CHAPTER 11

CARE COORDINATION FOR A MATERNITY PATIENT

In this chapter, we use the Care Coordination Clinical Reasoning (CCCR) systems model as described in Part I and explain how the model can be used to reason about a case, given the context of a patient in maternity care (labor and delivery). The case presented in this chapter illustrates how an advanced practice nurse works with an obstetrician coordinating the care for a patient who is in need of interventions for complications during pregnancy. The patient was admitted to a hospital labor and delivery unit for abdominal pain, vaginal bleeding, and decreased fetal movement. The advanced practice nurse provides care coordination through the application and use of critical-, creative-, systems-, and complexity-thinking processes to manage patient problems with an interprofessional team to design appropriate interventions and establish patient-centered outcomes. Depending on the nature of need involved in the case, referrals to other specialty or primary care providers are determined and considered in managing care coordination and transitions (Haas, Swan, & Haynes, 2014).

The CCCR systems model framework begins with the patient story, which is derived from gathering data and evidence from an interview, history, physical examination, and the health record. The advanced practice nurse then develops a patient-centered plan of care using the Outcome-Present State-Test (OPT) model worksheets. In order to do this, one activates patient-centered systems-thinking skills for complex patient stories and consistently uses key questions to reflect on the specific sections of the model (Pesut, 2008), as well as the dimensions and elements of care coordination processes.

LEARNING OUTCOMES

After completing this chapter, the reader should be able to:

THE PATIENT STORY

We begin with the history and story of a 19-year-old English-speaking, Asian female, Sarah Chinn, who presents to the labor and delivery unit because of abdominal cramping. She is at 36 weeks gestation and for the past 3 hours rated her pain a 10 on a 1-to-10 scale. She is a gravida 2, para 0 (G2P0), and the electronic health record shows no prenatal care since week 22 of gestation and a net loss of 10 pounds at that visit.

Social assessment reveals that Sarah was “kicked out” of her parent’s home and has been staying with different friends. The father of the baby is no longer involved with her. She was waiting to “settle down” before resuming prenatal care. Sarah does not know where she will live after the baby is born. She denies taking childbirth classes or being prepared to take the baby home from the hospital. Ms. Chinn has no significant past medical history and she denies illicit drug use. She does not take any medications currently and denies taking prenatal vitamins.

The physical examination reveals a highly agitated young woman who is inappropriately dressed for cold weather. She is uncooperative with the application of the fetal monitor. The staff notes a moderate amount of bright red vaginal bleeding and no obvious leakage of fluid. Vaginal examination reveals a 1-cm dilated and 30% effaced cervix. The vertex is ballotable. Contractions are moderate to strong, lasting 40 to 60 seconds every 2 to 3 minutes. Sarah’s height is 5’ 7” (67 in.), her weight is 115 pounds at 22 weeks gestation, and her body mass index (BMI) is 18.01.

Admission laboratory results show a positive drug screen for cocaine and a urinalysis positive for ketones. The complete blood count reveals a hemoglobin of 10.2 g/dL, hematocrit of 30.8%, and platelet count of 98,000/mm³.

PATIENT-CENTERED PLAN OF CARE USING OPT WORKSHEETS

Once the story is obtained from all possible sources, care planning and reasoning proceed using the OPT clinical reasoning web worksheet (Figure 11.1), which helps determine relationships among issues and highlights potential keystone issues. The OPT clinical reasoning web is a graphic representation of the functional relationships between and among diagnostic hypotheses derived from the analysis and synthesis regarding how each element of the story and issues relate to one another. This activates critical and creative thinking. The visual diagram that results illustrates dynamics among issues and a convergence helps to point out central issues that require nursing care. As one thinks about this case, and begins to spin and weave a clinical reasoning web, relationships are identified among nursing domains and diagnoses as they are jointly considered with medical conditions. The medical conditions in this case are those of a 19-year-old pregnant female who lives alone (homeless) with a history of gravida 2, para 0, at 36 weeks gestation. She is experiencing vaginal bleeding and abdominal pain at the time of examination. Once the advanced practice nurse considers these diagnoses, the priority nursing care domain associated with them is safety and protection. The complementary nursing diagnoses most impacted in this case are risk for bleeding, imbalanced nutrition: less than body requirements, and ineffective coping.

