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Care Plan for Carlos' Discharge to Home - Coggle Diagram
Care Plan for Carlos' Discharge to Home
Care Issue 1: Dental Osteonecrosis
Dental
3 month routine exams and cleanings
Teach Carlos and family the risk of dental osteonecrosis and signs/symptoms of a rotten tooth
Teach and have Carlos demonstrate Proper brushing and flossing
Nursing/Nurse Practitioner
Evaluate dental plan of care in the home setting
Evaluate if Carlos is brushing and flossing
Observe Carlos take the prescription at home, and providing any reteaching
Social Work
Assist in making a referral in their area to a dental provider
Counsel mom and Carlos through a plan for dental upkeep
Pharmacy
Manage Prescription for Prevident 5000 and Chlorhexidine
Care Issue 2: Central Line Care & CLABSI Prevention
Dental
Supervise oral routine
Stress importance of daily oral care
Monitor for breakdown in mucus membranes
Nurse Practitioner
Telehealth check-ins for patient and parents
Teach back/ demonstration on central line care at home
PRN in home visits for line management
Ensure patient has correct supplies and usage techniques to properly manage central line and prevent CLABSI
Ensure that family’s Medicaid program covers enough supplies until next visit
Out of bed activity 3 times daily to promote GI motility and prevent CLABSI
Routine daily bathing with soap and water & skin care
Cover central Line dressing for bathing care activities
If dressing gets wet, change immediately
Signs and symptoms of infections and when to come into emergency room
Pharmacy
Teach patient and family about need for antibiotics if infection occurs
At home or over the counter medications cleared for use at home and safe for pediatric use
Social Work
Ensure that Carlos and family's insurance covers central line care supplies
Organize proper supply and medication delivery to patient home
Evaluate who may be at home to care for the patient while mom is at work
Evaluate mom’s care-giver role strain and make sure she has the necessary parenting tools to give him the care he needs
Care Issue 3: Transportation and Care Coordination
Dental
Resume with the pending dental plan as scheduled
Resume Dental Cleaning Schedule
Social Work
Coordinate with transportation services to and from Ann Arbor if needed
Confirm medicaid coverage is active
Ensure family has access to telehealth visits at home prior to discharge (ex. internet, computer, health portal log-in, etc.)
Pharmacy
Medication management and first line treatment for side effects
Verify local pharmacy/which pharmacies take Medicaid
Ensure proper medications are being prescribed by care team
Nurse Practitioner
Chemo side effect management; medications, integrative medicine methods, emotional/behavioral support
Nurse Line information for questions to be answered via telephone
Schedule telehealth or at home follow-up visit between chemotherapy
Care Issue 4: Adjustments Returning to School/Home
Social Work
Referrals to support groups or counseling in their area
Physical, cognitive, social, and psychological assessment of the child prior to returning to school
Help identify barriers for the family; employment/ financial concerns for parents and educational/ social concerns for the child.
Coordinate a Care conference with all health professionals on Carlos team to solidify discharge plan.
Nurse Practitioner
Have family identify Signs and Symptoms of Infection and when to notify provider or seek care
Provide locations of nearest medical facility for emergent and non-emergent medical attention if needed
Follow-up appointment coordination and scheduling
Ensure proper dietary needs and activity level requirements are met
Follow-up with Carlos school nurse to create at school plan
Pharmacy
Preferred pharmacy availability to get medications
Medication safety and guidelines of what to take during and in between chemo treatments
Dental
Local resource for regular and emergency dental care
Follow-up and resuming routine dental appointments