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Lucas Episode of Care

Lucas Episode of Care

Episode of Care 1 – Lucas
Background:
You are working as a Registered Nurse in Community Care in your local area. You have commenced work on the afternoon shift and have been assigned to care for Lucas.

The clinical handover outlined that Lucas is an 18-year-old, Wiradjuri man from Wagga Wagga. He moved to the city in January 2020 to attend university. Lucas found a job working in a café, close to where he lives. Lucas has a history of asthma and has had three visits to the emergency department since January for exacerbation of asthma related to bushfire smoke.

During these visits Lucas was able to connect with the Aboriginal and Torres Strait Islander Liaison Officer at the hospital, Tracy. Tracy supported Lucas to find a regular GP through the Winnunga Nimmityjah Aboriginal Health Service. On his last visit to his new GP in February he was given a new Asthma Action plan and he requires follow up to see how he is going. The community is currently in Stage 1 restrictions due to the COVID-19 pandemic. The community are required to stay at home where possible. Contact has not been made with Lucas since his last visit to the GP.

Community Care has been engaged to support the Winnunga Nimmityjah Aboriginal Health Service during this challenging time to allow them to ensure their clients are well supported. You are assisting the service with Telehealth follow-up today.

It is Friday the 25th of March 2020. It is 10:30am and you call Lucas. You introduce yourself and commence a discussion with him to assess his well-being. You obtained the following information during your discussion with Lucas.

Task:
1. Review the ‘Episode of care – Lucas’ page in ‘Assessment 1’ module on Canvas. This is where you will find the clinical case information.

2. Using the case information, complete a psychosocial assessment using the ‘Formulation Framework – 5 P’s’
o Presenting problem
o Predisposing factors
o Precipitating factors
o Perpetuating factors
o Protective factors

3. Identify case relevant ‘cues’ based on steps 1 & 2.

4. Using the ‘Nursing diagnoses: definitions and classifications – 2015-17’ (NANDA-I), identify one (1) nursing diagnosis (clinical judgement) related to Lucas’ psychosocial, spiritual or cultural well-being, based on the cues you identified in step 3.

5. Outline two (2) priorities of care for Lucas based on your nursing diagnosis (supported with evidence).
6. Document steps 2-5 as a handwritten clinical progress note guided by the:
o Minimum Standards of Nursing Documentation
o Nursing and Midwifery Content Audit Tool (NMCAT) criteria
o Legal requirements criteria

See Johnson, Jefferies & Langdon (2010) – Table 1 (Minimum standards and NMCAT criteria) & 5 (NMCAT legal requirements).

You are to write your notes as if you are the nurse looking after Lucas for the shift. Your handwritten notes do not require referencing. You are to provide a typed copy of your clinical progress notes in addition to the handwritten note, so that your work can be assessed for academic integrity via URKUND. Evidence to support your priorities of care (step 5) is to be provided via in-text referencing (typed version only) and a reference list.

Order from Course Researchers Assessment 1: Episode of Care Analysis-Lucas
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Lucas Episode of Care Example 

MRN: 497382455

Surname: Anderson

Given name: Lucas

DOB: 12.07.2002

Date and Time: Progress notes 25.03.2030 10.30 am

Lucas is an 18-year-old man from Wagga Wagga, who moved to the city in January 2020 to pursue a teaching course at the university. He has a history of asthma and has had three visits to the emergency department in the last three months for exacerbation of asthma-related to inhalation of bushfire smoke. On his previous visit in February, he was given a new Asthma Action plan, and a follow up on his progress is due. Due to Stage 1 restrictions for containing the COVID-19 pandemic, the community is required to stay at home if possible. Community Care has been engaged to offer support to the Winnunga Nimmityjah Aboriginal Health Service throughout the challenging time to ensure proper support of clients.  His follow up is provided using telehealth services to assess his well-being and offer the best support. Lucas shared his present experiences and circumstances since his last visit to the GP in February.

In this case, the formulation framework will aid in understanding the broader context for the young patient (Marini, et al., 2011). The 5 Ps formulation framework will help understand Lucas’s strengths and problems because of his understanding of life events, social circumstances, history, relationships, and development. The NMCAT criteria relates to the recording of the   health status of the patient, use of objective data and logical presentation (Johnson et al., 2010). The information below was obtained from the discussion. The information will allow for the development of effective, flexible, and individualized intervention in collaboration with the patient and his family (Headspace Clinical Toolkit, 2020).

Presenting Problems: Lucas has a history of asthma and has had three visits to the emergency department in the last three months, low mood, idleness, melancholy, boredom and loneliness since he lives alone.

Predisposing Factors: The patient exacerbation of asthma is related to bushfire smoke and COVID-19 pandemic.

Precipitating Factors: Restricted face-to-face contact with the healthcare team and family due to the ongoing pandemic, hard time adjusting to the new environment, financial problems recently lost his job, does not have adequate cash for shopping and cannot proper healthy meals.

