FORMAT Discharge Plan

8/2/2019 FORMAT Discharge Plan

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Discharge Plan

Name: Pedro Bitangkol Age: 68 years old

Religion: Roman Catholic Sex: MaleDiagnosis: PneumoniaSurgery Undergone, if any: none Physician: Dr.OliverosHospital: Perpetual Soccour Hospital

A. ObjectivesThe time that client will be discharged he with the help of his familywill be able to:

1. Provide ventilation and oxygenation adequate for individualneeds.

2. Prevent or minimize complications.3. Understand disease process/prognosis and therapeutic regimen.4. Plan in place to meet needs after discharge.

I. Medication

Name ofDrug

Route andFrequency

Curative Effects Side Effects

Aspirin

Tylenol(acetaminoph

en)

PO, 1 or 2 tabletsevery 4 hours or 3tablets every 6hours, not toexceed 12 tabletsin 24 hours.

For adults andchildren 12 yearsof age and older,

the recommendeddose ofacetaminophen is650 to 1000 mgevery 4 to 6 hoursas needed, not toexceed 4000 mgin 24 hours.

Pain reliever/feverreducer.

Relieves pain,reducing fever, and

relieving thesymptoms of

allergies, cold,cough, and the flu.

Nausea,vomiting,stomach pain,heartburn

an allergicreaction

(difficultybreathing;closing of thethroat; swellingof the lips,tongue, or face;or hives);liver damage,blood problems(easy or unusualbleeding orbruising).


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II. Exercise/ Activity

Type of Activity allowed/ to be continued:

Complete Bed Rest

Deep Breathing ExerciseProcedure or Steps:1. Sit up straight. Exhale.2. Inhale and, at the same time, relax the belly muscles. Feel asthough the belly is filling with air.3. After filling the belly, keep inhaling. Fill up the middle of your

chest. Feel your chest and rib cage expand.4. Hold the breath in for a moment, then begin to exhale as slowlyas possible.5. As the air is slowly let out, relax your chest and rib cage. Begin topull your belly in to force out the remaining breath.6. Close your eyes, and concentrate on your breathing.7. Relax your face and mind.8. Let everything go.9. Practice about 5 minutes.

Chest PercussionProcedure or Steps:

1. Turn the patient on side.2. Move fingers together and positioned like a cup.3. Use both hands rhythmically and position upward so secretions

may be expelled. Every areashould have 3-5 minutes of percussion.4. Avoid percussion on sternum , spinal cord , abdomen , female

breast areas, andother important organ areas such as stomach ,liver and kidney.And stop percussion if the ff symptoms appear

-Cyanosis (blue color of skin)-Shortness of breath-Rapid, significant change in vital signs-Blood-tinged sputum when coughing

Postural Drainage

Procedure or Steps:1. Position the client in a trendelenburg position.2. Use pillows or large towels to maintain a comfortable position for

the patient.Encourage deep breathing and coughing to expel secretions.


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3. Repeat 3-4 times every day depending on the patients condition

Use of Equipment (if any): NA

Restriction: lifting heavy weights and running more than 1 km.

III. Treatment (Prescribed treatment to be continued at home or toa referred

health institution)

cough suppressants- Vicks Formula 44 pain relievers and fever reducers, such as aspirin or

acetaminophen.

HEALTH TEACHINGS

Prevention, Self Care and Home Treatment forPneumonia

Prevention and Self-careIf you have pneumonia, the following measures can help you recovermore quickly and decrease your risk of complications:

Practice good hygiene. Get an influenza shot (pneumonococcal vaccine) Practice good preventive measures by eating a proper diet,

getting regular exercise and plenty of sleep. Quit smoking. Drink lots of fluids, especially water- Liquids keep you from

becoming dehydrated and help loosen mucus in your lungs. Take the entire course of any prescribed medications-

Stopping medication too soon can cause your pneumonia tocome back and contributes to the development of antibiotic-resistant bacteria.

Keep all of your follow-up appointments- Even though you feel

better, your lungs may still be infected. It's important to haveyour doctor monitor your progress.

Home TreatmentHome treatment is important for recovery from pneumonia. The followingmeasures can help you recover and avoid complications, such as furtherinfection or a buildup of fluid in the space between the lung and chest wall(pleural effusion).

While you are at home: Get plenty of rest and prevent dehydration by drinking plenty

of fluids.


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Take care of your cough if it is making it difficult for you torest- A cough is one way your body gets rid of the infection,and you should not try to eliminate coughing unless it issevere enough to make breathing difficult, cause vomiting, orprevent rest.

Consider taking acetaminophen (such as Tylenol) or aspirin tohelp reduce fever and make you feel more comfortable.

Always check whether any over-the-counter cough or coldmedicines you are taking contain acetaminophen. If they do,make sure the acetaminophen you are taking in your coldmedicine, plus any other acetaminophen you may be taking,is not higher than the daily recommended dose. Ask yourdoctor or pharmacist how much you can take every day.

V.a) Observed signs and symptoms that need reporting:If you do not feel better, your cough gets worse, you have shortness of

breath or a fever, you feel weak, or you feel faint when you stand up.

b) Interventions/Home remedies that may be doneimmediately prior

to seeking consultation:

oxygen administration temperature taking TSB Chest tapping BP taking

VI. DIETa) Prescribed Diet: increase fluid intake, proper intake of nutritious

food.

b) Restrictions: avoid cold foods or drinks.

VII. Spiritual and Psychological Needs[] Spiritual Counseling [] Confession [] Supportive

Counseling[ ] Grief Work [ ] Family Therapy [ ] join

organizations/church activities[ ] Anger Management [ ] Reconciliation of conflicted relationships

B. Discharge Detailsa) Date of Discharge: January 1, 2008b) Time of Discharge: 4:00 pmc) Accompanied by: His wifed) Mode of transportation: none


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e) e) General Condition upon discharge: patient was conscious,walks briskly and is capable of responding normally.

THESE DISCHARGE INSTRUCTIONS WERE EXPLAINED TO THE PATIENTAND/OR RELATIVE

READ and UNDERSTOOD: (translated according to patients convenience): If all measures fail, an interpreter is asked.

_______________________________________PATIENT / RELATIVE

(Signature over printed name)

Validated:

_______________________________________

STUDENT NURSE

_______________________________________CLINICAL INSTRUCTOR

FORMAT Discharge Plan

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