SUO NSG4055 W5 Case Management Strategies.pdf - Case Study...

Case Study
Let's now see how Nurse Nani Dee makes use of case management models and strategies in her
assignment to create patient-focused care plans focusing on the specific needs of the patients and their
families. Remember, in Week 3, we saw Nurse Dee creating a nursing assessment form and a care plan
grid that was to be completed during each patient visit.
As Nurse Dee prepares to compile all of the data for Jimmy, Cara, and Jack (the three patients who
represent three diagnostic groups: pediatric-asthma, adult-HIV, and geriatric-shingles), she reviews all of
the information that she has collected.
The clinic file of each patient includes the entire plan of care, which includes the medical treatment
plan/regimen, the nursing care plan/interventions, as well as the demographics, assessment, and the
clinic notes. Many tools, techniques, forms, and pathways may be chosen or combined.
The plans must be holistic and patient focused but can be formatted in a way that Nurse Dee thinks
would work best for the particular group. Nurse Dee is developing only the holistic patient-centered part
of the care plan. She will constantly be evaluating to see the effectiveness of the patient-centered part
and what improvements would work better for the physician, the clinic, and the patients.
Nurse Dee decides that the plans will be based on an adapted version of Gordon's functional health
patterns. Each diagnostic group folder will have the fact sheets, the treatment regimens, and the nursing
care plan or patient assessment or patient plan of care. Each patient will take the duplicate of the plan
of care home. Additionally, each diagnostic group folder will have the growth and development
information pertinent to the designated patients, the community resource referrals, and the contact
information sheets for the clinics, the hospitals, the providers, the pharmacies, and the insurance.
Case Management Models
Nurse Dee chooses the “Cookbook” format for Jack the geriatric patient, but realizes that the original
format that she ha d created is not worded to reflect the patient’s goals.
Jack’s revised POC.
Jack’s revised POC
Mercy’s Chronic Illness Clinic
Partial Patient-focused Plan of Care
Name: Jack DOB: 7/9/29
PCP: Nu Dx: PH Neuralgia/Shingles
Health perception-health management
Problem:

- Too weak to take care of myself anymore.
- Life is lousy. It hurts too much.
- Why take medication. They don’t help.
Goal/Action/Met:
- Get stronger/ Ask about physical therapy and occupational therapy for activities of daily living (ADLs)/ (Y/N)
- Stop pain/ Ask about other medications, treatment options/ (Y/N)
- Medications that work / Ask the doctor/ (Y/N)
Coping-stress tolerance
Problem: Bad mood, Mad all the time
Goal/Action/Met: Find something to do besides sitting in the W/C all day, read, or go on a scenic tour with the VA group/ (Y/N)
Goal/Action/Met: Be happier/ Try to smile and not yell/ (Y/N)
Role-relationship
Problem: Girlfriend sick at home; no one visits, lonely here
Goal/Action/Met: Talk to Girlfriend/ Call to check on her/ (Y/N)
Goal/Action/Met: Do something fun/ Go to weekly card game/ (Y/N)
Goal/Action/Met: Have someone to talk to/ Introduce self to a new person/ (Y/N)
Note: Nurse Dee uses a different format (cookbook format and not a tabular format) for Jack’s care plan.