| dc.description.abstract | The purpose of this study was constructing a hospital discharge plan model for patients with stroke. Hospital discharge is understood as the transferring of patient's care among the points of attention of the health network. Discharge planning is decisive in preventing readmissions, ensuring continuity of care and thus improving the quality of patients' life after a stroke. To prepare the patient to the Hospital discharge represents a great challenge for the health team sand the nurses are one of the main responsible for care planning. From the integrative review of the literature on three online databases: LILACS, Public MEDLINE (PUBMED and BIREME) and BDENF, in the months of June and July of 2018 with the descriptors: Stroke, Nursing care, hospital discharge and transitional care, in Portuguese and English emerged sixty-five articles. Fifteen of them was selected in which four categories were identify: Health-care guidelines; Involvement of family members in care planning; Communication among the Health care Network; and Nurse’s responsibility in the guidelines and care planning. The authors indicate strategies for discharge planning which include guidelines according to the individual needs of patient, development of instruments to record the patient's medical history, and organization of home-based follow-up with the health network. The generated product in this study consists in a hospital discharge plan for the patient suffering from stroke. The creation of this plan allows the nurse to facilitate the process of education of the patient and your family, providing information about the care for the follow-up of care for stroke victims. | en |
