Benchmark discharge summary note

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Benchmark Requires LopeswriteAssessment Description

Academic clinical discharge summary notes provide a unique opportunity to practice and demonstrate advanced practice documentation skills, develop and demonstrate critical thinking and clinical reasoning skills, and practice identifying acute and chronic problems and formulating an evidence-based plans of care.

This assignment uses a template. Refer to the “AGACNP Discharge Summary Template,” located on the Student Success Center page under the AGACNP tab.

Develop an academic clinical discharge summary note based on a hospital patient seen during clinical/practicum. The discharge summary note should include the following:

1. Reason for admission: Include the reason for admission, a list of diagnoses in order of acuity, and an ICD-10 diagnosis.

2. List of all procedures: Include all dates, significant findings, and any anesthetics and contrast used during procedures.

3. Complete list of consults during hospitalization: Include any providers or services consulted during the stay.

4. Patient’s condition at discharge: Include a physical exam prior to discharge that documents that patient is stable at discharge and has safe disposition and transportation. What diagnostic criteria confirmed the discharge diagnosis?

5. Complete list of discharge medications: Full list with all dosages, frequencies, and quantity of medications prescribed or dispensed.

6. Pending test results for follow up: Complete list of any pathology, cultures, radiology, or other diagnostic tests still pending, and who is responsible for follow-up on the final results.

7. Complete list of discharge instructions: Full list of directions regarding infection prevention, new medications, and returning to daily activities.

8. Complete list of discharge follow-ups: Full list of any therapies, treatments, referrals, consults, and follow-up appointments. What diagnostic criteria were needed after discharge?

9. Summary: What questions were raised during the hospital stay? Include all explanations and answers to these questions. What questions were raised that required further exploration? What kind of discharge planning did you need? Characterize your patient interaction activities.

10. Overall assessment: Identify health promotions, health education, ethical considerations, geriatric considerations, and expected outcomes.

Incorporate three peer-reviewed articles in the assessment or plan.

While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to LopesWrite. A link to the LopesWrite Technical Support Articles is located in Class Resources if you need assistance.

DISCHARGE SUMMARY: PCI IN THE ELDERLY PATIENT 1

DISCHARGE SUMMARY: PCI IN THE ELDERLY PATIENT

DISCHARGE SUMMARY: PCI IN THE ELDERLY PATIENT 6



DISCHARGE SUMMARY: PCI in the Elderly Patient

Professor: XXXX

Student Name

Grand Canyon University-ANP 654

Date

DISCHARGE SUMMARY

Discharge Summary

Date

XXXX-ANP 654

Patient Name: H.W.

MRN: 123456

Sex: Male

Date of Birth: 12/12/1933

Provider: C.H. APRN/MILLENIUM PHYSICIAN GROUP

Primary Care Provider: Dr. S.B.

Admission Date: xx/xx/xxxx

Discharge Date: xx/xx/xxxx

Admitting Diagnoses:


I25.1 Atherosclerotic heart disease of native coronary artery

R00.1 Bradycardia, unspecified (permanent pacemaker placed by Dr. R 12/28/2019)

I10 Renovascular hypertension

N18.6 End stage renal disease (on peritoneal dialysis)

Discharge Diagnosis:

I25.1 Atherosclerotic heart disease of native coronary artery-elective cardiac catheterization on this admission

R00.1 Bradycardia, unspecified

I10 Renovascular hypertension controlled

I70.1 Atherosclerosis of renal artery

N18.6 End stage renal disease (peritoneal dialysis 1/14/20 prior to discharge)

Admission Procedure:

01/13/20- Cardiac catheterization under moderate sedation with use of IVP contrast for coronary angiography

Impression: Non-dominant RCA without significant obstructive disease <60%. OM with an 80% proximal lesion, Circumflex with mid 90% lesion, LAD is without disease, large diagonals without disease. LV function is normal, EF 50%, no wall motion abnormalities. PCI to the OM and Circumflex were performed with good results.

Consultations:

Dr. R Interventional Cardiologist- performed elective cardiac catheterization 1/13/20

Course of Treatment:

This is an 86 year-old male patient with a complex cardiac history. The patient had a permanent pacemaker placed on 12/28/2019 for severe symptomatic bradycardia. After pacemaker placement, the patient underwent a Lexiscan showing ischemia. A planned cardiac catheterization was scheduled for 1/13/20. Dr. R. performed PCI and placed BM stents to the patient’s OM and Circumflex arteries. His RCA was assessed and was deemed not severe enough for intervention and was a non-dominant vessel. The patient was admitted for further observation overnight post procedure. He had no complaints of chest pain, no shortness of breath, no nausea or vomiting, no dizziness, and no numbness or tingling in his bilateral lower extremities. No hematoma, redness or swelling noted at his right groin catheterization site. Overall, the patient is stable for discharge this evening after his peritoneal dialysis treatment.

