Jared is a registered nurse (RN) caring for Ms. Jeffrey who has heart failure and is scheduled to bedischarged from the hospital in the next couple of days. Ms. Jeffrey had three admissions over thelast 6 months. The hospital has instituted a new program to assist with the transition to home toprovide continuity of care and decrease hospital readmission rates. Prior to discharge, Jared musteducate Ms. Jeffrey on self-care, plan for postdischarge medications, reconcile medications, andcheck on follow-up appointments. Ms. Jeffrey is anxious to go home to her cat and worried aboutbeing able to care for herself.Ms. Jeffrey has been home for 1 week, and Jared calls to check on her. She reports that her legsare a little more swollen today. Jared makes sure she knows the time and date for her follow-upappointment with her primary care provider. He also takes time to review some of the teachingthat he did prior to her discharge from the hospital. Ms. Jeffrey suddenly exclaims, “Oh, I knowwhere I went wrong!”Mrs. Jeffrey was eating canned chicken noodle soup when she got home from the hospital due toher weakness. She chose it because it was easy and she didn’t consider the high sodium content.After speaking with Jared, she was able to have a family member purchase some low sodium itemsthat met her needs. Jared was also able to work with the primary care physician to set up a homehealth nurse to check on her weekly for a couple of months to provide additional teaching andsupport to help her manage her heart failure at home.1. QUESTIONS:1. What types of self-care do you think Jared will be teaching?2. What would be important things to learn about Ms. Jeffrey in order to providecomprehensive teaching and planning for holistic care?3. What do you suspect the problem might be?4. What are other ways that healthcare providers can improve continuity of care toimprove outcomes for people?5. Clients often revert to old habits when they return home. What are some ideas forteaching to help clients understand changes they need to make and what the mostcommon problems are?