FIGURE 11.1 Outcome-Present State-Test clinical reasoning web worksheet.

ICD-10, International Classification of Diseases, 10th edition.

To spin and weave the web, the provider uses thinking processes to analyze and synthesize relationships among diagnostic hypotheses associated with a patient’s health status. The visual representation and mapping of these relationships support the development of patient-centered systems thinking and connections between and among the medical and nursing diagnoses under consideration, given the patient story.

The steps to the creation of the OPT clinical reasoning web using the worksheet are as follows:

TABLE 11.1 Relationships Among Nursing Domains, Medical Diagnoses, and Web Connections

Source: World Health Organization (2015).

An OPT clinical reasoning web worksheet, as seen in Figure 11.1, shows a template with the patient health care situation, medical diagnoses, and nursing diagnoses in the center. Around the outer edges of the web are nursing domains with ICD-10 codes derived from history and physical assessment associated with the patient story. The arrows create the web effect and represent connections, explanations, and functional relationships between and among the diagnostic possibilities. As one can see, the domains and ICD-10 codes with more connections converging on the circles display the priority problem or keystone, in this case, safety and protection. A keystone issue is one or more of the central supporting elements of the patient’s story that help focus and determine a root cause or center of gravity of the system dynamics and help guide reasoning and care coordination based on an analysis (breaking things down into discrete parts) and synthesis (putting the parts together in a greater whole) of diagnostic possibilities as represented in the web. A key question to ask here is: How does the clinical reasoning web reveal relationships between and among the identified diagnoses and to what degree do these relationships make practical clinical sense according to the evidence and patient story? Table 11.1 shows a summary of the connections highlighting the priority with the most connections.

After considering the full picture using the clinical reasoning web worksheet, the next step is to use an OPT clinical reasoning model worksheet to facilitate and structure the patient-centered systems thinking about the care coordination of the identified problems highlighted in Table 11.1. As the advanced practice nurse thinks about the patient, he or she will concurrently consider the frame, outcome state, and present state. Each aspect of the OPT clinical reasoning model contributes to the other. The OPT clinical reasoning model worksheet is a map of the structure designed to provide an illustrative representation and guide thinking processes about relationships between and among competing issues and problems. Some questions that guide the use of the OPT clinical reasoning model are shown in Table 11.2 (Pesut, 2008).

By writing each element on the worksheet, all the parts of the model become related to each other. As the health care provider moves from right to left, the model structures the plan of care. Critical thinking skills are used to consider the patient story and creative thinking is used to identify and reason about the keystone issues/themes/cues to determine the most significant evidence in the present state. Complexity thinking helps the provider to consider the outcomes desired and the gaps between the present and outcome states. Once interventions and tests are decided, the plan of care transitions over to a care coordination model and team-centered systems thinking that considers patient preferences within the frame of the situation.

The patient-in-context story (Exhibit 11.1) is on the far right-hand side, as depicted in Figure 11.2. The advanced practice nurse notes relevant facts of the story, which in this case include the patient demographics and characteristics; 19-year-old pregnant Asian female who lacks any social support and is homeless. Sarah has a diagnosis of pregnancy at 36 weeks gestation with complications. She is very agitated and uncooperative with the application of a fetal monitor. She has abdominal pain, vaginal bleeding, symptoms of fetal distress, and the cervix is 1-cm dilated. She is underweight with a BMI of 18.01 at 22 weeks. She has not received any prenatal care since 22 weeks gestation. She has not had any prenatal classes and is not prepared to take the baby home from the hospital. Significant laboratory data show anemia, thrombocytopenia, and urinalysis positive for ketones and cocaine. A key point at this juncture is to review and reflect on the patient story for accuracy and thoroughness to before proceeding with care planning for care coordination.

TABLE 11.2 Questions That Guide the Use of the OPT Model

OPT, Outcome-Present State-Test.

Adapted from Pesut (2008).

