Transition of care across all health care settings is crucial to ensure an effective and safe continuity of patient care after discharge at home. Sallie Mae Fisher, an aging 82-year old female was recently discharged after a 3-day hospitalization from an acute exacerbation of congestive heart failure (CHF). In the last six months, she has recurrent readmissions from the same condition. Due to this recurrent problem, Sallie Mae Fisher needs a comprehensive plan to manage her condition better and prevent future readmissions. This paper is composed of two parts. The first part will provide a care plan for Sallie, specifically identifying the problems encountered during the home visit, gather information and propose nursing interventions, supported
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Lack of Oxygenation
The first problem is the lack of oxygenation with Sallie’s congestive heart failure, atrial fibrillation, and hypertension. Hypertension (high blood pressure) can cause congestive heart failure. Congestive heart failure is a result of the ventricles not being able to pump an adequate amount of blood to the body. This causes blood and other fluids to back up inside the lungs, abdomen, liver, and lower body. Some signs and symptoms of CHF are shortness of breath and rapid breathing (Geib, Plappert, Roth & Birner, et al., 2015).
Sallie was given discharge orders to allow the Mountain Medical Group to place concentrated oxygen in her home. She chooses not to comply with this order (probably because of financial concerns). Sallie stated,” They tried to tell me that it was not gonna cost anything but that is not usually how it works.”
Nursing Intervention and Rationale
The first intervention is to convince Sallie to allow the medical group to come and set up oxygen in her home. Patient education regarding the need for supplemental oxygen is vital. Explain to her that (short term) oxygen deficit can cause increased confusion, rapid breathing and shortness of breath. Long term oxygen loss can lead to early dementia, disabilities and even death (Centers for Disease Control Prevention,
Lack of Oxygenation
The first problem is the lack of oxygenation with Sallie’s congestive heart failure, atrial fibrillation, and hypertension. Hypertension (high blood pressure) can cause congestive heart failure. Congestive heart failure is a result of the ventricles not being able to pump an adequate amount of blood to the body. This causes blood and other fluids to back up inside the lungs, abdomen, liver, and lower body. Some signs and symptoms of CHF are shortness of breath and rapid breathing (Geib, Plappert, Roth & Birner, et al., 2015).
Sallie was given discharge orders to allow the Mountain Medical Group to place concentrated oxygen in her home. She chooses not to comply with this order (probably because of financial concerns). Sallie stated,” They tried to tell me that it was not gonna cost anything but that is not usually how it works.”
Nursing Intervention and Rationale
The first intervention is to convince Sallie to allow the medical group to come and set up oxygen in her home. Patient education regarding the need for supplemental oxygen is vital. Explain to her that (short term) oxygen deficit can cause increased confusion, rapid breathing and shortness of breath. Long term oxygen loss can lead to early dementia, disabilities and even death (Centers for Disease Control Prevention,