CHAPTER 10

CARE COORDINATION FOR A PEDIATRIC 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 pediatric case. The advanced practice nurse is working with a family that is in need of health and wellness services to promote quality-of-life outcomes in a child who has diabetes. 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 a patient-centered 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 and elements of care coordination.

LEARNING OUTCOMES

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

THE PATIENT STORY

We begin with the history and story of a 12-year-old White female child, Sally Jones, who presents to the pediatric office with her mother, who states “She seems to be losing weight even though she eats all the time.” The mother reports she is concerned about Sally because the teachers at school have been reporting that “she is more irritable and seems to be having a difficult time focusing and asking to go to the restroom frequently.” One of the teachers has expressed concern that “she perhaps has attention deficit disorder and may need pharmacological intervention for this.” The advanced practice nurse asks the child whether she is sleeping well because she complains of nocturia. Sally’s developmental history is described by the mother as “normal” and she has not started menses yet. She is an only child in this family. In school, she is usually on the honor roll and achieves A and B grades for her work. In the past month, this has also changed as she is achieving only Cs and Ds.

During the interview, Sally appears fatigued and has difficulty focusing on the conversation. She is continually drinking water from a bottle and maintains poor eye contact. She is not on any prescribed medications at the time of the interview. Her physical examination reveals her breath has a faint fruity odor and her finger-stick blood sugar is 240 mg/dL. Her vital signs show a heart rate of 100 beats per minute and a respiratory rate of 22 breaths per minute. Her height is 4 feet 11 inches (59 inches), weight is 87 pounds (39.5 kg), and her body mass index (BMI) is 17.5.

The patient is referred to the nearest pediatric intensive care unit and her initial serum laboratory values show glucose 240 mg/dL, sodium 130 mEq/L, chloride 80 mEq/L, and potassium 3.3 mEq/L. Arterial blood gases were drawn and they reveal a pH of 7.19, PaCO₂ of 25 mmHg, PaO₂ of 92 mmHg, and an HCO₃ of 10 mEq/L.

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 10.1), 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 pediatric conditions in this case are type 1 diabetes mellitus with hyperglycemia and ketoacidosis. Once the advanced practice nurse considers these medical diagnoses, the nursing care domains associated with them are identified. The complementary nursing diagnoses most impacted in this case are imbalanced nutrition, risk of acute confusion, fatigue, and ineffective health maintenance.

FIGURE 10.1 Outcome-Present State-Test clinical reasoning web worksheet.

BMI, body mass index; 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 the ability to make 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:

The OPT clinical reasoning web worksheet in Figure 10.1 shows a template with the patient health care situation, medical diagnoses, and nursing diagnoses at 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 keystone, in this case safety and protection, health promotion, and nutrition. The keystone issues are 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 10.1 shows a summary of the connections highlighting the priorities with the most connections.

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 10.1. As the advanced practice nurse thinks about the patient, she or he 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 to 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 10.2 (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 consider patient and family preferences within the frame of the situation.

TABLE 10.1 Relationships Among Nursing Domains, Medical Diagnoses, and Web Connections

BMI, body mass index; DM, diabetes mellitus.

Source: World Health Organization (2015).

The patient-in-context story (Exhibit 10.1) is depicted in Figure 10.2 on the far right-hand side. The advanced practice nurse notes relevant facts of the story, which in this case include the patient demographics and characteristics; sick child brought into the office by her mother for concerns of decline in school function and weight loss. Her teachers report concerns of a possible attention deficit disorder as grades have significantly dropped. The child reports fatigue, nocturia causing insomnia, polyuria, polydipsia, and polyphagia. Menses has not begun. The BMI calculation shows she is below the percentile for her age.

A key point at this juncture is to review and reflect on the patient story for accuracy and thoroughness to be able to proceed with care planning for care coordination.

Moving to the left, there is a place to list the diagnostic cluster cues on the web of medical diagnoses and ICD-10 codes (Exhibit 10.2). At the bottom of this box is placed the designated keystone issues or themes that fall under the most significant nursing domain—type 1 diabetes mellitus with hyperglycemia E10.65 and ketoacidosis E10.10. 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?

TABLE 10.2 Questions That Guide the Use of the OPT Model

OPT, Outcome-Present State-Test.

Adapted from Pesut (2008).

FIGURE 10.2 Outcome-Present State-Test clinical reasoning model for care coordination worksheet.

BMI, body mass index; CDC, Centers for Disease Control and Prevention; DM, diabetes mellitus; ICU, intensive care unit.

At 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 10.3). The frame of this case is a White female child who presents to the office with her concerned mother. Child is fatigued, unable to focus, and drinks a lot of water. This frame (White female child with physiologic health and cognitive issues) helps one 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’s 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 10.4) and the outcome state (Exhibit 10.5) side by side. The present state in this case shows six primary health care problems related to the keystone issue: fatigue, polydipsia, weight loss with polyphagia, declined school performance, and new diagnosis of diabetes mellitus with hyperglycemia and ketoacidosis. The outcome state shows six matching goals to be achieved through care coordination: hemodynamic stabilization to correct nocturia, stabilization of hydration status, stabilization of weight appropriate for age and gender, return to baseline of As and Bs as honor roll student, and stabilization of type 1 diabetes mellitus. 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?

 

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EXHIBIT 10.5 OUTCOME STATE

  1.  Hemodynamic stabilization to correct nocturia

  2.  Stabilization of hydration status

  3.  Stabilization of weight appropriate for age and gender

  4.  Return to baseline of As and Bs as honor roll student

  5.  Stabilization of type 1 diabetes mellitus

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