CHAPTER 9

CARE COORDINATION FOR A VETERAN/MILITARY 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 an acute care context with a military patient. The advanced practice nurse is working with a patient who is in need of support services to promote quality outcomes with chronic pulmonary disease and comorbidities. The provider/clinic is the point of access for the patient. 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 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 64-year-old Vietnam veteran, Ralph Wiseman, who presents with complaints of increasing shortness of breath over the past 2 days. He is being seen in the veteran’s clinic by a family nurse practitioner to manage his chronic health problems. Mr. Wiseman was brought into an emergency department 11 days ago by the emergency medical system with similar symptoms. His oxygen saturations were in the 70% range, which was treated with an Albuteral nebulizer. He was discharged home on Zithromax. His symptoms abated until 2 days ago when the shortness of breath worsened and he developed “chest discomfort” that he describes as an “8” on a scale of 1 to 10. The pain is sharp and stabbing, which is different from the chest pain he experienced prior to having a coronary stent placement in the past.

At present, he has a one- to two-word dyspnea and has had minimal oral intake for the past 24 hours. He has a right lateral foot ulcer that “has been there for months.” The ulcer does give him pain but it improves when he dangles his foot. He denies fever, chills, change in cough, increase in sputum production, or change in sputum consistency. He smokes one pack of cigarettes per day with a 49-pack-year history. He denies recreational drug use but drinks several cups of caffeinated coffee daily. He does not exercise and has a poor sleep pattern of 4 to 6 hours of interrupted sleep nightly. He is single with no family support. He has a technical degree and worked as a mechanic until he was disabled with lung disease. He was exposed to Agent Orange during the war.

His past medical history includes the comorbidities of chronic obstructive pulmonary disease, for which he has had several hospitalizations over the past 5 years for exacerbations of symptoms, coronary artery disease with stent placement, hypertension, hyperlipidemia, and depression. He has a history of alcohol abuse with delirium tremens but has not taken a drink in 20 years. The current peripheral vascular disease related to the foot ulcer is going to be treated with vascular surgery in 1 month.

Current medications include Albuteral nebulizer treatments, Symbicort, tiotropium, theophylline, and prednisone. He also takes one 81-mg aspirin per day. His influenza vaccination is up to date but he has never had the pneumococcal or herpes zoster vaccine.

The physical examination reveals a height of 5’ 10”, weight of 64.04 kg, body mass index (BMI) of 20.3, blood pressure of 89/47 mmHg, heart rate of 118 beats per minute, temperature of 99.8°F, and a respiratory rate of 24 breaths per minute. His oxygen saturation is 100% on 4 L BiPAP (bilevel positive airway pressure), and the arterial blood gases show a pH of 7.467, pO₂ of 124.8 mmHg, pCO₂ of 33.5 mmHg, base excess of 0.7 mEq/L, and HCO₃ of 24.2 mEq/L.

Other laboratory values are as follows—white blood count: 14.2/mm³, hemoglobin: 11.3 g/dL, hematocrit: 34.2%, mean corpuscular volume: 93.4 mcm³, platelet count: 151/mm³, neutrophils: 82%, lymphocytes: 3%, monocytes: 13%, complete metabolic panel within normal limits, and cardiac enzymes negative. The electrocardiogram shows sinus tachycardia and the chest x-ray reveals hyperinflated lung fields with a possible right lower lobe infiltrate.

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 9.1), 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 history of chronic obstructive pulmonary disease, coronary artery disease, hypertension, hyperlipidemia, history of alcohol abuse, depression, and peripheral vascular disease. 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 breathing pattern and impaired gas exchange.

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:

FIGURE 9.1 Outcome-Present State-Test clinical reasoning web worksheet.

CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; ICD-10, International Classification of Diseases, 10th edition; HTN, hypertension; PAD, peripheral artery disease; RLL, right lower lobe.

The OPT clinical reasoning web worksheet in Figure 9.1 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 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 one of the circles display the priority problem or keystones, in this case elimination and exchange. 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 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 9.1 shows a summary of the connections highlighting the priority with the most connections.

TABLE 9.1 Relationships Among Nursing Domains, Medical Diagnoses, and Web Connections

COPD, chronic obstructive pulmonary disease.

Source: World Health Organization (2015).

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 individual patient-centered systems thinking about the care coordination of the identified problems highlighted in Table 9.1. 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 9.2 (Pesut, 2008).

TABLE 9.2 Questions That Guide the Use of the OPT Model

OPT, Outcome-Present State-Test.

Adapted from 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 preferences within the frame of the situation.

The patient-in-context story (Exhibit 9.1) is on the far right-hand side, as depicted in Figure 9.2. The advanced practice nurse notes relevant facts of the story, which in this case include the patient demographics and characteristics: 64-year-old Vietnam veteran male who lives alone and without social support. He has diagnoses of chronic obstructive pulmonary disease, coronary artery disease, nicotine dependence, alcohol abuse in remission, peripheral artery disease, and exposure to Agent Orange in the war. He currently has right lower lobe pneumonia complicated by sepsis and respiratory alkalosis. His initial treatment with Zithromax was not long standing. Respiratory distress reoccurs as well as sepsis, which requires intravenous fluids and antibiotics. Oral steroids are used to treat airway inflammation from the infection and aggravation of the chronic obstructive pulmonary disease. The peripheral ulcer is also considered a source of the sepsis. His continued respiratory infection has placed him in the caseload of the veteran’s clinic nurse practitioner, who is to assist him in adhering to the therapeutic regimen to promote pulmonary health. Significant laboratory data show hypotension and oxygen dependency caused by chronic obstructive pulmonary disease and respiratory infection in the right lower lobe. 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 of the worksheet, there is a place to list the diagnostic cluster cues on the web of medical diagnoses and ICD-10 codes (Exhibit 9.2). At the bottom of this box are placed the designated keystone issues or themes that fall under the most significant nursing domain—chronic obstructive pulmonary disease J44.9 and right lower lobe pneumonia J18.1. 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?

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 9.3). The frame of this case is a 64-year-old Vietnam veteran who presents to the emergency department with dyspnea and shortness of breath. This frame 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. 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?

FIGURE 9.2 Outcome-Present State-Test clinical reasoning model for care coordination worksheet.

BiPAP, bilevel positive airway pressure; BP, blood pressure; COPD, chronic obstructive pulmonary disease; CXR, chest x-ray; O₂ sat, oxygen saturation; PAD, peripheral artery disease; RLL, right lower lobe; WBC, white blood cell.

 

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EXHIBIT 9.4 PRESENT STATE

  1.  Dyspnea

  2.  Sepsis with right lower lobe pneumonia

  3.  Nicotine dependence

  4.  Does not exercise or do health-promoting activities

  5.  Ulceration to right lateral foot

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1. The Evolving Nature of Nursing Process and Clinical Reasoning
2. Knowledge Complexity and Clinical Reasoning: Standardized Terminologies
3. Care Coordination for a Patient in Acute Care
4. Care Coordination for a Maternity Patient

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