May 29, 2024

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The vital role of nurses in post-discharge support

8 min read
nurses in post-discharge support

A seamless transition from hospital to home helps with patients’ continued wellbeing. This requires careful coordination and support to avoid potential problems, such as a relapse. Nurses have an important role in ensuring patient safety and wellbeing post-discharge.

We look at the essential contributions of nurses in continuing to provide care after patients return home following a hospital stay. Medication assessments, effective coordination between healthcare teams, and regular check-ups are all part of the aftercare nurses provide. The expertise and dedication of nurses help to safeguard patients’ health beyond the hospital walls.

The transition from hospital to home

Adjusting from being in hospital to returning home is the next phase of a patient’s recovery after constant monitoring at a healthcare facility. This transition can present some challenges.

Some of the concerns during this phase are the risks of medication errors and adverse reactions. As patients move to self-managing their medications at home, there is the potential for confusion and mismanagement. These errors can stem from factors such as strict times when medication needs to be taken, dosage adjustments, and any other changes in prescription medications. Without proper guidance and management, patients might experience negative side effects that could have been prevented with careful monitoring in hospital.

To prevent this from occurring at home, nurses use their expertise in medication management to help educate patients and their families. Nurses not only bridge the information gap between patients, caregivers, and healthcare providers, but they also act as the frontline defense against medication errors. Monitoring patients’ responses to medications and addressing concerns promptly helps nurses to continue their pivotal role in reducing complications.

A proactive approach facilitates the successful transition from hospital to home. This includes medication assessments, coordination between healthcare teams, regular check-ups, and the consideration of previous medication reactions, all of which are discussed in more depth later.

Qualifications and work placements help prepare nurses for a healthcare career. This ensures they can provide the best care possible to their patients, whether this is in a hospital, or by helping them after they return home. Fast track nursing programs online, such as those offered by Wilkes University, help students find a balance between studying, working and other commitments. With programs like an Accelerated Bachelor of Science in Nursing (ABSN), students can graduate and start a nursing career in one year, providing they meet the admission requirements.

Coordinating medication assessments

Nurses are an essential part of post-discharge care. They carry out several critical tasks that ensure the seamless transition from hospital to home while looking after the safety and wellbeing of patients.

They coordinate different aspects of medication management, planning the entire process with precision. From verifying medication orders to educating patients, nurses are often the main source of information and support, minimizing the risk of errors, complications and hospital readmissions.

One of the challenges during the transition is ensuring the continuation or adjustment of medication when the patient returns home. Nurses meticulously review and cross-reference medications, dosages, and frequencies to identify any discrepancies. By ensuring accurate medication is prescribed, nurses prevent disruptions in treatment and reduce adverse reactions.

Medication routines can change due to a variety of reasons, such as the patient’s condition improving, new prescriptions added, or dosage adjustments. Nurses play a crucial role in explaining these changes to patients and their caregivers. Clear communication allows patients to follow the updated instructions for taking their medication, minimizing confusion and promoting safety.

Nurses also work closely with pharmacists to clarify any potential drug interactions or side effects. They communicate with physicians too, to ensure a shared understanding of the patient’s medication plan, creating a comprehensive and coordinated approach to care.

Regular check-ups

Post-discharge care requires a systematic approach to monitoring and assessment. Regular check-ups are carried out by nurses. These are important for ensuring medication adherence, evaluating the effectiveness of treatment, and addressing patients’ concerns.

Scheduled post-discharge follow-up appointments ensure that patients receive ongoing medical evaluation and guidance. These appointments provide nurses and other healthcare professionals with the opportunity to track patients’ progress, identify any emerging issues, and make necessary adjustments to the care plan.

Nurses use open dialogue, and an empathic and non-judgmental approach, to gain insights into patients’ daily routines and challenges. They can use this information to offer practical strategies for overcoming barriers to adherence. By creating a supportive environment, nurses encourage patients to follow their medication schedules.

The effectiveness of prescribed medications can vary from patient to patient. Nurses use their clinical expertise to evaluate how patients are responding to their medications. By getting the patient to keep a written record or use wearable devices, nurses can track changes in symptoms, vital signs, and other relevant indicators. Collaborations between nurses and physicians allow for informed decisions to be made when adjusting dosages or exploring alternative treatments. This improves patient outcomes.

Patients often have questions or concerns about their medications, whether related to potential side effects, interactions, or the reasons behind specific prescriptions. Regular check-ups give them the opportunity to address these concerns, and get accurate information, alleviating any apprehensions they may have. This personalized support empowers patients to learn and take an active role in their care.

Personalized patient care

During the delivery of personalized patient care, nurses take a proactive approach by meticulously collecting and documenting a patient’s medical history, including any medication reactions. This comprehensive record includes any past incidents of adverse effects, allergies, or sensitivities to specific drugs. Maintaining a detailed profile of these reactions ensures that nurses can tailor the patient’s care plan to their unique medical history, minimizing any risks.

