TransitionTheoryAfafIbrahimMelesis

My goal was to inspection and repair hem stay as independent as possible so they could proceed in their aver living environment as well as reduce hospitalizing and modify cores for the company worked for. Started to incorporate few of the concepts used in the Transition conjecture yet more specifically the work of Mary Anally and Janet forefront Cleave who developed the transitional C atomic number 18 object lesson from the University of Pennsylvania. By implementing the enjoyment of a transitional bang go down on, I was able to support my perseverings with tools and information they demand to function them stay wellnessy enough to remain in their own root word.FAA Abraham Miles is a reorient foster sociologist, educator, theorist, and investigateer that began her treat likeer in her native Egypt in the sasss (Alligator, 2014). FAA Miles archetypical developed Transition opening while operative on her doctorate in the mid sasss and further developed it over th e neighboring three decades while working as a she-goat educator and researcher. She conceptualized the idea of Transition Theory as it applies to nursing practice while working on her idea of role supplementation.Her theory is describe as having four types of transition- developmental, situational, health/ peaked(predicate)ness, and organizational Mles, Sawyer, Im, Hollering-Messiahs, & Schumacher, 2000, p. 17). FAA Miles Transitions Theory is used as its hypothetic basis for the University of Pennsylvania center call Transitions and Health, direct by Mary Anally (Alligator, 2014). Was first introduced to transitional criminal maintenance at a nursing conference go to to seek styluss to improve outcomes for our chronically bilious older forbearings and to keep them at plateful sort of of universe admitted in the hospital or nursing home.Often fourth dimensions a uncomplaining who is chronically ill is admitted to the hospital over multiple episodes of care for an exac erbation of an illness along with other commodities. Once the patient is stable, they are discharged to home with a purpose of care that does not reflect their leads, goals, learning style, or literacy level (Anally & caravan Cleave, 2010, p. 459). Usually nobody is intricate in developing the discharge plan from his family or in the teaching of new medicinal drugs prescribed. There whitethorn even be possible dietary changes that posit to be make by the patient.I am authentic the hospital does an exceptional job managing their acute aesculapian checkup episode solely they do not train season to address the root cause of their multiple, fresh hospitalizing (Anally & Van Cleave, 2010, p. 459). Most patients do not watch what was discussed with them while inpatient. They just want to go home and bequeath say they understand just to be able to do just that. They may not have the means to uprise to the pharmacy to get their new medications or they may not be able to affor d the new medication. There are so some variables that can occur and that is wherefore a transitional defy may be beneficial.According to Anally & Van Cleave, the Transitional Care Model (ETC) provides door-to-door discharge planning and home acquire-up care for chronically ill, high risk older adults admitted to the hospital for common deiced pin downs. A transitional care nurse, who is ordinarily master-prepared, follows patients from the hospital to their homes, providing evidence-based services aimed to meet the patient and family goals, improve health outcomes, and stop usual patterns of going to the requisite room for non- emergent needs (Anally & Van Cleave, 201 0, p. 60). The transitional care nurse focuses on increasing the patient and family ability to manage the frequent transitions in health that characterize chronic illness trajectory (Anally & Van Cleave, 2010). In relation of person, transition theory takes into unthoughtfulness that all people are unique and will interpret their transition in different dashs. The nurse must be able to assess how the patient perceives their change and develop therapeutics geared toward their perception, assessing for feedback along the way (Chick & Miles, 1986).This can be achieved by using the Transitional Care Model as a guideline. The home care agency worked for decided that I would follow our patients with a diagnosis of congestive heart ill and/or chronic obstructive pulmonary perturbation with commodities and Medicare was their primary indemnification. My role as the ruinations care nurse was to be the primary coordinator of care to assure that thither was continuity of care throughout the next thirty days (episode of care) and readmission would be avoided.When a patient of ours was admitted to the hospital, I would promise the patient to do an in-hospital assessment and utter to the discharge planner to let them know what my role was once the patient was discharged. Once the patient was home , I would make home chatters every week for the first two weeks and then follow- up band calls the tierce and fourth week. Also was available by phone if they needed me anytime in between. My first home visit consisted of helping them fill out a in the flesh(predicate) health record which included current medications, medical conditions, emergency contacts and so forth.This is when I would discover if they sincerely understood what medications they were supposed to be taking and if they knew the crusade why they were taking it for. Most patients had no clue why they were taking medicine for what medical condition or they were not taking the medication as prescribed by their physician because they did not recover it was that important or they could not afford it. sometimes the patient was taking the same medication but the deicing was labeled differently from different pharmacies. Ad the time to explain what each medication was and what it was used for. Was to a fault able to resolve any medication dissension from the discharge instructions for the patient. We would call the physicians office unneurotic so it gave them a sense of well-being and gave them deem of their own health which is a positive outcome according to Melanies transition theory. The second home visit usually consisted of education regarding their diagnosis and which red flags to be aware of pertaining to their illnesses.Socioeconomic status, education bevel, and cultural beliefs all match potential health related outcomes (Mles et 2000). It is important as a nurse to be mindful of how to present information in a way that the patient will understand and be willing to make the changes needed to remain a healthful person. Emphasis on early acknowledgement of red flags and how the patient and/or family responds to the symptoms is a way to achieve positive outcomes and avoid readmission (Anally & Van Cleave, 201 0, p. 461).Contact is made via a telephone call instead of a home visit fo r the third and fourth consultation. This is the time hat would answer any remaining medication questions, discuss the outcomes of their recent follow-up appointment with all their primary care physician or specialist, help them make an appointment with their physicians if they have not already done so, and reinforce when or if the patient would need to seek medical treatment. Often times, the patient and or family felt comfortable with their health goals because they were a routine of making them which made them feel more accountable.Even though would not be following up with them on a regular basis they knew they could contact me and I would help them in any way I could. While in my role as the transitional care nurse, felt I made a difference in the company by up(a) outcomes and patient satisfaction. It was very rewarding to be a part of the patients health experience but in a different way than I was before. I witnessed a transition or change in the patients attitude towards their health because they were made to be a part of the process not just a person with an illness who did not know anything.Unfortunately, imputable to zero reimbursement from insurance companies, the transitional care nurse position was eliminated. The Transitional Care Model is a good concept but more research deeds to be done so insurance companies can see the value in much(prenominal) a program. Ms. Melanies Transition Theory has been applied to many different nursing research projects that apply to lucid populations undergoing change (Alligator, 2014). Through the nursing research that is being performed at the university of Pennsylvania where Ms.