Admission Home Medications:

Auryxia 210mg, 2 tabs, po three times daily

Entresto 24/26mg, 1 tab, po twice daily

Thiamine 100mg po daily

Docusate sodium 100mg po twice daily

Discharge Medication:

Auryxia 210mg, 2 tabs, po three times daily

Entresto 24/26mg, 1 tab, po twice daily

Thiamine 100mg po daily

Docusate sodium 100mg po twice daily


New
:

Nitroglycerine 0.4mg, one tablet SL every 5 minutes (may repeat x 3) as needed for chest pain-call 911 if no relief-dispense #30, 1 refill


New
:

Clopidogrel 75mg, one tablet by mouth daily, dispense-#30, 1 refill

Physical Exam:

Vital signs: BP 125/55, HR paced, 70, Pulse Ox on room air >92%, RR 18

General: no acute distress, well developed, well nourished, appears younger than stated age, pleasant and cooperative

Chest: Clear to auscultation and percussion, breath sounds normal, equal expansion, air movement good, no cyanosis, or clubbing of fingers, no kyphosis, no scoliosis

Cardiovascular: S1, S2, no murmurs, bruits, or thrills noted. Peripheral pulses +2, no JVD, trace pedal edema noted

Extremities: right groin catheterization site without swelling, redness, or drainage, dressing in place, no cyanosis or edema

Abdomen- soft, non-tender, slightly distended, undergoing peritoneal dialysis, bowel sounds positive, last BM this morning, tolerating po diet

GU- no discharge, no abnormal bleeding, does not void

Neuro: Alert and oriented x 3, no motor or sensory deficits noted, cranial nerves II-XII intact, sensation and strength normal

Laboratory values:

Gluc-125, BUN 67, Cr 11.69, Na 139, K 3.4, Ca 7.9, Pt 12.2, INR 1.04, Wbc 6.21, Hgb 8.3, Hct 26.0, Plt Ct 220, Mg 2.0

EKG (1/14/2020)-Ventricular paced rhythm, no acute changes

Assessment and Plan-

1. Coronary artery disease s/p PCI to OM and Circumflex due to abnormal lexiscan/abnormal findings on cardiac catheterization-continue current home medications, add SL Nitroglycerine, add Plavix, ok to remove dressing at home or prior to discharge, ok to shower, no heavy lifting, bending or strenuous activity for 1 week

From a cardiology standpoint, the patient is stable for discharge once his dialysis treatment is complete. All questions and concerns were answered at bedside with patient and wife.

Pending Results: All tests are completed, no results are pending at time of discharge

Discharge Condition: Stable

Disposition: Home with wife

Time of Assessment: 09:20am

Time spent on Discharge and Care Planning: >30min

Discharge Instructions:

Diet– Cardiac/Heart Healthy, Renal Diet

Physical Activity– 1 week no heavy lifting, bending or strenuous activity

Follow up provisions:

Primary Care Provider: Dr L.C, please call 123-1234 to schedule an appt in 1 week

Cardiology: Dr R. 2/14/20 at 09:00am. Ph-123-2345 to change if not convenient

*Discharge and PCP medication list has been reviewed and verified with patient. Prescriptions have been given to patient with in depth instruction for use.

Considerations:

This patient underwent stenting to his OM and distal Circumflex arteries with bare metal stents. Current guidelines are a minimum of one month of antiplatelet therapy following elective percutaneous coronary intervention (Kereiakes, Yeh, Massaro, 2015). In this patient’s case it was decided that he should remain on clopidogrel indefinitely secondary to residual coronary disease and PCI. Antithrombotic treatment in cardiovascular disease consists of oral anticoagulation and antiplatelet agents. Aging is the primary risk factor in the development of arteriosclerosis. The elderly patient is at high risk for developing thrombosis but also has a higher risk of bleeding. Increased risks make it more difficult for providers to choose appropriate anticoagulant strategies for their patients. Elderly persons also have more comorbidities, such as diabetes, and renal disease, which increase adverse reactions and risk factors in patients. Three major problems are identified in selecting the best therapy for the patient. They are polypharmacy, comorbidity, and medication adherence (Arahata, Asakura, 2018). Providers need to evaluate these problems and make a decision for each patient based on benefit versus risk. Another important thing is for providers is to involve an interdisciplinary approach and view the overall health of the patient. The intervention should not be based on one disease process alone but should be based on the overall health of the patient.

This is an active 83 year-old without physical mobility compromise. He has no history of falls and uses no assistive devices. He is compliant with his health care regimen. He is aware of the increased risk of bleeding secondary to renal disease (Ruscin, Linnebur, 2018). His health care goal is to maintain a good quality of life. Benefit outweighs risk in this patient’s case.

References

Arahata, M., & Asakura, H. (2018). Antithrombotic therapies for elderly patients: handling problems originating from their comorbidities. Clinical interventions in aging13, 1675–1690. doi:10.2147/CIA.S174896

Kereiakes DJ, Yeh RW, Massaro JM, et al. Antiplatelet Therapy Duration Following Bare Metal or Drug-Eluting Coronary Stents: The Dual Antiplatelet Therapy Randomized Clinical Trial. JAMA. 2015;313(11):1113–1121. doi:10.1001/jama.2015.1671

Ruscin, M., Linnebur, S., (2018). Drug categories of concern in older adults. Merck Manual, Professional Version. Retrieved from
https://www.merckmanuals.com/professional/geriatrics/drug-therapy-in-older-adults/drug-categories-of-concern-in-older-adults

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