NUR1101 : Nursing Care

The patient, Lucinda, is a 37-year-old overweight Mexican-American female referred for integrated case management by insurance reviewers specifically looking for patients who use many health services. She came to their attention because a request was being made for approval to remove a gangrenous toe. Lucinda has had numerous procedures, hospitalizations, and emergency room visits in the past 2 years. During the past 12 months, she has filled 32 prescriptions for eight different medications from six independent physicians, one of whom is a diabetic specialist, one a psychiatrist (for diazepam), and one a surgeon (for a pain medication). Three prescribers are primary care physicians. Lucinda has four other physicians who have submitted medical charges for her care in the past year. Her last ad-mission was 2 weeks earlier for 2 days and she has been to the emergency room three times in the last month. During her hospitalization, At that time, she had blood sugar levels of 400?, a gangrenous toe, and a fever of 104 degrees Fahrenheit. Her last HbA1c was 9.2.

2. ROBERT’S STORY

Robert is a 49-year-old electrician for a large manufacturer who has been identified through the employer’s disability management report. The disability management company at Robert’s worksite notes that he has been on short-term disability for 4 months and would be a candidate for long-term disability soon. Robert’s disability manager, Charlene, is concerned that if Robert is placed on long-term disability, which has more rigorous definitions of what constitutes disability, he will not remain qualified for disability support. Robert would then find it difficult to obtain alternative employment because of his health history. Charlene indicates to her supervisor that Robert has been seen in the emergency room five times in the last 2 months and has been in contact with his personal doctor twice monthly. He is on five medications, all prescribed by his general practitioner, Dr. Couch, who, as a retired surgeon, is supplementing his income doing general practice during a challenging economy. In addition to chronic lung disease, Robert has a long history of anxiety with panic attacks. There is, however, no mental health professional involved in his care. Since the company’s contracting health plan changed 3 years earlier, Robert has been forced to see Dr. Couch because his old primary care doctor was not in the new health plan network. Dr. Couch is. For three years, Robert’s work performance record has deteriorated. Dis-ability and family leave time tracking indicate that he has taken time of for breathing problems, chest pain, back pain, headaches, anxiety, and flu-like episodes. This is, however, the first extended leave that he has taken. Dr. Couch, who signs Robert’s disability forms, projects that he will be permanently disabled according to a discussion he has had with the disability plan’s medical director. Since his early 20s, Robert has been treated for anxiety disorder with panic attacks, a condition that runs in his family, but has stopped going to a therapist or psychiatrist because he can save out-of-pocket expenses by getting all of his care from Dr. Couch. Robert’s last admission of 2 days was 6 months earlier for chest pain. At that time, oxygen saturation was 91% and FEV1 was 58% of predicted. Despite a normal heart tracing and little other evidence of a cardiac origin for his chest pain, Robert refused to leave the emergency room because he thought he was going to die. He smokes two packs of cigaretes per day.

3. PAUL’S STORY

Paul is a 13-year-old male with truncus arteriosis, a congenital heart condition, for which he is currently receiving symptomatic care. The reason for the cardiology clinic visit was to evaluate high levels of fatigue, which significantly affect his ability to attend school. Consistently for the past 9 months, Paul’s oxygen saturation levels have been running between 85% and 89% (pO2 50–55), a dangerously low range, and are slowly becoming progressively worse. His extremities have a blue/purple tint, and there is significant clubbing of his fingers. Paul has very limited daily activities. He becomes easily fatigued when he goes out, and he has not attended middle school since the beginning of the academic year (nearly 6 months). Despite nonattendance at his school, he receives no tutoring or home schooling and is far behind in the special program provided by his middle school teachers. Medical management consists of water pills and heart strengthening medications. His cardiologist also recommends the use of oxygen while sleeping. However, Paul is very anxious about wearing an oxygen mask or even nasal prongs. His parents have not followed through to arrange for this and are not pushing him. As a result, Paul has been to the emergency room six times in the last 2 months for water pill adjustments and oxygen supplementation. He has never been admitted to the hospital, though it was encouraged on three occasions. Paul’s cardiologist recommends cardiac catheterization to determine the status of his heart condition. Paul and his parents, however, are very fearful about his undergoing this procedure. Paul underwent several surgeries during his first few years of life to correct his cardiac defect. Paul’s doctors feel that given the physical deterioration observed in him, he will likely require further corrective surgery. Both parents are fearful that surgery will kill Paul or that it would provide little benefit to their son’s quality of life.

Answer: