CHAPTER 12
CARE COORDINATION FOR A NEONATAL 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 primary care neonatal case. The advanced practice nurse is working with a mother who is in need of support services and education to promote quality outcomes for a preterm newborn. The provider–clinic is the point of access for patients–families. 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, community services, and living environments 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 an individual plan of care using the Outcome-Present State-Test (OPT) model worksheets. In order to do this, one activates the patient-centered systems-thinking skills for complex patient stories and habitually uses key questions to reflect on the specific sections of the model (Pesut, 2008), as well as the dimensions of the care coordination processes.
LEARNING OUTCOMES
After completing this chapter, the reader should be able to:
1. Explain the components of a care coordination framework that are needed to manage the problems, interventions, and outcomes of neonatal patients
2. Describe the different thinking processes that support clinical reasoning skills and strategies for determining priorities for neonatal patient care coordination
3. Define the cognitive and metacognitive self-regulatory processes that support individual provider critical reflection related to levels and perspectives associated with clinical reasoning for neonatal patient care coordination
4. Describe how the communication between interprofessional health care team members is essential for care coordination to address neonatal patient and family needs
5. Describe the critical meta-reflective processes that support team reflection related to levels and perspectives associated with the care coordination challenges and clinical reasoning required to navigate neonatal patient care plans
THE PATIENT STORY
We begin with the history and story of a 5-day-old White female baby, Ashley Ford, who was born at 36 weeks and is in the pediatric office for a weight check at 72 hours after hospital discharge. She was delivered at 2,021 g, placing her in the 10th percentile. Ashley’s occipital frontal circumference (OFC) was 32.5 cm (50th percentile) and her length was 45.4 cm (25th percentile). After delivery, Ashley remained with her mother on the postpartum unit where there were no problems with blood sugar or temperature. Her weight on the day of discharge was 1,947 g (decreased 5%), and her bilirubin was 8.9 mg/dL.
The physical examination in the pediatrician’s office reveals a temperature of 96.2°F rectally, heart rate of 168 beats per minute, respiratory rate of 36 breaths per minute, and oxygen saturation of 98%. Ashley’s weight is 1,798 g, which is decreased by 11% from her birthweight. The rest of the examination is unremarkable except that she has jaundiced-appearing skin and a slightly depressed anterior fontanelle. Her muscle tone is normal and her neurological responses are normal. Her mother states that she breastfeeds every 4 hours during the day and every 5 hours during the night, however, she often has to wake the infant up for feedings. Ashley has had four wet diapers and one stool in the past 24 hours. Her bilirubin level in the office is 18.5 mg/dL. The mother was advised to take Ashley to the pediatric unit in the hospital for further assessment and treatment.
Laboratory values on admission to the hospital are as follows—white blood count: 8.2/mm3 with an unremarkable differential, hemoglobin: 18.5 g/dL, hematocrit: 56%, platelets: 298,000/mcL, reticulocytes: 2.1%, blood urea nitrogen: 22 mg/dL, creatinine: 0.5 gm/dL, glucose: 78 gm/dL, potassium: 4.8 mEq/L, calcium: 8.9 mEq/L, chloride: 112 mEq/L, sodium: 151 mEq/L, aspartate aminotransferase (AST): 52 U/L, alanine aminotransferase (ALT): 24 U/L, bilirubin-total: 18.7 mg/dL (high), and bilirubin-direct: 0.3 mg/dL. Arterial blood gas analysis reveals pH: 7.34, PaO2: 80 mmHg, PaCO2: 39 mmHg, and HCO3: 21 mEq/L. Blood cultures were also drawn and sent to the laboratory.
PATIENT-CENTERED PLAN OF CARE USING OPT WORKSHEETS
Once the story is obtained from all possible sources, care planning and clinical reasoning proceed using the OPT clinical reasoning web worksheet (Figure 12.1) to help determine relationships among issues and highlight 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 and issue of the story 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 combined with medical conditions. The primary care conditions in this case are a late-preterm infant with newborn jaundice, metabolic acidemia, and underfeeding. Once the advanced practice nurse considers these diagnoses, the nursing care domains associated with them are identified. The complementary nursing diagnoses most impacted in this case are ineffective infant feeding pattern–weight loss, hypothermia, and neonatal jaundice.
FIGURE 12.1 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 systems thinking and making 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:
1. Place a general description of the patient in the respective middle circle—5-day-old newborn delivered at 36 weeks gestation (Ashley Ford).
2. Place the major medical diagnoses in the respective middle circle—Late-preterm infant with metabolic acidemia, newborn jaundice, and underfeeding of a preterm infant.