Perpetuating factors: Does not have social support since calling friends is costly, has not talked to anyone in two weeks, poor coping strategies in a new country, cannot afford expensive Asthma medication, and single mother is extremely overwhelmed with raising siblings alone.

Protective factors:  Receiving support from the community care services, Asthma Action plan, receiving support from family, expecting to access Centrelink payments, potential food and financial support from the university.

Nursing diagnosis: After reviewing the cues, the nursing diagnoses is ineffective coping (00069) related to Lucas’ psychosocial well-being (Herdman, et al., 2014). ). Another diagnosis is imbalanced nutrition, less than body requirements (00002) that is related to his cultural well-being. The clinical judgment is validated by his incapability to form valid assessment of his stressors and incapability to use accessible resources provided by the university (Carpenito, 2013). The clinical judgment was based on presence of defining characteristics, influence of cultural values on the Lucas’ effective coping perceptions, causes of ineffective coping (lack of support and recent changes in life situations due to COVID-19), and identification of specific stressors (Macneil, et al. 2012).

Order from Course Researchers Assessment 1: Episode of Care Analysis-Lucas
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  Domain  Class Defining characteristics Related Factors
Imbalanced nutrition, less than body requirements (00002) Nutrition Ingestion ·  Food aversion

·  Food intake below recommended daily allowance

·  Inadequate information and interest in food

·  Economically disadvantaged

·  Insufficient dietary intake

Ineffective coping (00069) Coping/stress tolerance Coping responses ·  Changes in communication patterns

·  Destructive behaviour towards self

·  Inability to ask for help, attend to information, deal with the situation,

·  Meet basic needs, role expectations, coping strategies

·  Inadequate access to social support

·  Inadequate goal-directed behaviour

·  Insufficient confidence in aptitude to deal with the situation

·  Uncertainty

·  Insufficient opportunities to prepare for stressors

·  Insufficient resources

·  Inadequate social support

·  Situational crisis

         

Priorities:

 There are two main priorities of care for Lucas based on the nursing diagnosis.

NURSING PRIORITY NO. 1.

To assess the client’s coping skills and abilities

  • Evaluation of ability to understand varied life’s events offer a realistic appraisal of the current situation.
  • Determine the smoking habits, drug use, alcohol intake, and sleeping patterns.
  • Evaluate the level of anxiety and how the patient is coping continuingly.
  • Note the communication and speech patterns.
  • Clear observation and description of the client’s behaviour recorded in objective terms and validated observations.
  • Ascertain the understanding of the present situation and its impacts.
  • Active-listening and identifying the perceptions of the client regarding what is happening
  • Evaluation of the decision-making ability
  • Determine the client’s previous methods of dealing with his life problems to detect successful techniques that could be applied used in the current situation.

NURSING PRIORITY 2

To assist Lucas to deal with the present situation by

  • Using the name of the client to enhance the sense of self and promote self-esteem
  • Encouraging constant communication with the Winnunga Nimmityjah Aboriginal Health Service staff.
  • Provide support for continuity of care with similar personnel taking care of the client as frequently as possible.
  • Explain the asthma treatment process, events, and management simply and concisely.
  • Devote ample time for listening to help the client to express his emotions, grasp the current situation, and feel in control.
  • Help the client use diversion, relaxation, and recreation techniques.
  • Stress the positive body response to the underlying medical condition without negating the seriousness of the situation
  • Encourage the client to adopt coping behaviours and progressively the master situation.

References

Carpenito, L. J., & Ovid Technologies, Inc. (2013). Handbook of nursing diagnosis. Wolters Kluwer/Lippincott Williams & Wilkins Health.

Herdman, T. H., Kamitsuru, S., & North American Nursing Diagnosis Association. (2014). NANDA International, Inc. Nursing diagnoses: Definitions and classification: 2015-2017. Wiley-Blackwell.

The Headspace Clinical Toolkit (2020). Formulation Framework – the 5 P’s. Headspace National Youth Mental Health Foundation. Retrieved from: https://headspace.org.au/clinical-toolkit/formulation/?stage=Live

Macneil, C. A., Hasty, M. K., Conus, P., & Berk, M. (2012). Is diagnosis enough to guide interventions in mental health? Using case formulation in clinical practice. BMC Medicine, 10, 111. https://doi.org/10.1186/1741-7015-10-111

Marini, M., & Chaves, E. H. B. (December 01, 2011). Evaluation of the accuracy of nursing diagnoses in a Brazilian emergency service. International Journal of Nursing Terminologies and Classifications, 22, 2, 56-67.

Johnson, M., Jefferies, D. & Langdon, R. (2010). The Nursing & Midwifery Content Audit Tool: A Short Nursing Documentation Audit Tool. Journal of Nursing Management, 18, (7), 832-845 http:// doi: 10.1111/j.1365-2834.2010.01156.x

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