SHRS Collaborative Care Conference - Case Study Packet - School of ...
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SHRS
Collaborative
Care
Conference
Case Study Packet
Everyday Care (Nutrition, Self
Care, Exercise): Long-Term
Recovery Burn Patient
Noah is a 34-year-old male who lives at home with his wife and two children, aged 7 and 3,
with one on the way. About two months ago, while preparing dinner for his family, a grease
fire began on the stove. Although his wife promptly rushed to help put out the fire, Noah
suffered third-degree burns to his right arm and second-degree burns up his neck and on
his face.
Noah spent six weeks in the ICU where he required multiple splints/bandaging and a
feeding tube. As a result of his ICU stay and prolonged bed rest, he presented with a
significant decrease in endurance and notable loss of lean body mass. Following his ICU
stay, Noah spent two weeks doing in-patient rehabilitation working on increasing his
endurance and formulating a stretching program to break down and prevent further
scarring.
Noah is now ready to be discharged home. The ICU medical provider has talked to Noah’s
wife, his primary caregiver, about the continuance of his care. Currently, Noah has
increased his endurance to be able to navigate his home independently but requires
moderate assistance to complete all activities of daily living. Noah’s goals are to get back to
‘normal’ life including cycling with his wife and going camping with his family. He speaks
daily of getting back to work at his construction company and assisting in preparing for the
new baby's arrival.
Discussion Questions
What are some complications from his hospital stay that can affect his long term
health?
Discuss the impact of this case on Noah’s family.
How would you approach setting realistic goals with Noah regarding his recovery
progress?
What are some primary goals for management of this patient during the rehabilitation
phase of his care?
If your profession is not currently represented in this case, in what ways could the work
of your profession help?
1
Mental Health Care
Kaley Sanchez is a 21-year-old female who recently reported to her primary care
provider the absence of her period for two months. Upon further questioning, Kaley reveals
she has lost 38 pounds in the past three months and is currently 120 pounds with a BMI of
18.2. When the PCP asks Kaley more about her eating/exercise habits, Kaley explains that
she is a Division II collegiate track and field athlete. She finds it necessary to limit her
caloric intake to roughly 1,000 calories a day; she mostly sticks to “safe foods,” which
include spinach, carrots and hummus, nonfat yogurt and saltine crackers with low fat
cheese. Additionally, any time Kaley gets “too hungry”, she admits she drinks coffee with
low calorie creamer to avoid eating. In terms of training for her sport, Kaley runs, on
average, six miles a day, and completes intense workouts two times a week. Her team is
also active in the weight room 2-3 times a week. If Kaley feels that she ate more than 1,000
calories in a given day, she uses self-induced vomiting to expel the “extra calories.” Kaley
also meticulously records everything she eats and drinks in MyFitnessPal as well as using
her Apple watch to record all her workouts.
When Kaley’s doctor expresses her concerns about the physiological distress these
habits may cause, Kaley mentions that she has noticed a few uncomfortable changes that
came with her weight loss and lack of a period. She has also had a few emergency visits due
to loss of consciousness, extreme fatigue and dehydration during track practice. The ER
attending had discharged her each time without screening for an eating disorder. She
complains of constant aching pain in her hips and thighs when running and at rest and
often reports muscle aches. Kaley reports that her athletic trainer at her institution is
concerned that she has one or more bone stress injuries and has restricted her sport
participation; however, Kaley has continued to run on her own time to prevent weight gain.
Kaley also describes recent issues she’s had with throat and mouth pain as well as a raspy
voice. Upon further exploration, the doctor notices that Kaley’s throat and mouth are
severely irritated and appear to have some damage; additionally, when pressing on Kaley’s
nail beds, the blood isn’t restored promptly and displays pale.
After talking with Kaley for some time, the doctor recommends to Kaley that she enter a
treatment center for eating disorders. She is resistant, because she doesn’t want to get her
family’s insurance involved (which she is still a member of) and she doesn’t have the
means to support her own treatment. She also feels that her teammates will judge her and
treat her differently upon return to activity.
(continued on next page)
2
Mental Health Care (cont'd)
Discussion Questions
What are the features of Kaley’s case that qualify her for in-patient treatment?
a. What could hold her back from being able to enter an inpatient facility?
What specific areas of care (health care providers, etc.) would be pivotal to properly
treating Kaley?
What is the most pressing issue or concern that Kaley is facing from your perspective?
a. What other therapeutic interventions are necessary to ensure full and sustainable
recovery?
How can her sport and exercise fit into her recovery when she is stable and re-
nourished?
How can health technology assist Kaley’s recovery?
What could be improved to ensure patients like Kaley do not get discharged from the
emergency room without being screened for an eating disorder?
When would it be appropriate to see a speech pathologist rather than a dietitian?
Other than restricting Kaley’s running, how else can Kaley’s athletic trainer prevent
further injuries and gain her trust?
If your profession is not currently represented in this case, in what ways could the work
of your profession help?
