Free Nursing Discharge Care Plan Template
Nursing Discharge Care Plan
Patient Information
Patient Name: Tom Walter
Date of Birth: January 15, 1975
Discharge Date: December 15, 2050
Diagnosis: Total Hip Replacement (Right)
Discharge Destination: Home
Primary Care Physician: Dr. Emmy Green
Phone Number: 222 555 7777
Emergency Contact: Berta Flatley
Contact Number: 222 555 7777
1. Medications and Instructions
|
Medication Name |
Dosage |
Frequency |
Instructions |
|---|---|---|---|
|
Pain Reliever (Ibuprofen) |
200 mg |
Every 8 hours |
Take with food to avoid stomach upset. |
|
Antibiotic (Amoxicillin) |
500 mg |
Every 12 hours |
Complete the full 7-day course, even if symptoms improve. |
|
Blood Thinner (Aspirin) |
81 mg |
Once daily |
Take at the same time every day, preferably with breakfast. |
|
Stool Softener (Docusate Sodium) |
100 mg |
Once daily |
To prevent constipation due to pain medication. |
2. Wound Care Instructions
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Wound Site: Right hip incision
-
Care Instructions:
-
Keep the wound clean and dry.
-
Change the dressing every 48 hours or sooner if it becomes wet or dirty.
-
Use sterile gauze pads to cover the wound.
-
Apply a thin layer of antibiotic ointment if instructed by the physician.
-
-
Signs of Infection to Watch For:
-
Increased redness, warmth, or swelling around the incision.
-
Pus or drainage from the wound.
-
Fever above 100°F (38°C).
-
3. Activity Restrictions and Instructions
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Weight-Bearing Status: No weight-bearing on the right leg for 4 weeks. Use crutches for mobility.
-
Movement Restrictions:
-
Avoid bending the hip more than 90 degrees.
-
Do not cross legs while sitting or lying down.
-
Limit walking to short distances, and rest frequently.
-
-
Exercise and Rehabilitation:
-
Start physical therapy on December 17, 2050 (contact the rehab center at [YOUR COMPANY NAME] for scheduling).
-
Follow the prescribed therapy exercises for strengthening and range of motion.
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Do not lift objects heavier than 5 pounds until cleared by the physical therapist.
-
4. Follow-Up Appointments
|
Appointment Type |
Date |
Time |
Location |
|---|---|---|---|
|
Primary Care Follow-up |
December 22, 2050 |
10:00 AM |
[YOUR COMPANY NAME] Clinic, 1234 Health St. |
|
Physical Therapy |
December 17, 2050 |
1:00 PM |
[YOUR COMPANY NAME] Rehab Center, 5678 Wellness Rd. |
|
Orthopedic Specialist |
January 5, 2051 |
2:30 PM |
[YOUR COMPANY NAME] Orthopedic Center, 9101 Joint Blvd. |
5. Emergency Instructions
-
Signs of Complications to Watch For:
-
Sudden or severe pain in the hip or leg.
-
Swelling or tightness in the calf (possible blood clot).
-
Shortness of breath or chest pain.
-
-
When to Call for Help:
-
If you experience any of the symptoms listed above, call [YOUR COMPANY NAME] at [YOUR COMPANY NUMBER] or seek immediate medical attention.
-
6. Additional Information
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Home Support and Assistance:
-
Family members are encouraged to assist with daily activities like meal preparation and transportation to appointments.
-
A home health nurse will visit on December 20, 2050, to monitor recovery and assist with wound care.
-
-
Patient Education:
-
Avoid sitting or lying down for long periods; change positions frequently to reduce the risk of blood clots.
-
Stay hydrated and eat a balanced diet to aid in the healing process.
-
Prepared by: [YOUR NAME]
Email: [YOUR EMAIL]
