Word Length: 2000 words
Notes: Written assignment
Liam is a 15-year-old male patient who has recently joined the program. You have not met Liam previously and he and his mother, Erica, are due to attend the surgery later today. In preparation for Liam’s appointment you review his patient’s notes and shared care plan. On review you note that the shared care plan has been started however is not yet complete.
Also read: Nursing Licensure Exam
Review the attached case study of Liam and his shared care plan then answer the following questions:
Complete the missing information on Liam’s care plan and provide the relevant information;
- Patient Care Team: Identify all of the facilities, organisations and professionals Liam and his parents will have to access/interact with to achieve his treatment goals. Separate these into primary secondary or other (if relevant) and document the referral process and their role in Liams’ care.
- Patient’s barriers to care goals: Review the patient care goals identified on the care plan. Identify barriers for achieving the care goals (note: may be: medical, situational system. Consider self-management strategies, health literacy and the team goals, this is not exhaustive).
Role of the RN as the complex care coordinator to deliver the shared Care Plan
- Nursing practice: Outline the relevant care coordination skills you as the Registered Nurses require to effectively manage Liam’s shared care plan.
- Identify Strategies: As the complex care coordinator you have to effectively implement Liam’s shared care plan. Identify any/all projects, programs, technology, organisations, innovations etc. that would assist with delivering the goals identified in Liam’s shared care plan.
HSNS363 Assessment 2 case study: Liam
Liam is a 15-year-old male who lives in Westtown with his mother, Erica. Liam is a patient of Dr Jones and moved to the clinic when her practice merged with another local practice to form the Youbeaut clinic late last year.
Liam has a history of Juvenile Idiopathic Arthritis (JIA) and Asthma. Liam attended the Accident and Emergency department at the Westtown Hospital four times last summer, including one overnight admission, due to acute exacerbation of Asthma. The Westtown region has been drought declared for the last two years and is experiencing large dust storms which triggered Liam condition. Liam fractured his right hand three years ago when he fell of his bike.
In addition to his recent asthma exacerbations Liam has also been experiencing pain related to his JIA, particularly in his right wrist and right knee. Dr Jones has referred him for review with his regular paediatric rheumatologist in Sydney which is located 500km away. Liam is to have an MRI prior to attending the appointment. In light of his recent Asthma exacerbations Liam is also due to visit his regular paediatrician to review his Asthma Action Plan. His paediatrician is located in a rural service centre 250km from Westtown.
- JIA – diagnosed at the age of 8, four joints involved
- Asthma – diagnosed at the age of 10
- Right carpel/scaphoid fracture 3 years ago (cycling accident).
- NSAIDS – BD naproxen 250mg
- Paracetamol PRN for pain.
- Inhaled corticosteroid preventer (daily)
- Salbutamol PRN
Liam lives with his mother Erica (37), step father John (39) step-brother Sam (7) and step-sister Molly (4). Liam has a god relationship with Erica, John and his younger siblings however, this is a busy household with both parents working and all children attending different school/childcare facilities. John is a supervisor at the local mine. He is a shift worker and his hours include evening and weekend work. Erica works full time at the local bank.
Liam spends alternative weekends and half his school holidays with this father, Michael (45), his step mother Annie (44) and twin step-sisters Charlotte and Grace (18 months). Michael and Annie live on a mixed farming property 25km from Westtown. Annie and Michael tried unsuccessfully to have children for several years prior to the arrival of their daughters. Charlotte and grace are very welcome additions to the family however Michael and Annie are finding the demands of caring for two young children (largely unassisted) and running the farm incredibly tiring with little-to-no spare time.
Liam has a good relationship with his father and Annie however, when he is at the farm he feels as though there is a ‘burden’ and is largely left to himself due to the time and attention required to care for the twins and run the farm.
Michael and Erica often struggle to balance the responsibilities of transporting Liam the multiple medical appointments and therapy sessions including:
- Monthly medical appointment in Sydney
- Local fortnightly physiotherapy
- GP appointments as required
- Paedtrician appointment quarterly.
