Nursing Assignment: Treatment Plan For A Patient Of Juvenile Idiopathic Arthritis (JIA)
Task: Case Study
Liam is a 15-year-old male who lives in Westtown with his mother, Erica. Liam is a patient of Dr Jones and moved to the clinic when her practice merged with another local practice to form the Youbeaut clinic late last year.
Liam has a history of Juvenile Idiopathic Arthritis (JIA) and Asthma. Liam attended the Accident and Emergency department at the Westtown Hospital four times last summer, including one overnight admission, due to acute exacerbation of Asthma. The Westtown region has been drought declared for the last two years and is experiencing large dust storms which triggered Liam condition. Liam fractured his right hand three years ago when he fell of his bike.
In addition to his recent asthma exacerbations Liam has also been experiencing pain related to his JIA, particularly in his right wrist and right knee. Dr Jones has referred him for review with his regular paediatric rheumatologist in Sydney which is located 500km away. Liam is to have an MRI prior to attending the appointment. In light of his recent Asthma exacerbations Liam is also due to visit his regular paediatrician to review his Asthma Action Plan. His paediatrician is located in a rural service centre 250km from Westtown.
JIA – diagnosed at the age of 8, four joints involved
Asthma – diagnosed at the age of 10
Right carpel/scaphoid fracture 3 years ago (cycling accident).
NSAIDS - BD naproxen 250mg
Paracetamol PRN for pain.
Inhaled corticosteroid preventer (daily)
Liam lives with his mother Erica (37), step father John (39) step-brother Sam (7) and step-sister Molly (4). Liam has a god relationship with Erica, John and his younger siblings however, this is a busy household with both parents working and all children attending different school/childcare facilities. John is a supervisor at the local mine. He is a shift worker and his hours include evening and weekend work. Erica works full time at the local bank.
Liam spends alternative weekends and half his school holidays with this father, Michael (45), his step mother Annie (44) and twin step-sisters Charlotte and Grace (18 months). Michael and Annie live on a mixed farming property 25km from Westtown. Annie and Michael tried unsuccessfully to have children for several years prior to the arrival of their daughters. Charlotte and grace are very welcome additions to the family however Michael and Annie are finding the demands of caring for two young children (largely unassisted) and running the farm incredibly tiring with little-to-no spare time.
Liam has a good relationship with his father and Annie however, when he is at the farm he feels as though there is a ‘burden’ and is largely left to himself due to the time and attention required to care for the twins and run the farm.
Michael and Erica often struggle to balance the responsibilities of transporting Liam the multiple medical appointments and therapy sessions including:
Monthly medical appointment in Sydney
Local fortnightly physiotherapy
GP appointments as required
Paediatrician appointment quarterly.
Academic & Social
Liam enjoys school however; he is socially introverted and is sometimes bullied. He finds it difficult to complete school work when his hand is painful due to JIA particularly at the fracture site (Liam is right-handed). Liam has one very close friend, Jack, who he has attended school with since kindergarten. Jacks and his parents recently relocated to Sydney for work.
Erica is concerned that Liam is becoming increasingly socially withdrawn. These days he mainly stays in his room and plays video games. Erica is concerned that he is becoming depressed. She has to constantly remind him to take his medication (he was previously independent) feels like she is ‘nagging’ concerned about what is happening with his medication when he is at the farm.
Erica is hopeful that participating in the Healthcare Homes program will assist in better managing Liams’ care, particularly given his current physical and mental health status.
Liam’s has JIA (polyarticular) which was diagnosed age 8. Liam reports increasing pain levels in the joints, particularly R wrist, which was fractured in a cycling accident 3 years ago. He also reports increasing discomfort in his shoulders and knees over the last 6 months. Erica reports that prior to this latest exacerbation Liams’ symptoms have been well controlled with regular medications since his last flare up two years ago.
Liam has allergic Asthma diagnosed aged 10. His primary triggers are dust and pollen. Liam had 4x attendances at the Westtown Regional Hospital A&E department last summer. Three acute exacerbations were associated with large dust storms in the area (currently in drought) and once after being exposed to large amounts of dust while assisting his farther load cattle onto a truck in the stock yards.
Current presentation 3/3/20XX
On examination R hand, R shoulder and L knee have mild swelling and are warm to the touch. Liams complains of 4/10 pain on movement of these joints. Liam report having to use his Asthma reliever medication at least once per week for the last 2-3 months.
