Inability to independently maintain a safe growth-promoting immediate environment.
Assessment Data
• Lack of skills with which to function independently outside the hospital
• Lack of confidence
• Dependence on hospital
• Perceived helplessness
• Nonexistent or unrealistic goals and plans
• Lack of knowledge
• Inadequate support system
• Inadequate financial resources
• Disorganized or dysfunctional living environment
Expected Outcomes
Immediate
The client will:
• Verbalize concrete realistic plans regarding:
• Meeting essential physical needs (housing, employment, financial resources, necessary transportation, and physical care, if needed)
• Meeting emotional needs through significant relationships, social activities, a general support system, and so forth
• Dealing with stress or problems
• Dealing with other facets of living specific to the client (legal problems, physical or health limitations, and so forth)
Stabilization
The client will:
• Demonstrate the ability to meet essential needs (self-reliance when possible)
• Verbally identify and contact resource people in the community for various needs
• Identify needed services or resources to use after discharge
• Express willingness to follow through with identified plans
Community
The client will:
• Participate in follow-up care
• Implement plans to maintain community functioning
Implementation
NURSING INTERVENTIONS
* denotes collaborative interventions
On admission, ask the client about his or her expectations for hospitalization and plans for discharge. Attempt to keep the discharge plans as a focus for discussion throughout the client’s hospitalization.
Discussing discharge plans will reinforce the idea that the client’s hospitalization is temporary and that discharge is the eventual goal.
Encourage the client to identify his or her goals and expectations after discharge.
Help the client assess personal needs for specificity and structure. If it is indicated, assist the client in making a time schedule or other structure for activities (work, study, recreation, solitude, social activities, and significant relationships).
Focusing on the client’s life outside the hospital may help to diminish fears of discharge.
Encourage the client to continue working toward goals that have been identified but not yet realized during hospitalization (eg, obtaining a high school diploma, vocational plans, divorce). Give positive support for goal identification and work that has begun.
The client may be overwhelmed by the lack of structure in the home environment after a stay in an institution, which often is very structured and in which the client’s choices and need for decision making are limited.
The client is leaving a supportive environment and may need encouragement to continue working toward goals outside the hospital.
Talk with the client regarding medication or other treatment schedules and reasons for continuing therapy. Attempt to involve the client in treatment decisions, especially regarding therapies after discharge.
The client’s participation in decisions may increase his or her motivation to continue therapies.
Talk with the client about ways to meet personal needs after discharge (eg, obtaining food, money, shelter, clothing, transportation, and a job).
The client may need direction or assistance in making these plans.
* Assess the client’s skills related to meeting the above needs (eg, using a telephone and directory, managing a checkbook and bank accounts, contacting other community resources, and arranging job interviews). Work with the client and obtain help from other disciplines if indicated, such as vocational rehabilitation, therapeutic education, and so forth.
The client may lack daily living skills and may need to develop and practice them before discharge.
* Before discharge, encourage the client to make arrangements as independently as possible (eg, find housing, open bank accounts, obtain a job). Give support for these activities. Refer the client to social services if additional assistance is needed in obtaining housing.
The client will be leaving the support of the hospital and staff and needs to be as independent as possible.
Use role playing and setting up hypothetical situations with the client when discussing discharge plans.
Anticipatory guidance can be effective in preparing the client for future situations. Role playing and hypothetical situations allow the client to practice new behaviors in a nonthreatening environment and to receive feedback on new skills.
Teach the client about his or her illness, medications (action, toxic symptoms, and side effects), nutrition, exercise, and medical conditions requiring physical care, if needed.
The client needs health information to participate effectively in his or her own care and to achieve independence and optimal health outside the hospital.
If the client is transferring to another facility, give the client factual feedback regarding his or her progress, and discuss the need for further treatment. Point out the reasons for the transfer, if possible, such as the need for long-term care, another type of care, different treatment structure, or another location. Involve the client in the decision-making process and offer the client choices as much as possible.
It is important that the client understand the reasons for continued treatment, transfer decisions, and so forth, as much as possible. Giving the client choices or input will help diminish feelings of helplessness and frustration.
Stress that the transfer is not a punishment.
