For a patient returning home after total hip replacement surgery, there is a need for the case manager to address any issues that may hinder proper healing or safety issues. In the case of Mr. Trosack, there are several issues that the case manager must address prior to discharge. First, Mr. Trosack is a newly diagnosed diabetic. He was prescribed Glucophage to help control his blood sugar and has demonstrated that he is able to perform his own blood glucose check using a glucometer. He has verbalized that he is not happy about having to take the “darn” medications and his family seems to be in denial about his diabetes.
They believe that diet alone will control his blood sugar. Mr. Trosack’s unhappiness about taking medication and his family’s lack of concern about continuing the medication will put Mr. Trosack at risk for non-compliance with his medication regimen. It is important that Mr. Trosack receive ongoing education about controlling his diabetes including proper diet and taking his medications at specific times. This also needs to be addressed with his family so they are supportive in providing a healthy atmosphere for Mr. Trosack. Mr. Trosack is at a risk for falls given his age and history of falling down the stairs.
His home is cluttered and there are many throw rugs which can interfere with safe ambulation. He is reliant on a walker for balance and lives on the second floor of his apartment building. It is important that any clutter and tripping hazards are cleared before Mr. Trosack can return home to decrease his chance of falling. It is also important that a physical therapist evaluate Mr. Trosack’s ability to climb 2 flights of stairs safely. Being newly diagnosed with hypertension, Mr. Trosack must be educated on the importance of rising slowly to prevent dizziness which may lead to falls.
He also may become tired or dizzy from his Percocet. Any educational materials should be in larger print to compensate for his impaired vision and any verbal education must be done to his right to compensate for the hearing loss in his left ear. Mr. Trosack is at a risk for social isolation due to his inability to navigate two flights of stairs which lead to the outside of his apartment. His brother helps him manage the family bakery and will have to work extra hours since Mr. Trosack is unable to work. His son and daughter-in-law both work 60 hours a week and are trying to conceive a child.
They were hoping to assist Mr. Trosack but admit that they have little spare time. They were intending to investigate whether there was a local grocery store that could deliver food. This social isolation could lead to depression or force Mr. Trosack to attempt risky behaviors to fend for himself. If he has a fall at home, there is no telling how long it would take for someone to come to his aid. Interdisciplinary Team Members and Roles Several disciplines should be involved in the discharge planning for Mr. Trosack. The nurse case manager will oversee the patient’s care to ensure that they have access to the resources they need to recover.
They help coordinate the patient’s care and make sure all aspects of care are covered. Case managers communicate with other specialists and ensure that the care is delivered in a timely manner. The physician will assess Mr. Trosack and clear him medically for discharge to home. The physician will monitor the healing process and prescribe any medications necessary. Any referrals to specialists will originate from the physician. The physical therapist will work with Mr. Trosack to set up an exercise regimen to improve strength and stamina. He can assess whether or not Mr. Trosack is able to safely navigate the stairs leading to his home.
Educating the patient about total hip precautions and safety is important. The physical therapist will teach the patient how to use the walker, safely get up from a seated or lying position, climb stairs and use the toilet while maintaining total hip precautions. He may recommend a raised commode or grab bars in the bathroom for safety. The social worker can assess the patient’s support system and recommend resources that can make life a little easier for the patient.
She may recommend an aide to assist Mr. Trosack with bathing, dressing, shopping or light housekeeping. The social worker could set up the delivery of meals from Meals on Wheels or other service. She could help find a grocery store that delivers food to the patient’s home. Since Mr. Trosack will be alone most of the time and he has an increased risk for falls, the social worker could help set up a medical alert system, like Lifeline, that will allow Mr. Trosack to call for immediate medical assistance in the event of an emergency. Safety Assessment The entry to Mr. Trosack’s apartment requires walking up 2 flights of stairs. There is no elevator in the building.
Mr. Trosack will not be able to safely navigate the stairs without the assistance of another person. He will not be able to carry his walker and safely descend the steps. If he does have the assistance of someone who will carry his walker, there must be a handrail available for extra stability. The physical therapist needs to educate Mr. Trosack on the safe way to ascend and descend stairs. When going up, Mr. Trosack should lead with his “good” leg, and then bring his operative leg to the same step. When descending the stairs, he should lead with his “bad” leg and then bring down his “good” leg. Mr. Trosack’s apartment is described as small and cluttered.