Nurses are skilled at recognizing early signs of potential allergic reactions or adverse effects. Through attentive observation, assessment of vital signs, and close communication with patients, they can quickly identify any unexpected responses to prescribed medications. This vigilance allows for timely interventions, preventing the escalation of side effects and ensuring patient safety.

Personalized care highlights cases where a patient has demonstrated sensitivity or intolerance to specific medications. When this happens, nurses act as intermediaries between patients and the broader healthcare team. By communicating the patient’s history of medication reactions, nurses contribute to informed discussions about alternative treatment options. This collaborative effort ensures that the patient receives medication and treatment that aligns with their unique medical history.

Empowering patients and caregivers

In post-discharge care, patient education is still the cornerstone of empowerment, ensuring that patients and their caregivers possess the knowledge needed for effective medication management. Nurses recognize that informing patients better equips them to navigate their treatment journey, because constant supervision is not always possible.

Beyond simply relaying dosages and timings, nurses explain the schedule and the patient’s overall care plan in ways they can understand and contribute to and highlight the reasoning behind each medical decision. This understanding enables patients to actively engage with their treatment, making informed decisions and adhering to their prescribed medications more consistently.

Also, nurses extend their educational role to cover the potential risks and benefits of each medication. Discussing potential side effects and adverse reactions empowers patients with the foresight needed to recognize and manage them, promoting safety and minimizing anxiety. This educational process extends to caregivers as well, equipping them with the knowledge and confidence to support patients in adhering to their medication routine and recognizing any concerning developments.

So, even if the patient is unable to comprehend some or all of this, their caregiver can be empowered to provide care for them. This allows the patient to remain at home and avoid being readmitted to hospital unless absolutely necessary.

Leveraging technology

Within post-discharge care, technology is a powerful ally in enhancing medication management and patient engagement. Technological tools offer innovative solutions that streamline the complexities of post-discharge medication routines, optimizing safety and adherence while creating seamless communication between patients and healthcare providers.

Electronic health records

Electronic health records (EHRs) play a transformative role in improving medication safety by providing a centralized platform for comprehensive patient data. Nurses and healthcare professionals can access real-time information about a patient’s medication history, allergies, and previous adverse reactions, enabling them to make informed decisions. EHRs promote seamless communication between different members of the healthcare team, ensuring that everyone involved is up to date with the patient’s current medication plan and any modifications. This integration of data reduces the risk of errors and supports a holistic approach to post-discharge care.

Smartphones and mobile apps

The increased use of smartphones and mobile apps offers an innovative solution to patients who tend to lose track of their healthcare routine. Mobile apps equipped with medication reminders and tracking features make it easier for patients to manage their own medical plans. These tools send timely reminders for dosage schedules, enabling patients to stay on track during their busy lives.

Nurses can also show patients how to use their smartphones to scan the barcodes on medication labels to access information about dosages, potential interactions, and side effects. This information can be overwhelming at first. However, it saves patients time and stress if they can access this information whenever they forget or are unsure about something. They can usually get a quick answer without having to wait to speak to a nurse.

Virtual communication platforms

Virtual communication platforms have also emerged as valuable assets for post-discharge care. Virtual consultations and check-ins make ongoing interactions between patients and healthcare providers easier than ever. They allow for real-time updates, clarifications, and assessments, without the patient having to risk their recovery by traveling to appointments in person. This technology-driven approach is particularly useful for patients with mobility challenges or those living in remote areas.

Resting is crucial to recovery, and although a patient has been released from hospital, nurses are still responsible for caring for them. They can make use of advanced technology such as smart medication dispensers that automatically dispense medication or remind the patient to take the right medication at the required time.

Wearable devices and remote monitoring

Wearable devices such as smartwatches or fitness trackers can be useful tools, for remote monitoring of vital signs, activity levels, and even medication adherence. Traditionally, the patient would have needed to attend an in-person appointment to monitor some of these. The real-time data from these devices can be shared with nurses, enabling them to make more informed decisions during remote follow-up appointments.

Other devices such as home blood pressure monitors, glucose meters, and pulse oximeters can transmit data directly to healthcare providers. This continuous monitoring helps detect any fluctuations in a patient’s health status, enabling timely interventions. They also contribute to empowering patients to play a bigger role in their own care.

Additionally, predictive analytics can be useful. By analyzing patient data, potential complications can be identified before they escalate. This technology allows healthcare providers to intervene early, preventing readmissions and promoting better results.

Delivering optimal post-discharge care 

There are lots of other ways nurses use technology to help patients discharged from hospital care, from directing patients to AI chatbots for answering simple questions, to guiding them towards social support platforms and groups where they can get further support and advice. Rather than taking over the role of nurses, these technologies supplement it and leave nurses with more time to focus on the human side of nursing, and more complex tasks that require their skills and knowledge.

Nurses are indispensable in delivering patient care and ensuring wellbeing. They have a range of roles that include medication assessment, coordination, education, and vigilant monitoring. Their expertise in ensuring accurate medication understanding in their patients, identifying potential risks, and collaborating with healthcare teams, forms the foundation of effective care. They make use of the tools around them, alongside their own experience, educational background and empathy, to ensure that patients can continue their recovery at home.

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