Older Adult Group Project

Improving Care Transition

🙠 🙢
Kerry Chou, Brooklyn Maher, Neela Minesinger, Michelle Nenadich &
Natalie Placencia
10/16/22

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 Case Study Overview - King Cup

🙡 Joaquin Espinoza, 85M, Native American, Catholic, Full Code

o Widower, Lives with daughter (manages meds)
🙡 Dx: Right Hip Fracture
o Multiple prior falls, 2 story house, Frequently walks at home
o Has cane (refuses to use it), Using walker in hospital
o R hip replacement yesterday
🙡 Meds: Hydrochlorothiazide, Lisinopril, Irbesartan, Allopurinol,
Gabapentin, Oxybutynin, Unknown Eyedrops, OcuVite
o Hypertension, Gout, Back Pain, Overactive Bladder,
Glaucoma, Multi-Vitamin
🙡 Worsening vision (glaucoma)
o No longer can drive or read
🙡 Assess: 4/10 pain, Limited R hip ROM (pain)
🙡 Discharge Notes: Tomorrow, Worries about burdening daughter 2
What is Concerning about Case

🙡 Priority concerns: Safety upon discharge,

reinjury and readmission, and deteriorating
health status

🙡 Safe discharge consists of

o Discharge planning
o Education on self-management
o Follow-up
(Mitsutake et al., 2020)

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 Boost Model 8P’s
Problems w Meds Psychological

🙡 <10 medications, no 🙡 No depression diagnosis,

high risk drugs, worries about burdening
daughter managed daughter
medication 🙡 Talk to daughter
🙡 Educate o Caregiver fatigue
• Increased care over time,
o Teach back education
no / small support group
to patient and (Kaminishi et al., 2017)
daughter o Assistance needed?
🙡 Manage Side Effects o Discuss concerns
o Diuretic + Overactive 🙡 Assess support systems
Bladder o Family, friends
o Discuss diet impact o Educate on resources 4
 Boost Model 8P’s
Principal DX Physical Limitations

🙡 Principal Diagnosis: 🙡 position, mobility & right

Right Hip Fracture - sided pain/weakness,
compounded by HTN, worsened by dangerous
Gout, Back Pain, and environment
Glaucoma.
🙡 Discuss installation of
🙡 Complete teach back safety equipment
🙡 Cover action plan 🙡 Collaborate with home
🙡 Discuss goals of care health services
🙡 Phone call follow up
(Rnpedia, 2017)
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 Boost Model 8P’s
Poor Health Literacy Patient Support

🙡 Teach the importance 🙡 Follow up with patient in

of using cane or 72 hours
walker after surgery 🙡 Make sure the patient
🙡 Discuss about a follow has the information or
up with already has a follow up
ophthalmologist due to appointment within in
two weeks of surgery
worsening glaucoma
o New medications?
🙡 Discuss with daughter
living plans and goals
for discharge
o Talk about her taking

care of herself as
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well
Boost Model 8P’s
Prior Hospitalization Palliative Care
🙡 Patient has not had any 🙡 Talk to patient and
prior hospitalizations daughter about future
🙡 Educate the patient on palliative services
how and why they o Are they interested
should be using their in them now?
cane o Discuss logistics
o Help his daughter

worry less
🙡 Identify goals for the
🙡 Educate on how to take future with the patient
care of post surgical site to prevent
to prevent complications rehospitalization and
and readmission future falls
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What P’s were Concerning or Overlooked?

🙡 Overlooked concerns
1. interpersonal conflicts between role and
caregiver and patient
2. non-compliance and difficulties with good habit
development
3. medication side effects complicate loss of ADL’s

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Reflection on Prior Rotations

🙡 TMC - Orthopedic Unit

🙡 Microsystems
o Organizational Support
o Interdependence
🙡 Examples:
o Case management
o PT/OT
o Travel nurses

(Johnson, 2001)
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References

Johnson, J. K. (2001). Clinical Microsystem Assessment Tool. D2L.

https://d2l.arizona.edu/d2l/le/content/1159525/viewContent/13594168/View
Kaminishi, K. S., Safavi, R., & Hirsch, C. H. (2017). Caregiver burnout. Geriatric Psychiatry, 691-708.
https://doi.org/10.1007/978-3-319-67555-8_34
Mitsutake, S., Ishizaki, T., Tsuchiya-Ito, R., Uda, K., Teramoto, C., Shimizu, S., & Ito, H. (2020). Associations of hospital discharge
services with potentially avoidable readmissions within 30 days among older adults after rehabilitation in acute care hospitals in
Tokyo, Japan. Archives of physical medicine and rehabilitation, 101(5), 832-840.
Rnpedia. (2017). Total hip replacement surgery nursing care plans & management. RNpedia.
https://www.rnpedia.com/nursing-notes/medical-surgical-nursing-notes/total-hip-replacement-surgery/

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