Liams’ mother Erica has expressed concerns in relation to his current psychological status. She states that she believes Liam is becoming increasingly socially withdrawn and is not participating as actively in the management of his JIA or Asthma as he has in the past. She states that his year advisor has also been in touch as he is displaying reduced effort in class which is out of character as he is usually a good student. Liam was somewhat reluctant to engage in discussion regarding management and treatment of either of his conditions.
Patient Care Team:
Personal Support Team:
Mother- Erica Smith
Step father- John Smith
Father- Michael Taylor
Step mother- Annie Taylor
Patient’s care goals (chronic and preventive)
- “I am sick of feeling different – I just want to be normal like everyone else”.
- “I want to be able to play weekend sport again. All the other guys in my year seem to play something on the weekends I’m the odd one out”.
- “I am very concerned about Liams’ psychological health and want to identify a strategy to address this issue ASAP”
- “We want to get to the specialists to review his JIA an Asthma management. We need to get to the bottom of what has caused his Asthma and JIA to get worse over the last 6 months”
- “We need to come up with a better plan for organizing and managing all of Liams’ appointments and the information we receive from them – we seem to just be reacting when thing go wrong these days”
Patient’s self-management tools:
- Consult paediatric rheumatologist and paediatrician ASAP.
- Develop a plan for staged increased activity and return to team sport (hockey).
- Develop strategy for competing school-based tasks when JIA/Asthma flares.
- Attend counselling/psychotherapy
- Develop a strategy for being independent at school, and home (x2) regarding medications and trigger identification (with minimal supervision).
- Erica, Michael and Liams to develop plans for medication adherence, 1-1 time and medical response plans for both households in the event of an acute exacerbation of Asthma or JIA.
Patients barriers to care goals
Team Goals: (chronic and preventive)
- Devise a plan/for communication between all relevant specialists (regardless of location) including the use of an electronic health record.
- Develop collaborative care strategy for Liams monthly case conferences (including Liam and parents) every 2 months for 6 months.
- Foster Liams’ independent management of both chronic conditions (with minimal parental supervision).
- Monitor effectiveness of physical and psychological interventions closely over the next 6 months with monthly clinic visits (care coordinator). Relevant team members to collaborate and revise plans as necessary.
Adapted from: Patient Centred primary Care Institute (2020) The basic person-centred care plan – Providence Medical Group Southeast, Available at: http://www.pcpci.org/sites/default/files/resources/Shared%20Care%20Plans_0.pdf
Consider the above case scenario and prepare a nursing assignment addressing the following parts:
Patient Care Team: Identify all of the facilities, organisations and professionals Liam and his parents will have to access/interact with to achieve his treatment goals. Separate these into primary secondary or other and document the referral process and their role in Liam’s care.
Patient’s barriers to care goals: Review the patient care goals identified on the care plan. Identify barriers for achieving the care goals.
Role of the RN as the complex care coordinator to deliver the shared Care Plan
Nursing practice: Outline the relevant care coordination skills you as the registered nurses require to effectively manage Liam’s shared care plan.
Identify Strategies: As the complex care coordinator you have to effectively implement Liam’s shared care plan. Identify any/all projects, programs, technology, organisations, innovations etc. that would assist with delivering the goals identified in Lucas’ shared care plan.
The report on nursing assignment focuses on the treatment required by Liam, who is a patient of Juvenile Idiopathic Arthritis (JIA). Liam has also been diagnosed with allergic asthma and dust and pollen are said to be the main asthma triggers. The treatments associated with Liam are separated into primary and secondary categories and are discussed in this report. The role of registered nurses in the case of Liam's care and treatment are discussed in this report and the strategies which would help in better treatment of Liam have also been talked about.
1. Facilities, organisations and professionals that need to be accessed for Liam’s treatment
The illness which Liam is going through is Juvenile Idiopathic Arthritis and Asthma and both the illnesses need advanced treatment for Liam's betterment. Different professionals are required for each of Liam's illnesses. As per the case study, Liam's parents struggle to take out time for Liam's treatment procedures but it is crucial that Liam is provided with proper care and treatment. The priority for Liam's parents should be the treatment of the Juvenile Idiopathic Arthritis that Liam is going through. The treatment of Juvenile Idiopathic Arthritis is a time-taking process and various processes are involved in it (Barut et al., 2017).
