NRS-460 Benchmark – Case Study: Timothy Smith – Discharge Planning Directions: Read the case study below. Evaluate the information and formulate a conclusion based on your evaluation. Complete the critical thinking table and submit the completed template to the assignment dropbox. It is necessar

NRS-460 Benchmark – Case Study: Timothy Smith –

Discharge Planning

Directions: Read the case study below. Evaluate the information and formulate a
conclusion based on your evaluation. Complete the critical thinking table and submit the
completed template to the assignment dropbox.
It is necessary for an RN-BSN-prepared nurse to demonstrate an enhanced understanding of the
complex management of disease during the discharge of a patient, and the additional aspects of
communication and safety in the work environment. The purpose of this assignment is to
participate in discharge planning for a patient utilizing communication and information
technology, and in a scenario where patient and provider safety is a concern.
PART I: Health History and Medical Information
Evaluate the health history and medical information for Timothy Smith, presented below.
Mr. Smith is ready to be discharged from the hospital. Timothy has been weaned off of
oxygen. His tube feedings have been discontinued and he is tolerating a pureed diet. To
facilitate safe discharge, the hospital case manager has set up services with a transitional
care manager from a Home Health agency. The goal is for Mr. Smith to attain safe
recovery and rehabilitation.
1. Broken left leg status
2. Weight bearing status: non-weight bearing, stand pivot with right leg only
a. Assistive devices: wheelchair
b. PICC line present for discharge
3. Left upper leg wound care: dressing changes as needed for open reduction internal
fixation (ORIF) on leg
4. Psychiatrist telehealth follow-up scheduled for a Zoom call upon discharge
5. Telehealth follow-up visit scheduled two weeks after discharge with Primary Care
Physician (PCP)
Lab Tests and Vitals
1. Room air, respiratory rate 16 breaths per minute
2. Vital signs are within normal limits

PART II: Critical Thinking Activity
Use the findings from your evaluation to complete the following:

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Home Health Care and Rehabilitation Therapy
During care coordination and transition of care planning, it is important to consider the type
and level of care a patient might need.
You are the transitional care
manager assigned to Mr.
Smith prior to discharge.
Based on Mr. Smith’s
assessment findings, develop
a discharge plan that
encompasses his care needs
following discharge. Your
response should be a
minimum of 200 words.
Discuss three to five
interdisciplinary roles that
will be essential in
supporting Mr. Smith’s home
health and rehabilitative
care needs. Your response
should be a minimum of 150
words.
You are the home health
nurse assigned to treat Mr.
Smith. Identify two areas of
concern that you might
prioritize during your initial
visit with him following
discharge. Your response
should be a minimum of 150
words.
Psychosocial and Spiritual Considerations
Providing holistic nursing care for patients with complex conditions requires that the nurse
takes into account the patient's psychosocial and spiritual needs.
Given the patient's current
situation, discuss ways in
which the nurse can take into
account and address the
patient's psychosocial and
spiritual needs. Your

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response should be a
minimum of 150 words.
Just Culture
The patient is due to receive his IV antibiotic prior to discharge. As the nurse reviews the
electronic orders, she notices that the antibiotic dose seems incorrect. Upon discussion with
the provider and pharmacy, it is determined the dose entered was incorrect.
Discuss how reporting this
near miss will help
contribute to a just culture
reflecting civility and
respect. Your response
should be a minimum of 200
words.
Discuss how clinical
judgement and critical
thinking should be applied
despite the use of
information and
communication technologies.
Your response should be a
minimum of 150 words.
Levels of Risk
As Mr. Smith is waiting for the nurse, he becomes impatient and starts to verbally attack the
patient care technician as she obtains his vital signs.
Identify actual and potential
levels of risk to the care
team within this situation
given the patient's history of
PTSD. Your response
should be a minimum of 150
words.
What can the nurse do to
diffuse this situation? What
steps can be put in place to
ensure safety for both
patients and providers in
the future? Your response
should be a minimum of 150

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words.
Patient Portal
The nurse is helping Mr. Smith log in to the Patient Portal (i.e. MyChart) before discharge.
Explain the considerations
for ensuring the patient
would be able to use this
resource at home. In your
discussion include
considerations related to the
patient's condition and
cognitive status based on his
assessment findings and
history of injury reviewed in
previous topics. Your
response should be a
minimum of 200 words.
Discuss the benefits for both
the patient and the care team
in using information and
communication technology
to support the patient-
provider relationship. Your
response should be a
minimum of 150 words.
What obstacles might hinder
his use of the Patient Portal?
Your response should be a
minimum of 150 words.
Telehealth
Mr. Smith is scheduled for a telehealth appointment with the psychiatrist upon discharge.
Discuss the information and
resources that the nurse
should ensure the patient has
available in preparation for
his visit. Your response
should be a minimum of 150
words.
References (Please include working hyperlinks.)