Academic & Social
Liam enjoys school however, he is socially introverted and is sometimes bullied. He finds it difficult to complete school work when his hand is painful due to JIA particularly at the fracture site (Liam is right handed). Liam has one very close friend, Jack, who he has attended school with since kindergarten. Jacks and his parents recently relocated to Sydney for work.
Erica is concerned that Liam is becoming increasingly socially withdrawn. These days he mainly stays in his room and plays video games. Erica is concerned that he is becoming depressed. She has to constantly remind him to take his medication (he was previously independent) feels like she is ‘nagging’ concerned about what is happening with his medication when he is at the farm.
Erica is hopeful that participating in the Healthcare Homes program will assist in better managing Liams’ care, particularly given his current physical and mental health status.
HSNS363 Assessment 2 Shared Care Plan: Liam
Risk Level: High
Last updated by:
Liam’s has JIA (polyarticular) which was diagnosed age 8. Liam reports increasing pain levels in the joints, particularly R wrist, which was fractured in a cycling accident 3 years ago. He also reports increasing discomfort in his shoulders and knees over the last 6 months. Erica reports that prior to this latest exacerbation Liams’ symptoms have been well controlled with regular medications since his last flare up two years ago.
Liam has allergic Asthma diagnosed aged 10. His primary triggers are dust and pollen. Liam had 4x attendances at the Westtown Regional Hospital A&E department last summer. Three acute exacerbations were associated with large dust storms in the area (currently in drought) and once after being exposed to large amounts of dust while assisting his farther load cattle onto a truck in the stock yards.
Current presentation 3/3/20XX
On examination R hand, R shoulder and L knee have mild swelling and are warm to the touch. Liams complains of 4/10 pain on movement of these joints. Liam report having to use his Asthma reliever medication at least once per week for the last 2-3 months.
Liams’ mother Erica has expressed concerns in relation to his current psychological status. She states that she believes Liam is becoming increasingly socially withdrawn and is not participating as actively in the management of his JIA or Asthma as he has in the past. She states that his year advisor has also been in touch as he is displaying reduced effort in class which is out of character as he is usually a good student. Liam was somewhat reluctant to engage in discussion regarding management and treatment of either of his conditions.
Patient Care Team:
Personal Support Team:
Mother- Erica Smith
Step father- John Smith
Father- Michael Taylor
Step mother- Annie Taylor
Patient’s care goals (chronic and preventive)
- “I am sick of feeling different – I just want to be normal like everyone else”.
- “I want to be able to play weekend sport again. All the other guys in my year seem to play something on the weekends I’m the odd one out”.
- “I am very concerned about Liams’ psychological health and want to identify a strategy to address this issue ASAP”
- “We want to get to the specialists to review his JIA an Asthma management. We need to get to the bottom of what has caused his Asthma and JIA to get worse over the last 6 months”
- “We need to come up with a better plan for organizing and managing all of Liams’ appointments and the information we receive from them – we seem to just be reacting when thing go wrong these days”
Patient’s self-management tools:
- Consult paediatric rheumatologist and paediatrician ASAP.
- Develop a plan for staged increased activity and return to team sport (hockey).
- Develop strategy for competing school-based tasks when JIA/Asthma flares.
- Attend counselling/psychotherapy
- Develop a strategy for being independent at school, and home (x2) regarding medications and trigger identification (with minimal supervision).
- Erica, Michael and Liams to develop plans for medication adherence, 1-1 time and medical response plans for both households in the event of an acute exacerbation of Asthma or JIA.
Patient’s barriers to care goals
Team Goals: (chronic and preventive)
- Devise a plan/for communication between all relevant specialists (regardless of location) including the use of an electronic health record.
- Develop collaborative care strategy for Liams monthly case conferences (including Liam and parents) every 2 months for 6 months.
- Foster Liams’ independent management of both chronic conditions (with minimal parental supervision).
- Monitor effectiveness of physical and psychological interventions closely over the next 6 months with monthly clinic visits (care coordinator). Relevant team members to collaborate and revise plans as necessary.
Adapted from: Patient Centred primary Care Institute (2020) The basic person-centred care plan – Providence Medical Group Southeast, Available at: http://www.pcpci.org/sites/default/files/resources/Shared%20Care%20Plans_0.pdf