The facilities needed by Liam are:
Blood tests- Liam may need blood tests frequently to measure his ESR. The ESR measurement is done to know about the inflammation degree (Barut et al., 2017). The rheumatoid factor of Liam also needs to be determined through blood tests.
Imaging or X-ray scans- The fractures, infections and tumours are detected through imaging or X-ray scans. Liam needs X-rays from time to time to monitor his condition and he may need imaging as well to monitor his bone development and for joint damage detection.
Therapies- Therapies come under the treatments for Liam’s condition. Liam has been recommended by the doctor to visit a physical therapist for assisting him to keep his joint flexible and his muscle tone and range of motion maintained.
Surgeries- If Liam’s condition reaches a severe stage, surgeries might be needed and his parents should be ready for it.
Liam is suffering from Asthma as well and proper care and treatment are also required specifically for Asthma. The facilities needed by Liam for the proper treatment of Asthma are:
- Spirometry- Spirometry is a tool that is used to test the functions of the lungs. The tool is used to measure the capacity of the lungs and Liam needs frequent visits to the hospitals for undergoing this process to monitor his lungs condition (Castillo et al., 2017).
Impulse Oscillometry- The airway impedance is measured by this tool and in Liam’s case this tool is significant for monitoring his condition and providing him appropriate treatment (Castillo et al., 2017).
Liam needs to visit professionals for each of his illnesses. The Juvenile Idiopathic Arthritis would be treated by Paediatric Rheumatologist and for the treatment of Asthma; Liam would need to consult an allergist and a pulmonologist. All of the above-mentioned treatments play a crucial role in Liam's care, without the proper facility and the professionals; it would not be possible for Liam’s parents to carry on with Liam’s treatment.
2. Patient’s barriers to care goals
The patient care goals which have been discussed in the case study are:
Consulting a paediatric rheumatologist immediately
Develop a plan for an increase in activity and ensure that Liam returns to sports.
Strategy development for completing the school tasks when the JIA or asthma increases in intensity.
Liam must attend psychotherapy sessions for the improvement of his mental health (Gilljam et al., 2016).
Strategy development for Liam to be independent in school as well as at home.
Liam’s parents must develop strategies to adhere to his medications and should plan accordingly for any sudden exacerbation of JIA or asthma.
A plan for effective communication between all professionals related to Liam’s case and his treatment must be developed.
A plan for the collaboration between Liam's parents and his specialists must be developed through conferences arranged over a gap of 2 months or 6 months.
Liam must be prepared to manage his conditions by himself without the maximum supervision of his parents.
The effectiveness of the physical and psychological treatments of Liam must be monitored for the next 6 months and monthly visits to the clinics must be ensured.
Liam and his parents have been facing a lot of problems regarding the maintenance of Liam’s treatments. Liam's step-father is a supervisor in the mine and he works in shifts. Liam's step-father often has to work on weekends as well which leaves him very little time to spare for Liam. Liam's mother Erica is a full-time worker in a local bank and she gets time only after her work gets over, that is, in the evening. Liam is left in the child care facility for the daytime and he visits his own father and stepmother on every alternative weekend. The professionals who are suggested by the doctor for Liam's consultation has their medical clinics far away from Liam's home. The regular paediatric rheumatologist of Liam stays 500 km away from Liam’s hometown and the paediatrician stays 250 km away from Liam’s hometown. All these factors have made it very hard to achieve the care plan goals for Liam. The distance of the professionals related to Liam’s treatment has made it very hard for Liam and his parents to visit them frequently and this has created a barrier in Liam’s treatment. Michael, Liam's father and Erica find it very hard to maintain the transportation of Liam to the healthcare facilities due to the shortage of time and long-distance.
1. Nursing practice
There is a range of nursing interventions that are required for Liam. Liam has JIA and asthma and the interventions the registered nurses should undertake to manage Liam's shared care plan are as follows:
The nurse must assess the joint pains and closely consider the location, severity, exacerbations of the pains and the factors which aggravate the pains (Martin, 2018).
The nurse must assess the activities of the patient, mobility of the patient and should check for any deformity present in the joints.
The medications which are prescribed by the doctors must be administered by the nurse and the effectiveness of the medications in relieving pain must be monitored by the nurse.
