A hospital discharge planned by nurses should be
individualized. Lack of communication among nurses
and patient and caregiver hinders care plan. Nursing
documentation should contain instruction concerning
discharge and take into account the patient’s cognitive skills.
Factors that may contribute to failures in a discharge plan
include: few nurses per shift and a high number of patients
to care for. Nurses should also evaluate the financial, safety
and psychosocial needs of patients that may hinder the
patient’s and family’s ability to follow the discharge plan.
Nurses who monitor through phone calls contribute to early
patient-identification of signs and symptoms indicating that
CHF is worsening. This measure reduces re-hospitalization
rates.