3. Place the major nursing diagnoses in the respective middle circle—ineffective infant feeding pattern—weight loss, hypothermia, and neonatal jaundice.
4. Choose the nursing domains for which each medical and nursing diagnoses are appropriate—elimination and exchange, health promotion, safety/protection, growth and development, and nutrition.
5. Generate all the International Classification of Diseases-10 (ICD-10) codes that are appropriate for the particular patient and family story that coincide with the nursing domains—newborn jaundice (P59.9), metabolic acidemia (P19.9), underfeeding of a newborn (P92.3), hypothermia (P80.9), preterm newborn at 36 weeks gestation (P07.39), failure to thrive (P92.6), hypernatremia (P74.2), and dehydration (P74.1).
6. Once the nursing domains, diagnoses, and ICD-10 codes are identified, reflect on the total web worksheet, and concurrently consider and explain how each of the issues is or is not related to the other issues. Draw lines of relationship to spin and weave the web connections or associations among the ICD-10 codes/diagnoses. As you draw the lines, think out loud, justify the reasons for the connections, and explain specifically how the diagnoses may or may not be connected or related.
7. After you have spent some time connecting the relationships, determine which domain/domains have the highest priority for care coordination and most efficiently and effectively represent the keystone nursing care needs of the patient by counting the arrows that connect the medical problems (ICD-10 codes). In this case, counting six lines (Table 12.1) pointing to or from the nursing domains of elimination and exchange and health promotion represents the priority present-state keystone issue, which result from a late-preterm infant with metabolic acidemia, newborn jaundice, and underfeeding.
8. Look once again at the sets of relationships and determine the theme or keystone that summarizes the patient-in-context or the patient story—the problems related to elimination and exchange and health promotion are the keystone issues for this case.
The OPT clinical reasoning web worksheet offered in Figure 12.1 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 directional arrows that create the web effect 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 one of the circles display the priority problem or keystones, in this case elimination and exchange and health promotion. A keystone issue is one or more 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 helps 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 12.1 shows a summary of the connections highlighting the priority with the most connections.
TABLE 12.1 Relationships Among Nursing Domains, Medical Diagnoses, and Web Connections
NURSING DOMAINS | MEDICAL DIAGNOSES (ICD-10 CODES) | WEB CONNECTIONS |
Elimination and exchange | Newborn jaundice P59.9 | 6 |
Health promotion | Underfeeding of newborn P92.3 | 6 |
Safety/protection | Hypothermia P80.9 | 5 |
Growth and development | Preterm newborn 36 weeks gestation P07.39 | 5 |
Nutrition | Failure to thrive P92.6 Hypernatremia P74.2 Dehydration P74.1 | 5 |
Source: World Health Organization (2015).
TABLE 12.2 Questions That Guide the Use of the OPT Model
Patient-in-context | What is the patient story? |
Diagnostic | What diagnoses have you generated? |
cue/web logic | What outcomes do you have in mind, given the diagnoses? What evidence supports those diagnoses? How does a reasoning web reveal relationships among the identified problems (diagnoses)? What keystone issue(s) emerge? |
Framing | How are you framing the situation? |
Present state | How is the present state defined? |
Outcome state | What are the desired outcomes? What are the gaps or complementary pairs (~) of outcomes and present states? |
Test | What are the clinical indicators of the desired outcomes? On what scales will the desired outcomes be rated? How will you know when the desired outcomes are achieved? How are you defining your testing in this particular case? |
Decision making (interventions) | What clinical decisions or interventions help to achieve the outcomes? What specific intervention activities will you implement? Why are you considering these activities? |
Judgment | Given your testing, what is your clinical judgment? Based on your judgment, have you achieved the outcome or do you need to reframe the situation? How, specifically, will you take this experience and learning with you into the future as you reason about similar cases? |
OPT, Outcome-Present State-Test.
Adapted from Pesut (2008).
After considering the full picture using the clinical reasoning web worksheet, the next step is to use the 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 12.1. 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 12.2 (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 outcomes 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 and family preferences within the frame of the situation.
EXHIBIT 12.1 PATIENT-IN-CONTEXT STORY
A 5-year-old White preterm female infant (Ashley Ford) with a diagnosis of weight loss, newborn jaundice, and metabolic acidemia. She shows an 11% weight loss since discharge from the hospital and she has signs and symptoms of dehydration at the 72-hour postdischarge checkup in the pediatrician’s office. She has only had four to five wet diapers and one stool in the past 24 hours. Her skin appears jaundiced and she has a depressed anterior fontanelle. She is admitted to an acute care pediatric unit in the hospital for further assessment and treatment of dehydration.