The area will need to be cleared so there is a safe pathway for him to walk through that includes enough room for his walker. Any throw rugs should be removed to prevent tripping. The bathroom should be equipped with grab bars to give Mr. Trosack extra stability. A bath seat should be placed in the tub so Mr. Trosack does not have to stand while bathing, thus reducing the chance for a slip and fall. A raised seat commode would be useful to prevent breaking total hip precautions. Any old medication in the medicine cabinet should be thrown away to prevent confusion.
The kitchen is small and cannot accommodate the walker. Mr. Trosack will have to be taught to safely navigate the kitchen using the counters for support. An occupational therapist could assess the situation and make recommendations for kitchen safety. The stove seems to be accessible with the controls on the front in easy reach. Old food in the refrigerator should be thrown away to prevent food borne illness. If an aide is involved in Mr. Trosack’s care, she could help with food shopping, throw away all old food each week and take the trash out. Discharge Plan Needs Mr. Trosack will require an environment that is safe and supportive during is recovery. His home will need to be cleaned and all tripping hazards taken away.
He will need supervision in activities of daily living (ADLs) like bathing, cooking and ambulation. His groceries will need to be delivered and his trash will need to be taken down the stairs. He will need some form of communication to alert emergency services if he falls. His family is extremely busy working 60 hours a week and they have little spare time to help. The family needs to decide if they can take on this responsibility alone. Mr. Trosack needs to realize that he will not be able to help in the bakery until he is healed.
The stairs to his apartment are a huge barrier to him leaving the home for any reason and he cannot do it safely without help. Social Isolation Mr. Trosack is at risk for social isolation due to living alone, lack of family support and inability to leave his house due to surgery. According to the World Health Organization, social isolation is associated with “increased rates of premature death, lower general well-being, more depression, and a higher level of disability from chronic diseases” (Children’s, Women’s and Seniors Health Branch, British Columbia Ministry of Health [BC Ministry of Health], 2004, p. ).
The isolated tend to have a higher incidence of depression and stress-related conditions. People who feel alone are at an increased risk of early death. A British study found that the most socially isolated were 26% more likely to die than those who were active (Szalavitz, 2013). Some of this is due to delayed medical care caused by medical conditions going unnoticed until the condition has become advanced. Some is due to the lack of health benefits of social, physical contact like holding hands. Physical contact can help reduce pain and blood pressure while decreasing stress hormones and inflammation.
The stress caused by social isolation generates the production of cortisol in the body. This has a deleterious effect on wound healing. On the other hand, during social contact and bonding, the body produces oxytocin. This hormone blocks the effects of cortisol and helps promote healing (Detillion, Kraft, Glasper, Prendergast, & DeVries, 2003). Psychological Factors Mr. Trosack will be alone most of the time. He is a widower and his family is busy with work. He is unable to leave his home due to mobility issues. He will not be able to function at the bakery as he wishes.
This may lead to loneliness and frustration which will negatively impact his well being. He may become depressed and lack the motivation to continue with his therapy program. His sleep patterns may be affected and he may lose track of time which may make it difficult for him to maintain proper medication administration times. Recommendations It should be recommended that Mr. Trosack be discharged to home with several services in place to assist him. A visiting nurse will provide additional education about medications and monitor Mr. Trosack’s medication compliance. She can also reinforce teaching about diet and total hip precautions.
A nurse aide can help with ADLs and some light housework to make sure the home remains uncluttered. The aide can help with shopping, cooking and taking out the trash. A physical therapist can visit and help with mobility and exercises. The therapist can determine when Mr. Trosack can advance to use of a can instead of a walker. The case manager can provide outside resources like transportation and Meals on Wheels. An occupational therapist can teach Mr. Trosack how to safely dress and bathe himself to promote independence. Visits from these professionals will also decrease the feeling of loneliness and social isolation.
Courtney from Study Moose
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