The patient must be allowed to assume a position where he feels comfortable and the nurse must provide support to the painful areas of the patient during any changes in position (Martin, 2018).
The nurse must provide methods of immediate relief to the patient to decrease the pain.
The patient must be explained about the causes of the pain and intervention which are involved in the relieving of pain.
The parents of the patient must be provided with enough information by the nurse about the factors which increase pain and they should also be instructed to report the pain to the medical team at the onset.
The patient and his parents must be instructed by the nurse to avoid over-activity and movement of the joints which are affected.
The nurse must encourage and teach the patient with relaxing activities such as reading books, arts, music and others.
The nurse must instruct the patient and his parents about the appropriate administration of the medications along with the side effects and the importance of adherence with the schedule.
For Liam’s asthma, the nurse must follow the methods and interventions discussed below:
The nurse must free the airway through suction, monitor the retraction of the chest wall and check the respiratory rate (Belleza, 2017).
The nurse must monitor the lung sound and check the oxygen delivery of the patient.
The colour and consistency of the sputum of the patient must be assessed by the nurse frequently.
The patient must be encouraged for deep breathing or deep coughing by the nurse.
The patient and his parents must be provided with enough information about the factors which triggers asthma in the patient (Belleza, 2017).
The patient must be distracted from thinking about the anxiety state and must be instructed on effective breathing by the nurse.
The nurse must provide support to the patient when the patient goes through difficult or laboured breathing (Papi et al., 2020).
The nurse must monitor the breathing rate while the patient performs any activity. Any abnormality in respiration, blood pressure and pulse must be monitored and reported by the nurse (Belleza, 2017).
It is important for the nurse to have enough information about the medical condition which is being handled by him/her. Reports state that information flow is required before and after each task for the continuity of care. The tasks which are performed by the nurses are not isolated but they are interdependent on each other and help to achieve patient goals altogether (Bresnick, 2017). Nurses must be involved intimately in the collaborative activity of planning the care coordination strategies and executing them. In care coordination, value-based care becomes an important driving force. One of the key features of care models, which are evolving and which are designed to avoid periodic care for patients, is care coordination.
With the progress of the patient, the care plan evolves and the evolution of the care plan requires open collaboration and strong communication among the nurses, physicians and other team members (Bresnick, 2017). For an effective improvement of the patient, the nurse must provide emotional support to the patient. The patient must be encouraged to be verbal about concerns of the disease and the nurse must provide positive reinforcements to the patient (Hoover, 2018).
2. Identification of strategies
There are a variety of goals that have been developed for the effective treatment of Liam. Along with the goals, a range of barriers has also been identified which are responsible for the inefficiency in Liam's treatment. In order to reach the goals of Liam's treatment and care, strategies are needed to be developed to overcome the barriers of the patient care goals. The strategies are discussed below:
Liam’s parents must communicate and collaborate with each other for the effective treatment of Liam.
Liam’s parents must search for efficient doctors in their hometown as it has been an issue for them to take Liam 250 or 500 km away for his treatment.
The hometown professionals must be reached in case of any emergency but the medical team which stays distant from Liam’s hometown can be visited once in 2 months.
Liam must be taught how to manage his medical conditions without maximum adult supervision.
A registered nurse must be appointed to accompany Liam at home and wherever he goes.
Erica, Liam’s mother, must communicate with John, Liam’s step-father, to make him understand his role and importance in Liam’s treatment. If John does not assist Erica in the process of the treatment, it would be harder for her to manage.
Liam’s parents can use virtual means of communication to connect with the professionals who stay out of their hometown.
The physiotherapist who is related to Liam’s treatment can be appointed for a monthly visit at Liam’s residence. This would help Erica and Michael as they would not have to take Liam outstation frequently.
It can be concluded from the above discussion that Liam is affected with JIA and asthma and needs proper care and treatment for effective recovery. Liam’s parents are struggling with the process of Liam’s treatments and it has been a cause of the inefficiency in Liam’s treatments. The facilities and the professionals which Liam must access have been discussed along with the barriers of his treatments. The role of registered nurse have been observed to be crucial in achieving Liam shared care plan and it is important that Liam must be supervised under a registered nurse for effective improvement. The strategies which need to be developed for delivering the goals identified for Liam’s shared care plan have been discussed in the above context.
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