Patient Transitional Care Plan

Course title

Student name

Institution affiliation 

PATIENT TRANSITIONAL CARE PLAN

Patient’s Name: Mrs. Snyder      

Age: 91  

Gender: Female

Admitted to facility date: 30/03/2018

Reason for Admission: Dementia

Occupation or former occupation: Teacher/Housewife

Medical Diagnoses: Dementia (with additional hypertension)

Allergies: Peanut and Garlic  

Primary Healthcare Provider: Anne Brown

Prescriptions for Care

The diet will include soft foods and liquids except for alcohol due to her poor dentition. She may not be able to manage very long periods of physical activity and a Hoyer lift is required for her transfer because she is unable to support her body weight because of her weak muscles. There are no tests required for her because she is on hospice (Toles, Colon-Emeric, Naylor, & Barosso, 2016).

Activity treatment plan and schedule

Under physical therapy, the assessment will focus on rehabilitation of gait and muscle weakness, with speech therapy focusing on the assessment of her ability to swallow and speak to test for risks of aspiration. Occupational therapy will deal with the evaluation of her ability to care for herself.

Balanced Nutrition

The patient will be assisted by the caregiver to reduce the possibility of aspiration by implementing changes in diet within one month. She will also be provided with a diet which is high on nutrients or supplemented with additional nutrients to improve her food intake within one month. To achieve these dietary changes, the patient will be placed seated upright while having her meals to reduce the possibility of choking on foods or liquids upon intake. Also, she will be fed meals at times when she is wide awake and alert, such as in the morning or after taking a nap; this would reduce the likelihood of feeling drowsy while being fed and choking in the process.

The patient will be fed soft liquids using a dropper instead of a cup. This would enable the caregiver to control the amount of food, juice, and water for the patient to receive nutrients without the risk of choking. Nutritional supplements will be provided for her to improve her daily intake of vitamins as this would help in maintaining her normal cardiac function (Naylor & Berlinger, 2016). She will be provided with foods high in calories like nutritional shakes to provide the patient with minerals and vitamins that help the body to maintain normal balance. Proteins will also be added to her diet to help in wound healing incase the patient is injured by a cut, illness or infection.

If these nutritional goals are met, the patient will improve in nutritional status and weight. The risk of aspiration would decrease, due to the changes in posture while feeding, increasing the level of vitamin and nutrient intake. Her wounds would also heal faster, and she would show an increase in energy due to the modified nutrition plan (Peters, 2017).  

Physical Mobility

The caregiver will perform motion exercises to increase limb mobility and help her maintain her muscle tone to prevent contractures. The caregiver will also support her sleeping and sitting spots with pillows to provide support to her limbs and prevent swelling, joint pain and inflammation and enhance her motion. They will also collaborate with the physical therapy staff to create an exercise plan within the patient's physical capabilities.

The caregivers will also auscultate lung fields every eight hours by listening to lung sounds to note any abnormal findings early and treat them appropriately to prevent further lung complications (Naylor, Bowles, & Maccoy, 2013). Also, have the patient repositioned every two hours to prevent fluids from settling from settling in the bases of the lung. The repositioning will ensure deep breathing and prevent any atelectasis from impairing oxygen exchange.

If these goals are met, the patient will be able to prevent illnesses and impairment related to immobility such as impaired breathing, impaired muscle tone, and respiratory distress. Failure to fulfill these goals would make the patient develop lung infiltrates, decreased respirations, dyspnea and atrophy.

Combating the Issue of Loneliness

Decrease social isolation by ensuring the patient participates in group events a minimum of two times daily every month. She will also participate in one on one activities with the caregiver every day, each month. The social activities will allow the patient to be around others and participate in meaningful activities. The caregiver will encourage the patient's family to be involved in preventing her loneliness by visiting her regularly. This will increase her level of interaction with the people she cares about, reducing the loneliness.