ADVENTIST MEDICAL CENTER COLLEGE

Brgy. San Miguel, Iligan City

SCHOOL OF NURSING

DISCHARGE PLAN

Name of Client:____________________________________ Age: ________ Gender:

_____________
Religion: ________________ Diagnosis:
__________________________________________________
Surgery if any:
_______________________________________________________________________
Hospital: _____________________________________ Room/Ward Bed No.
____________________
Attending Physician/s:
________________________________________________________________
A. OBJECTIVES
At the end of an hour of health education the client will be able to:
1.
2.
3.
4.
5.

B. METHODS
1. Medications
Name of Dosage Route Curative Side Instructions
Drug Preparation Effects Effects
(Generic Frequency
and Trade Duration
Name)

Salbutamol One tab 2 oral Bronchodilator Rapid

(Ventolin) mg 4x a day heart
for 7 days rate
Nausea

2. Exercise/Activity and Home Environment

Types of activity that should not be allowed

Type of Activity Allowed/To be continued:

_____________________________________________
 Procedure or Steps: (cite the source)
a.
b.
c.
d.
e.
Use of Equipment (if any):
__________________________________________________________
Restrictions:
a.
b.
c.

Home Environmental Hazards:

a.
b.
c.

3. Treatments/Therapies (e.g., Chest physiotherapy, warm compress, steam

inhalation, hydrotherapy, nebulization, etc)
a.
b.
c.

4. Health Teaching/Education (e.g., asthma)

Health Prevention/Promotion
a.
b.
c.
d.
e.

5. OPD Visit
Clinic Appointment Schedule:
______________________________________________________
Follow-up Diagnostic or Laboratory Exam:
____________________________________________
Referrals:
__________________________________________________________________
_____
6. Diet
a. Prescribed
Diet:___________________________________________________________
_____
 3- Day Sample Menu

Day 1 Day 2 Day 3

Breakfast Breakfast Breakfast

Lunch Lunch Lunch

Dinner Dinner Dinner

b. Diet Restrictions:

7. Spiritual Care and Psychological or Sexual Needs (Give special

consideration to religious and cultural practices)
Spiritual and Psychological Needs
( ) Spiritual Counseling
( ) Grief Work
( ) Anger Management
( ) Confession
( ) Family Therapy
( ) Reconciliation of Conflicted Relationships
( ) Supportive Counseling
( ) Join Church Organizations/Activities
( ) Prayer
( ) Meditation, Reflection, and Spiritual Devotion
( ) Religious Rituals
( ) Religious/Spiritual Materials

Sexual Needs
( ) Marriage Counseling
( ) Sex Therapy
( ) Sexual Violence
( ) Referral to Appropriate Agencies

C. DISCHARGE DETAILS
a. Date and Time of Discharge:
___________________________________________________
b. Accompanied by:
_____________________________________________________________
c. Mode of Transportation:
_______________________________________________________
d. General Condition upon Discharge:
_____________________________________________
This discharge plan was explained to me by my student nurse and I have understood
it.

_____________________________
CLIENT/SIGNIFICANT OTHER
(Signature over Printed Name)

Instructed By: Approved By:

____________________________
________________________________
STUDENT NURSE CLINICAL
INSTRUCTOR
(Signature over Printed Name) (Signature over Printed
Name)