Moving to the left of the worksheet, there is a place to list the diagnostic cluster cues on the web of medical diagnoses and ICD-10 codes (Exhibit 11.2). At the bottom of this box are placed the designated keystone issues or themes that fall under the most significant nursing domain—safety/protection: premature separation of placenta, third trimester 045.93; antepartum hemorrhage, third trimester 046.93; newborn (suspected to be) affected by other forms of placental separation and hemorrhage P02.1; abnormality in fetal heart rate and rhythm complicating labor and delivery 076; and neonatal withdrawal symptoms from maternal use of drugs P96.1. Remember diagnostic cluster cues web logic is the use of inductive and deductive thinking skills. Some key questions to ask here are: What diagnoses were generated? Is there evidence to support those diagnoses? Is the keystone issue appropriate, given this patient story?

In the center and background of the worksheet are places to indicate the frame or theme that best represents the background issues regarding thinking about the patient story (Exhibit 11.3). The frame of this case is a 19-year-old adolescent female who is at 36 weeks gestation with high levels of anxiety and agitation, restlessness, and is uncooperative. The frame helps to organize the present state, outcome state, illustrates the gaps, and provides insights about what tests need to be considered to fill the gap. Decision making and reflection surround the framing as the advanced practice nurse thinks of many things simultaneously. Reflective thinking is used to monitor thinking and behavior. Some key questions to ask here are: How am I framing the situation and does it agree with the patient view of the situation? Given my disciplinary perspectives, what are the results I want to create for this person?

At the center of the sheet are spaces to place the present state (Exhibit 11.4) and outcome state (Exhibit 11.5) side by side. The present state in this case shows six primary health care problems related to the keystone issue: generalized abdominal pain for 3 hours; moderate amount of bright-red vaginal bleeding; gravida 2, para 0; fetal heart rate of 170 with repetitive late decelerations; 1-cm dilated 30% effaced cervix with vertex ballotable; and positive urine drug screen for cocaine.

The outcome state shows six matching goals to be achieved through care coordination: control of pain, hemodynamic stability, delivery of healthy newborn, fetal viability and maternal stability, emergent C-section with positive course of recovery, and substance use control. Putting the two states together creates a gap analysis that naturally shows where the patient is and what the goals are in terms of the patient’s care. Some key questions to ask here are: Are the outcomes appropriate given the diagnose? Are there gaps between the outcomes and present state? Are there clinical indicators of the desired outcome state?

The gap between where the patient is and where the advanced practice nurse wants the patient to be is one way to create a test (Exhibit 11.6). Clinical decisions are choices made about interventions that will help the patient transition from present state to a desired outcome state. As interventions are tested, the advanced practice nurse evaluates the degree to which outcomes are being achieved or not. The tests chosen in this case include: pain scale rating, feminine napkin pad count, Apgar score, fetal monitoring device, no postsurgical complications, and urine drug screen. Testing is concurrent and iterative as one gets closer and closer in successive increments toward goal achievement. Some key questions to ask here are: How is the advanced practice nurse defining testing? On what scales will the desired outcome be rated? How will the advanced practice nurse know when the desired targeted outcomes are achieved?

FIGURE 11.2 Outcome-Present State-Test clinical reasoning model for care coordination worksheet.

BMI, body mass index.

 

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EXHIBIT 11.2 DIAGNOSTIC CLUSTER CUE WEB LOGIC

  1.  Antepartum hemorrhage, third trimester 046.93

  2.  Abnormality in fetal heart rate complicating labor and delivery 076

  3.  Newborn affected by forms of placental separation and hemorrhage P02.1

  4.  Neonatal withdrawal from maternal use of addictive drugs P96.1

  5.  Maternal care for known or suspected poor fetal growth 036.5

  6.  Cocaine use, unspecified F14.929

  7.  36 weeks gestation pregnancy, insufficient antenatal care, third trimester 009.33

  8.  Noncompliance with medical treatment 291.19

  9.  Homelessness 259.0

10.  Generalized abdominal pain R10.84

11.  Anxiety disorder, unspecified F41.9

12.  Parent–child estrangement 262.890

13.  Decreased fetal movements 036.8190

14.  Toxic effects of ketones, undetermined, initial encounter T52.4X4A

15.  Newborn affected by maternal nutritional disorder P00.4

16.  Low weight gain in pregnancy, third trimester 026.13

KEYSTONE ISSUE

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