The client may see the need for continued care as a failure on his or her part.
Attempt to give the client information about this new environment; arrange a visit before the transfer, if possible, or provide the name of a contact person at the new facility.
Information about the new environment will help diminish the client’s anxiety.
Anxiety
Vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often is nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger. It is an alerting signal that warns of impending danger and enables the individual to take measures to deal with the threat.
Assessment Data
• Verbalized nervousness, apprehension
• Fear of failure
• Withdrawn behavior
• Reappearance of symptoms as discharge is near
• Refusal to discuss future plans
• Lack of confidence in own skills and abilities
Expected Outcomes
Immediate
The client will:
• Discuss termination of staff–client relationships
• Verbally acknowledge eventual discharge
• Verbalize feelings about hospitalization, discharge, and follow-up services
Stabilization
The client will:
• Participate actively in discharge planning
• Demonstrate alternative ways to deal with stress or problems
• Evaluate own skills related to proposed discharge realistically
• Terminate staff–client relationships
Community
The client will:
• Solve problems and make decisions independently
• Manage anxiety, stress, or life events effectively
Implementation
NURSING INTERVENTIONS
* denotes collaborative interventions
Help the client identify factors in his or her life that have contributed to hospitalization (eg, living situation, relationships, drug or alcohol use, work problems, inadequate coping mechanisms). Discuss each contributing factor, how the client sees these now, what can be changed, what the client is motivated to change, and how the client will deal differently with these things to prevent rehospitalization.
The client’s therapy and work inside the hospital must be integrated with his or her life outside the hospital to remain effective. Outside influences or situations may need to be changed to promote the client’s well-being. Anticipatory guidance can be effective in helping the client prepare for future situations.
Always orient discussions with the client toward his or her eventual discharge.
Providing a focus on discharge will minimize the client’s focusing only on the hospitalization and will promote the client’s acceptance of discharge plans.
Support the client and give positive feedback when the client plans for discharge or talks positively about discharge.
Positive support may reinforce the client’s positive anticipation of discharge.
Encourage the client to view discharge as a positive step or sign of growth, not as being forced to leave the hospital. Try to convey this in your attitude toward the client.
The client may see discharge as punishment or rejection.
Encourage the client to express feelings about leaving the hospital, including a discussion of anticipated problems, fears, and ways to deal with the outside world.
The client may be fearful of being outside a structured, supportive environment; may fear a return of symptoms; or may be anxious about dealing with significant others, his or her job, and so forth.
* Use formal and informal group settings for discussions. A discharge group that includes all clients who are near discharge may be helpful
Groups can offer support for feelings by others in similar situations, and they provide a nonthreatening environment in which to explore new behaviors.
Talk with the client about the feelings he or she may experience after discharge (such as loneliness) and how the client will deal with those feelings.
Identifying feelings and exploring ways to deal with them can help diminish the client’s fears.
* Give the client a telephone number and name (if possible) to call in case of a crisis or situation in which the client feels overwhelmed.
Tangible information can help decrease the client’s fears and prepare for dealing with crises in ways other than returning to the hospital.
Deliberately terminate your relationship with the client, and talk with him or her about this. First, try to acknowledge and deal with your own feelings about the client and the client’s discharge; try not to merely withdraw attention from or avoid the client because he or she will be leaving.
Your relationship with the client is a professional one and must be terminated at the time hospitalization ends. The client needs to develop and maintain optimal independence. Your own feelings of discomfort must not prevent you from helping the client acknowledge and work through termination of the relationship
Encourage the client to express his or her feelings regarding termination of therapeutic relationships and loss of the hospitalization.
Discharge from the safety, security, and structure of the hospital environment represents a real loss to the client for which grief is an expected and appropriate response. Encouraging the client to work through his or her feelings regarding this loss will foster acceptance and growth
Do not encourage the client’s dependence on the staff members or hospital by suggesting the client pay casual visits to the unit or by giving the client home addresses or telephone numbers of staff members. It may be necessary to establish a policy that clients may not visit the unit socially after being discharged.
It is not desirable or therapeutic for clients to become friends with staff members or to engage in social relationships with them after discharge.
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