Significant laboratory data—bilirubin: 18.5 mg/dL, weight: 1,798 g, pH: 7.34
The patient-in-context story (Exhibit 12.1) is on the far right-hand side, as depicted in Figure 12.2. The advanced practice nurse notes relevant facts of the story, which, in this case, include the patient demographics and characteristics; 5-year-old female late-preterm infant presenting to the pediatrician’s office for a routine 72-hour posthospital discharge. She has a diagnosis of weight loss, newborn jaundice, and metabolic acidemia. Her failure to thrive has placed her in the case load of a pediatric nurse practitioner who is to assist the mother in making some primary care decisions about admitting her to the hospital for further assessment and treatment. Significant laboratory data show a total bilirubin of 18.5 mg/dL, pH of 7.34, and sodium of 151 mEq/L. The mother has been breastfeeding every 4 to 5 hours, but the baby has only had four wet diapers and one stool in the past 24 hours. The skin appears jaundiced and there is a depressed anterior fontanelle. Assessment and treatment of Ashley’s fluid status need acute care attention at this time. A key point at this juncture is to review and reflect on the patient story for accuracy and thoroughness to proceed appropriately with care planning for care coordination.
Moving to the left of the worksheet, there is a place to list the diagnostic cluster cue on the web of medical diagnoses and ICD-10 codes (Exhibit 12.2). At the bottom of this box are placed the designated keystone issues or themes that fall under the most significant nursing domain—weight loss P92.3, newborn jaundice P59.9, and metabolic acidemia P19.9. Remember diagnostic cluster cue 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 12.3). The frame of this case is a 5-day-old female preterm infant with a 5% weight loss and bilirubin level in the medium-risk zone at the time of hospital discharge. Her skin appears jaundiced. This helps to organize the present state and 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. A key question to ask here is: How do I frame the situation and does it agree with the patient–family view of the situation?
FIGURE 12.2 Outcome-Present State-Test clinical reasoning model for care coordination worksheet.
CBC, complete blood count; IV, intravenous.
EXHIBIT 12.2 DIAGNOSTIC CLUSTER CUE WEB LOGIC
1. Failure to thrive P92.6
2. Hypernatremia P74.2
3. Dehydration P74.1
4. Underfeeding of newborn P92.3
5. Hypothermia P80.9
6. Preterm newborn 36 weeks gestation P07.39
KEYSTONE ISSUE/THEME
1. Weight loss P92.3
2. Newborn jaundice P59.9
3. Metabolic acidemia P19.9
EXHIBIT 12.3 FRAMING
A 5-day-old preterm infant presents with a 5% weight loss, bilirubin in the medium-risk zone at the time of hospital discharge, and jaundiced skin.
At the center of the sheet are spaces to place the present state (Exhibit 12.4) and outcome state (Exhibit 12.5) side by side. The present state in this case shows five primary health care problems related to keystone issue—bilirubin: 18.7 mg/dL, metabolic acidosis pH: 7.34, infrequent breastfeedings, dehydration, and hypernatremia—sodium 151 mEq/L. The outcome state (Exhibit 12.5) shows five matching goals to be achieved through care coordination: bilirubin decreased within 6 hours of starting phototherapy, normalization of arterial blood gases by 6 hours after the start of intravenous fluids, mother breastfeeding every 3 hours, 6 to 10 wet diapers within the next 24 hours, and serum sodium within normal limits within 24 hours. 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 diagnoses? Are there gaps between the outcomes and present state? Are there clinical indicators of the desired outcome state?
EXHIBIT 12.4 PRESENT STATE
1. Bilirubin: 18.7 mg/dL (high risk)
2. Metabolic acidosis pH: 7.34
3. Infrequent breastfeedings
4. Dehydration
5. Hypernatremia—sodium: 151 mEq/L
EXHIBIT 12.5 OUTCOME STATE
1. Bilirubin decreased within 6 hours of phototherapy
2. Normalization of arterial blood gases
3. Mother breastfeeds every 3 hours
4. Infant has 6 to 10 wet diapers within the next 24 hours
5. Serum sodium within normal limits within 24 hours
EXHIBIT 12.6 TESTING
1. Laboratory studies: bilirubin, complete blood count (CBC), blood cultures
2. Arterial blood gases
3. Number of breastfeedings in 24 hours
4. Diaper counts
5. Serum sodium level
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