3
Neonatal Intensive
Care Unit (NICU)
Nicholas is a 4-day-old newborn who has been staying in the Neonatal Intensive Care
Unit (NICU) due to being born prematurely at 30 weeks, which has resulted in several
health complications. With being born ten weeks early, one of the initial concerns is that
Nicholas weighs 2 lbs. 5 oz., which is extremely underweight.
He has been diagnosed with Respiratory Distress Syndrome, which is a lung disease in
newborns that prevents normal breathing, and is on a Bubble CPAP*. His medical team is
treating him with a course of antibiotics until his cultures come back.
Nicholas is positioned in a Dandleroo in prone with a gel pad underneath his abdomen.
A Dandleroo helps position a newborn in prone, side-lying and supine to better their
musculoskeletal system, neurodevelopment and sleep. His arms are under the gel pad in a
fetal position. Every three hours, Nicholas is switched from supine to prone and his head
positioning is changed every three hours in order to decrease skin irritation. He is
positioned side-lying occasionally too. Neck rolls or support pillows are placed under
Nicholas’ head to keep it in midline and helps the shaping and molding of his head without
restraints.
Nicholas has a delayed moro reflex checked by nursing staff and a delayed sucking
reflex. Nicholas is being fed orally every four hours along with supplemental nutrition via
a peripheral IV. His oral feeds will be increased gradually and then a decrease in the rate of
parenteral nutrition will follow.
Nicholas attempts both breastfeeding and bottle-feeding, but struggles to latch. He also
chokes on liquid that enters his mouth. Nicholas is diagnosed with Gastroesophageal
Reflux Disease (GERD), a disease in which the muscles between the esophagus and the
stomach inadequately relax or contract, resulting in increased risk of reflux and
aspiration.
For the next few weeks, Nicholas is monitored and continues to use the IV line. Nicholas
successfully latched onto a bottle, but the reflux still occurs. Positioning and medicines to
assist are continued. A nasogastric (NG) tube, which is used for feeding, is being discussed
if problems persist with eating and nutrition is inadequate.
(continued on next page)
4Neonatal Intensive Care
Unit (NICU) - (cont'd)
After 36 weeks gestation and six weeks in the NICU, Nicholas has begun to stabilize.
However, care team members have noted that Nicholas appears to not react to sound as is
expected from a neonate. Despite this concern, the health care team plans to start
discussing with his parents the possibility of discharge within the next couple of days.
While consulting the parents regarding Nicholas’s discharge, his mother appears to be
very anxious. Upon further discussion, she appears withdrawn, explains that she has
barely slept at night since delivery and states, “I am afraid he will die at home and it will be
my fault.”
She is screened for depression and scheduled for a follow up with her PCP concerning her
symptoms.
*His other vitals are as follows: Blood Pressure (BP) is 84/52, Oxygen Saturation (SpO2) is
95%, Heart Rate (HR) is 150 beats per minute, Respiratory Rate (RR) is 54 breaths per
minute, and Temperature is 36.7 C’.
*Continuous Positive Airway Pressure on positive end expiratory pressure (peep) on 5 fio2
is 21% oxygen. Bubble CPAP is a non-invasive ventilation for newborns who are typically
diagnosed with Respiratory Distress Syndrome. A peep of 5 is the amount of pressure that
will remain in the airway at the end of exhalation and 21% oxygen is normal room air.
Discussion Questions
What are ways in which the health care team can assist Nicholas with latching?
What are some emotional, financial and medical considerations to discuss with
Nicholas’s parents when preparing for discharge?
What are some complications that can arise due to GERD?
When is discharge planning started for a NICU patient?
What are some ways to properly monitor Nicholas’s physical and neurodevelopmental
progress after discharge? Why is this especially important for NICU graduates?
Since going home, Nicholas has started to develop a contracture in his wrist. A
contracture is where muscle atrophy results in a joint resting in an abnormal position.
What specialists can Nicholas’ parents take him to?
If your profession is not currently represented in this case, in what ways could the work
of your profession help?
5Pediatrics
Jane is a healthy 17-year-old African American female who plays volleyball for her
high school team. Jane collided with her teammate Anna during a game. After jumping to
block a spike, she and Anna fell awkwardly, and Anna landed on the outside of Jane’s knee.
Jane also hit the back of her head on the court after the fall.
During the initial evaluation, Jane’s chief complaint was moderate, sharp pain on the
medial (inside) portion of her knee. Significant swelling and mild bruising were observed
but there was no obvious deformity. Jane was very sensitive to touch on the inside of her
knee and struggled to bear weight. Jane was also not able to bend or straighten her knee
without help.
Additional symptoms included a mild headache, sensitivity to light and sound, mild
dizziness, and the inability to remember all five words you told her to remember at the
beginning of the evaluation.
An ambulance was called because Jane’s knee pain was getting worse. Jane gave
further detail on the way to the hospital. She described the feeling of the impact as if her
knee “gave out.” In the ambulance, Jane’s mom became concerned about the cost of her
care, lack of insurance and how this injury would affect Jane’s athletic scholarship.
