L12 · Not ready for discharge
Actual Learning and self-management
Definition
The person or home situation is not yet prepared for safe discharge.- Unresolved symptoms
- no support
- unprepared home
- lack of teaching
- Unsure about care
- no equipment
- no helper
- anxiety
📋 Scenario
A patient is told to go home but cannot walk or cook.
Subjective (S): "I'm not ready to go home."
Objective (O): Cannot walk or cook; no equipment; anxious about discharge.
Assessment tools for this scenario: CP-LEARN Learning Readiness Check CP-MIND Mood & Mind Screen
Validated scales to consider: Teach-back, PHQ-9, GAD-7, C-SSRS
**CarePath diagnosis:** Not ready for discharge related to unresolved mobility problems and no home support, as evidenced by being unable to walk or cook, having no equipment, and feeling anxious about going home.
**Interventions and rationale**
| Intervention | Rationale |
|---|---|
| Assess readiness. | Checking symptoms, mobility, skills and home conditions shows whether he can manage safely and what is still missing. |
| Teach. | Teaching the skills he lacks, such as moving safely and basic meal preparation, prepares him for home. |
| Arrange equipment and home support. | Equipment and home help provide what he cannot do himself, so he is not alone and unsafe on the first day. |
| Delay discharge if needed. | Sending him home before he can walk or cook risks falls, poor nutrition and readmission, so waiting is safer. |
| Give a written plan. | A written plan gives clear instructions and contacts that he can check at home when worried or confused. |
**Expected outcomes**
- Discharge delayed until safe.
- Equipment and help arranged.
- Patient states the plan and who to call.
**Linking the data to the diagnosis**
The patient cannot walk or cook, has no equipment at home, and is anxious about discharge. These unmet needs are present now, so the statement is actual. The nurse checks readiness against safe discharge criteria, not only the date. The plan aims to delay discharge until it is safe, arrange equipment and home help, and give a written plan so that the patient can state it and knows whom to call.
CarePath diagnosis
Not ready for discharge related to unresolved mobility problems and no home support, as evidenced by being unable to walk or cook, having no equipment, and feeling anxious about going home.
Interventions and rationale
Listed in priority order.
| Intervention | Rationale |
|---|---|
| 1. Assess readiness. | Checking symptoms, mobility, skills and home conditions shows whether he can manage safely and what is still missing. |
| 2. Teach. | Teaching the skills he lacks, such as moving safely and basic meal preparation, prepares him for home. |
| 3. Arrange equipment and home support. | Equipment and home help provide what he cannot do himself, so he is not alone and unsafe on the first day. |
| 4. Delay discharge if needed. | Sending him home before he can walk or cook risks falls, poor nutrition and readmission, so waiting is safer. |
| 5. Give a written plan. | A written plan gives clear instructions and contacts that he can check at home when worried or confused. |
Expected outcomes
- Discharge delayed until safe.
- Equipment and help arranged.
- Patient states the plan and who to call.
Linking the data to the diagnosis
The patient cannot walk or cook, has no equipment at home, and is anxious about discharge. These unmet needs are present now, so the statement is actual. The nurse checks readiness against safe discharge criteria, not only the date. The plan aims to delay discharge until it is safe, arrange equipment and home help, and give a written plan so that the patient can state it and knows whom to call.