Long term care scenario

Su is a 78 year old widow who had a severe stroke.  She was taken to the ER and admitted to acute care.  She is transferred using a mechanical lift, has expressive aphasia, is not able to swallow and is fed through a PEG tube.

She has a supportive family but her daughter lives in Manitoba with her husband and 3 young children, one son is single and lives 3 hours away and another son lives in the same city as Su with his wife and 2 young children. 

Su, her family and the health care team have decided that she will be transferred to a long term care (LTC) facility.

What information should be included in the discharge summary?

Learner lists ideal summary - compares to exemplar - Learner adds omissions, corrections.

What preparation should be done at the long term care facility?

Staff education, assessments

What education for staff should be provided?

What referrals should be made at the LTC facility?

Who should be involved in care planning for Su?

After 4 weeks working with a Physiotherapist and Dietician, Su has made significant progress and is now able to transfer with the assistance of 2 care workers.  She is beginning to swallow and is trying a modified diet.  A family meeting has been arranged to discuss her progress.

How can staff monitor and assess education needs?

What education would be appropriate at this time?

How can Su and her family help the team?