Jane’s head and knee injuries remove her from activity for 6-8 weeks. She is
struggling with the loss of connection to her team and usual volleyball schedule. Jane is
having a hard time focusing on school due to the ringing sound in her ears. Her academics
have also suffered as a result. After her splint was removed, Jane had difficulty with her gait
and balance.
Discussion Questions
Which health care professionals should continue monitoring Jane following her injury
and recovery?
What are some possible explanations for the symptoms Jane is experiencing?
What resources could be offered to Jane to help her be successful in school?
Are there any medications that could help Jane?
What type of monitoring and how much recovery time will Jane need?
If your profession is not currently represented in this case, in what ways could the work
of your profession help?
6Pain Management
Karla is a 68-year-old white female with no significant past medical history, who is post-
op day one of a right total knee replacement. The surgery went well with no complications
and the surgeon says that Karla has an excellent prognosis and should be able to return to
full activity. However, since the anesthesia has worn off, Karla has refused all forms of pain
management other than Tylenol.
“I’ve been prescribed some of these pills before for my knee pain and they make me feel
sick. I’ve also been hearing all sorts of terrible things on the news about people who get
addicted to pain pills after a surgery and then it completely ruins their lives. Addiction runs
in my family; my brother and father were alcoholics... I don’t want to take these pills and
then get addicted to them. I would rather not even give myself the temptation.”
Due to her refusal to take even the non-narcotic pain medicine, like gabapentin, Karla has
been struggling to meet her physical therapy and occupational therapy goals because she is
restricted by her pain. This has caused her therapists to recommend that she be discharged
to a skilled nursing facility rather than to her home. Karla is adamant that she does not
want that and wants to be discharged to home. She also states that she does not want to use
the walker that was recommended for her because it “makes her feel like an old lady.” Her
home support system consists of a healthy husband, daughter and son-in-law. She also has
two young grandsons with whom she likes to play and spend time.
Discussion Questions
What are your thoughts on Karla’s decision to forgo pain medicine?
How would you counsel Karla? How can PDMP, EHR track the opioid use and make sure
she is not overdoing it?
What are some alternatives to medicinal pain management?
How would you address the opioid epidemic with your patients?
If your profession is not currently represented in this case, in what ways could the work
of your profession help Karla?
7Traumatic Brain Injury
Tasha Johnson is a 35-year-old gym teacher who was recently admitted to the local
hospital following a car crash. Tasha sustained a blow to the right side of her head and
shoulder, which resulted in a severe Traumatic Brain Injury (TBI) (Glasgow coma scale
score of 7). Upon arrival at the hospital, a head CT revealed a subdural hematoma, which
was treated by puncturing her skull to drain the blood. She was in a medically induced
coma for one week before she was extubated to room air. She also suffered a right tibia and
fibula fracture due to her legs being rapped in her vehicle.
Tasha is now conscious and recovering but is in significant pain. She complains of hearing
loss, dizziness, confusion, memory loss, a quiet voice and vomiting. She is currently
receiving nutrition/hydration from a nasogastric tube. She had her hearing tested today,
which revealed a moderate mixed hearing loss in her right ear. Due to her quiet speaking
volume post-extubation, an ENT performed flexible endoscopy, which revealed edema
(vocal fold swelling) and right vocal fold paresis. Tasha’s swallowing and cognition were
evaluated at the bedside, which revealed signs/symptoms of aspiration with thin liquid
trials and moderate cognitive-linguistic deficits in attention, memory, problem-solving
and executive functions. She then underwent a modified barium swallow study (MBSS)
which revealed moderate oropharyngeal dysphagia (difficulty swallowing) and a
recommendation of a dysphagia level II/nectar thick liquid diet. Since Tasha was put on an
oral diet, her nasogastric tube was removed following the MBSS. Due to her extended
period of immobility and lower extremity fractures, she has been unable to ambulate or
participate in out-of-bed activity. As a result, her endurance and strength are significantly
diminished.
Tasha is concerned about returning to work since her job requires her to be active, and she
is anxious to return to training for an upcoming marathon since she is an avid runner. Her
support system consists of a sister who lives nearby and a boyfriend who lives out of state.
(continued on next page)
8Traumatic Brain Injury
(cont'd)
Discussion Questions
What would you target first in therapy for Tasha given her goals (e.g. return to work, run a
marathon)?
What may be realistic short-term goals to assist Tasha in attaining her long-term goals?
How would you coordinate care for Tasha across disciplines?
Why would thickened liquids be used to mitigate swallowing problems?
What type of counseling may be relevant for Tasha?
What could lead to HIM and orthotics becoming involved in this patient’s care?
What devices may be available/appropriate for Tasha to use to help with mobility?
How could you gain Tasha’s trust to help her return to running to reach her marathon
training goal?
If your profession is not currently represented in this case, in what ways could the work of
your profession help?
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