadequate discharge planning and follow up care (Palmer, Appleton and Rodrigues, p. 694). The patient will be provided with educational tools and support that will improve his health and reduce the probability of rehospitalization with an acute exacerbation. The transitional care nurse, home health nurse and the medical case manager would oversee his care coordination
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Clients with CHF, “need to be able to manage his salt, fluid, and caloric intake; measure and document their weight; exercise regularly; take prescribed medications; and recognize when to call their health care provider” (Alspach, 2015, p.10). The client’s health literacy about this condition can create a barrier to acquiring the necessary knowledge to manage this disease and the self-care behaviors needed to manage the condition (Alspach, 2015, p.11). The discharge planner should assess the client’s ability and health literacy needed to manage this complex health …show more content…
During the transition from the hospital to the home will be the time when the client is at the greatest risk for fragmented care (Lamb, 2014, p. 86). Even though the client has received the vital information needed to provide self-care, the client may lack the resources to care for himself and negotiate the transition between the settings. This change may cause the client to lose control of his condition and could lead to hospital readmission. As a result, the client should be assigned to a home health nurse and a community medical case worker to coordinate services needed following the discharge from the
Clients with CHF, “need to be able to manage his salt, fluid, and caloric intake; measure and document their weight; exercise regularly; take prescribed medications; and recognize when to call their health care provider” (Alspach, 2015, p.10). The client’s health literacy about this condition can create a barrier to acquiring the necessary knowledge to manage this disease and the self-care behaviors needed to manage the condition (Alspach, 2015, p.11). The discharge planner should assess the client’s ability and health literacy needed to manage this complex health …show more content…
During the transition from the hospital to the home will be the time when the client is at the greatest risk for fragmented care (Lamb, 2014, p. 86). Even though the client has received the vital information needed to provide self-care, the client may lack the resources to care for himself and negotiate the transition between the settings. This change may cause the client to lose control of his condition and could lead to hospital readmission. As a result, the client should be assigned to a home health nurse and a community medical case worker to coordinate services needed following the discharge from the