Transition Care Plan

Transition Care Plan
Sending Health Care Organization Phone Number
St. Anthony Medical Center (314) 264-0935
Receiving Health Care Organization Phone Number
Fern Hill Center (314) 123-4567
Nursing Station Phone Number
(314) 264-0935 ext. 2266
Patient Name
Rebecca Snyder
Date of Birth Date of Assessment
04/24/1953 1/19/20
Address
1375 Cadburry Lane
City
State Zip Code
St. Louis Park MN 55402
Emergency Contact Relationship Phone
David Snyder Husband (952) 493-9302

Avi Snyder Son (952) 783-0021
Religion Preferred Language
Orthodox Jewish English
Principle Diagnosis
Metastatic ovarian cancer, uncontrolled DM, GIB, metastatic brain mass.
Past Medical History
Poorly uncontrolled DM, HTN, Hypercholesterolemia, obesity, recent falls, decline in functional
status.
Prior Hospitalization
Patient was hospitalized seven months ago due to c/o hyperglycemia ranging from 230 to 389 for
over 10 days, frequent urination, malaise, mild abdominal discomfort, dyspnea on exertion, and
hypertension.
History of Present Illness
Patient is a 57-year-old Orthodox Jewish woman who was diagnosed with ovarian cancer seven
months ago. She was re-admitted due to severe pain. She just completed a series of tests that shows
the cancer has metastasized to the brain and other parts of the body. Patient is in a great deal of pain
and has made her decision to go under hospice care.
Plan of Care/Goals
Treatments have been discussed with the patient and family members. One option is to take the
surgical route. The plan of care would be initiated with an operation to remove as much cancer cells
as possible from the ovary of the patient, which is the primary organ affected by the disease.
Subsequent to the surgery, the patient will be administered chemotherapy and other suitable
adjuvant therapies to treat her for already spread cancer cells in other parts of her body. The other
option would be for hospice care. Hospice care gives patients the ability to choose the way they
want to spend their last days. The main focus of hospice care is to address the physical,
psychological, social, and spiritual needs of not only of dying patients, but also their families (West,
2018).
The goals are to establish transparency, trust and understanding with the patient to manage ethical
concerns related to her religious and personal beliefs. Provide end of life care to the patient. Show
empathy and provide support to the family. Monitor patient’s pain level to ensure her pain is being
managed properly.
Medication List – Allergies: NKDA
Name Dosage / Route Time Frequency
Lisinopril 40 mg po 0800 QD
Xanax 0.5 mg po prn Q 8 h prn
Lantus 30 units SQ 0800 Q am
Novalog 10 mg SQ 0800, 1100, 1630 TID
Carboplatin IV 0800 Q 30 days
Metformin 1500 mg po 0800, 2000 BID
Pravastatin 60 mg po 0800, 2000 BID
Motrin 800 mg po 0800, 1600, 2400 Q 8 hr
Special Needs and Considerations
Rendering care to a patient suffering from progressive cancer is in itself a challenging task to
perform. Even though the medical science applied today is far more advanced than it was a few
years back, cancer is still perceived as one of the most challenging life-threatening diseases to be
cured. Patients suffering from cancer have a relatively low survival rate, which has been in general
considered as 5 years since the diagnosis or less. Nonetheless, the care facilities available today
show an array of hope for the cure of the patient (“Survival Rates for Ovarian Cancer”). However, in
this case, the patient has been diagnosed with Metastatic Ovarian Cancer, which is commonly
referred to an advanced phase of ovarian cancer that is malignant and has spread to other parts of the
body (“Where Does Metastatic Ovarian Cancer Spread To?”). This implies that even if the care
facilities were able to cure the cancer affected ovary for the patient, principally and most necessarily
by the removal of her ovary through surgical procedures, she will still have to be treated for the
cancer cells already spread to her brain and other organs. Another challenge that may occur in this
case is the orthodox religious belief of the patient, which may make then reluctant to undergo a
surgical procedure, especially with the removal of her ovaries (Seibaek, Hounsgaard & Hvidt, 2013).
This requires the healthcare professionals to establish transparency, trust and understanding with the
patient by informing them about the treatment options available in their case and the pros and cons
associated. The patient must be given complete liberty to decide whether they want to undergo the
surgery. The patient should also be duly informed about their survival chances with due permission
of her family members (Smith, 2017). In this case, the survival chances of the patient are
considerably low, which increases ethical challenges to communicate and administer medical care to
the patient, especially considering her religious beliefs.
Prior Level of Activity:
Independent (I), Minimal Assistance (Min A), Moderate

Assistance (Mod A), Maximum Assistance (Max A)
Eating - I
Toileting - I
Bed mobility/Transfer - I
Bathing - I
Dressing - I
Ambulation (with assisted device) (without assisted device)

– Independent without assisted device
References
Ovarian Cancer Survival Rates | Ovarian Cancer Prognosis. (2020). Retrieved 11 January
2020, from https://www.cancer.org/cancer/ovarian-cancer/detection-diagnosis-
staging/survival-rates.html
Seibaek, L., Hounsgaard, L., & Hvidt, N. (2013). Secular, Spiritual, and Religious
Existential Concerns of Women with Ovarian Cancer during Final Diagnostics
and Start of Treatment. Evidence-Based Complementary And Alternative
Medicine, 2013, 1-11. doi: 10.1155/2013/765419
Smith, C. (2017). A Resident’s Perspective of Ovarian Cancer. Diagnostics, 7(2), 24. doi:
10.3390/diagnostics7020024
West, Temple D. (07/01/2018). "Hospice Care Needs Study". American journal of
medical quality (1062-8606), 33 (4), p. 443.
Where Does Metastatic Ovarian Cancer Spread To?. (2020). Retrieved 11 January 2020,
from https://moffitt.org/cancers/ovarian-cancer/faqs/where-does-metastatic-
ovarian-cancer-spread-to/

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Transition Care Plan

Sending Health Care Organization Phone Number

St. Anthony Medical Center (314) 264-0935

Receiving Health Care Organization Phone Number

Fern Hill Center (314) 123-4567

Nursing Station Phone Number

(314) 264-0935 ext. 2266

Date of Birth Date of Assessment

1375 Cadburry Lane

St. Louis Park MN 55402

Emergency Contact Relationship Phone

David Snyder Husband (952) 493-9302

Metastatic ovarian cancer, uncontrolled DM, GIB, metastatic brain mass.

Past Medical History

History of Present Illness

Special Needs and Considerations

Independent (I), Minimal Assistance (Min A), Moderate

Ambulation (with assisted device) (without assisted device)

2020, from https://www.cancer.org/cancer/ovarian-cancer/detection-diagnosis-

Existential Concerns of Women with Ovarian Cancer during Final Diagnostics

and Start of Treatment. Evidence-Based Complementary And Alternative

Medicine, 2013, 1-11. doi: 10.1155/2013/765419

West, Temple D. (07/01/2018). "Hospice Care Needs Study". American journal of

medical quality (1062-8606), 33 (4), p. 443.

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