Helping Robert Leave the Rehab Facility After a StrokeSummary: Robert suffered a stroke and a broken leg. His recovery had been very slow due to an inattentive nursing team at his rehabilitation hospital and poor coordination with his physician. Working with Robert’s son, Allegiant’s nurse care manager coordinated his treatment plan and accelerated his rehabilitation, helping Robert regain lost weight and live independently again.SituationRobert had suffered a stroke, and he was in rehab for treatment related to the stroke. While he was in rehab, however, Robert fell and broke his leg in an accident, further complicating the treatment plan.Allegiant staff received a call from Robert’s son, who lives in Oregon. He was concerned about the quality and coordination of care his father was receiving at a rehab facility in the New York City area. His rehab facility is generally well-regarded and familiar to Allegiant staff. However, Robert’s condition required attention from multiple doctors from different disciplines, and important elements of care were being lost in communication.ChallengesWhen our nurse care manager first visited Robert, he had been in the rehab facility for nearly two months. His leg was fitted in a boot, but no member of the care team at the rehab facility knew the plan to remove the boot. Robert’s orthopedist had visited the facility twice over two months, and a physical therapist had been by several times. However, there was a communication gap between the parties involved in Robert’s care. No one was taking charge of Robert’s recovery.In addition to the challenge of removing the boot and coordinating physical therapy, Robert had also lost nearly a third of his body weight while in rehab. Aside from borrowing several cans of Ensure from another patient, the rehab facility had no no plan in place for weight gain.OutcomesAllegiant’s nurse care manager immediately developed a weight gain plan, adding calories and nutrients into Robert’s diet. Soon, he began to gain weight. Our nurse also involved the family in the plan, explaining what Robert needed and how they could help. She encouraged the family to bring Robert’s favorite foods when they visited.The RN also spoke with the orthopedist and physical therapist to clarify the plan for removing the boot. She then informed the rehab hospital staff and included them in that plan. Within several weeks, the orthopedist removed the boot, and the physical therapists began focusing on building muscle and coordination so Robert could walk again without the boot.Six weeks after Allegiant’s initial consultation, Robert was ready for discharge from rehab. He now lives independently at home.
Keeping Gerald Healthy After a Spinal Cord InfectionSummary: A severe spinal cord infection made it painful for Gerald to walk, much less bathe, clean, or leave his home. Allegiant’s nurse helped him avoid rehospitalization, wean off pain medications, and get the physical and massage therapy he needed.SituationGerald had recently been hospitalized for a spinal cord infection when his physician called Allegiant. The physician felt that without ongoing care Gerald was likely to be readmitted to the hospital. The next time, the infection might be even more severe.Gerald lived at home, and his housekeeper was trying to care for him. He received physical and occupational therapy three times a week in his large, three-story apartment. However, he couldn’t walk or get to the bathroom without assistance, despite strong pain medication.ChallengesWhen Allegiant’s nurse first met Gerald, he had lost thirty pounds and had not bathed in weeks. His housekeeper was not available around the clock to care for him, nor did she have healthcare training to help manage his complex condition. Gerald needed full-time, professional assistance.Additionally, Gerald’s reliance on pain medication was concerning. He needed a plan for weight gain, activities of daily life (bathing, walking, etc), and reducing his use of pain medications.OutcomesAllegiant’s nurses implemented 24-hour care schedule to assist with bathing, walking, and other personal care activities. Moreover, Allegiant nurses coordinated physical therapy six days a week to focus on sitting without a pad, self-bathing, and other self-care activities.Allegiant assisted with purchasing a new mattress and grab bars in the bathroom. The nurses then trained the housekeeper to assist with Gerald’s care.The nurses also managed Gerald’s medications. Over time, they gradually weaned him off pain medications. They found a massage therapist who could assist with the aches and pains resulting from Gerald’s new physical activity.During two months of care, Gerald did not return to the hospital and he began to walk on his own with a cane. His new goal is to get well enough to fly to his favorite vacation destination.
Traveling Internationally with Susan After a HospitalizationSummary: Susan has diabetes and was also hospitalized with an infection that went untreated for weeks. Allegiant’s nurse care manager helped her through discharge and rehab, managing the infection to avoid amputation and helping Susan return home.SituationSusan is semi-retired and loves to travel internationally. However, on atrip to the beach, Susan cut herself while swimming. The cut became infected and wasn’t treated for weeks. Eventually, the infection progressed to the point where Susan needed to be hospitalized. There, doctors removed significant skin, muscle, and bone in an effort to mitigate the infection. Susan remained in the hospital for over three months, with increasing doses of antibiotics to manage the infection.She also has diabetes that she contracted from medications related to an autoimmune disease, adding further complexity to her care plan. Susan hired Allegiant shortly before discharge from the hospital.ChallengesAllegiant’s nurse care manager needed to monitor the condition of Susan’s infection and make sure she took the prescribed antibiotics on the right timeline.During discharge, a hospital social worker advised Allegiant’s nurse to prepare Susan for the possibility of amputation should her condition worsen.Once Susan moved to the rehab facility, Allegiant’s nurse noticed inappropriate wound dressings and medication errors that could have stalled or worsened Susan’s recovery.OutcomesAllegiant’s nurses implemented 24-hour care schedule to assist with bathing, walking, and other personal care activities. Moreover, Allegiant nurses coordinated physical therapy six days a week to focus on sitting without a pad, self-bathing, and other self-care activities.The nurse care manager handled all aspects of the transition from hospital to rehab, making sure that Susan received continuity of care. Our nurses trained the rehab staff on correct wound dressings, doctor’s requests, and medication dosage and schedules. Allegiant’s team implemented 24-hour monitored care to make sure all the physician’s orders were followed in an effort to prevent amputation.After months in the hospital, Susan was also disconnected from many of her personal interests and work pursuits. Our nurses also helped with this aspect of the transition, reengaging Susan’s hobbies, and preparing her to return to work. After two months, Susan is now home and able to walk around her neighborhood. Amputation is no longer even remotely likely. She is planning an international trip with nurse accompaniment later this year.
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