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HSNS363 Report on Case Study of Asthma and Minor Arthritis Assessment Answer

Word Length: 2000 words Notes: Written assignment
This assessment relates to: Learning  Outcomes 1-3
The Youbeaut Clinic has been accepted to participate in the NSW Healthcare Homes program. As the senior RN in the practice you have been the given the task of care coordinator for patients who have agreed to participate it the program.
Liam is a 15-year-old male patient who has recently joined the program. You have not met Liam previously and he and his mother, Erica, are due to attend the surgery later today. In preparation for Liam's appointment you review his patient's notes and shared care plan. On review you note that the shared care plan has been started however is not yet complete.

Review the attached case study of Liam and his shared care plan then answer the following questions:
Part one
Complete the missing information on Liam's care plan and provide the relevant information;
1. 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 (if relevant) and document the referral process and their role in Liams' care. 2. Patient's barriers to care goals: Review the patient care goals identified on the care plan. Identify barriers for achieving the care goals (note: may be: medical, situational system. Consider self-management strategies, health literacy and the team goals, this is not exhaustive).

Part two

Role of the RN as the complex care coordinator to deliver the shared Care Plan

1. Nursing practice: Outline the relevant care coordination skills you as the Registered Nurses require to effectively manage Liam's shared care plan. 2. 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 Liam's shared care plan.

Please download and refer to the attached documents

• Case Study • Shared Care Plan Risk calculator

HSNS363 Assessment 2 case study: Liam

Meet Liam


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. 


Medical History

  • 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)
  • Salbutamol PRN 


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 
  • Paedtrician 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. 

HSNS363 Assessment 2 Shared Care Plan: Liam

Risk Level: High

Last updated by: S. Brown (RN) 3/3/2020

Original Author: S. Brown (RN). 3/3/2020

Medical Summary: 


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. 



This report evaluates a case study of Asthma and minor Arthritis. It also discusses the collaborative care strategies for self-care, counselling or psychotherapy while discussing the patient’s barriers to care goals and provides the best action plan to overcome these issues by monitoring the effectiveness of the plan and devising a communication plan between the specialists through an electronic health record. 

Patient Care Team

For Liam’s case, several facilities, organizations and professionals are required to achieve the goals of his treatment. These have been discussed as under-

A pediatric rheumatologist can be pursued for help regarding Liam’s case as he is a minor suffering from Juvenile Idiopathic Arthritis.

A pediatrician, primary care doctors and family physicians manages to treat children suffering from JIA or Juvenile Idiopathic Arthritis (Cloud, 2018). Liam is a minor, hence for his treatment, they must be appointed.

Since Liam has been diagnosed of Asthma, he has to undergo a lung function test which is done by a device called spirometer measuring the amount of air inhaled. An asthma drug will be used on Liam, and then the test will be conducted.

Since Liam has been under acute admission, the hospital should provide him with a 24- hour accessibility in case of any emergencies and he should be continuously monitored.

The teachings should be personalized and it should also facilitate recalling of the provided information. 

Being physically inactive can lead to obesity, increasing the risk of inflammatory mechanisms. Therefore, the physical activities which does not stress Liam too much, must be prescribed to him so that it helps him to maintain a healthy behavior.

The environmental and psychological factors that may trigger his condition must be eliminated (Menzies-Gow et al. 2018). These may include pets, dust, unhealthy habits like smoking and drinking or the exposure to other allergens or irritants present in the environment. 

Being under high risk, Liam must take the preventive measure which will help him to maintain and lead a healthy lifestyle. 

The patient’s response to the medications, hydration, oxygen therapy, as well as bedrest must also be studied.

The care providers must look out for the presence of any kind of complications such as ruptured bleb which is highly likely to cause a pneumothorax or the presence of respiratory failure.

Patient’s Barriers to Care Goals 

Certain barriers which hinder the improvement of Liam’s asthmatic conditions are-

Career stress issues- Regular counselling sessions and acupuncture by professionals or experts is recommended in order to reduce career stress issues (McBrien et al. 2017). Although acupuncture needs to be performed by insertion of a hair like thin needles into the different parts of the patient’s body, the process is considered to be non-invasive and gentle.

Chronic pain- Acupuncture is recommended for Liam to reduce the chronic pain. The procedure needs to be performed by insertion of a hair like thin needles into the different parts of the patient’s body.

Exposures to triggers for asthma- Wearing surgical masks and carrying inhaler at all the times would help in managing the asthmatic attacks. In case of emergencies, the patient can use spacer to manage such asthmatic attacks.

Mental health- Counselling can help in dealing with the mental health issues like anxiety, depression and stress. Having a positive outlook towards the life and regularly engaging in physical activities and community engagement can also help them in balancing the negative thoughts with their social life and not feel left out or isolated. 

Unstable living environment- Living in an unstable living environment causes a patient to be more prone to health issues and isolation leading to anxiety, stress or depression. Therefore, talking to someone close regarding the problem would help the patient.

Long- term maintenance of plans- Since the patient is in a very vulnerable stage at this point, the care team and the psychiatrist should motivate the patient to give continuous efforts. The care team must devise an action plan considering the emotional state of the patient (Martin et al. 2018).

Devise a plan/for communication between all relevant specialists (regardless of location) including the use of an electronic health record.

Despite being supported by the technologies, the referral communication that happens between the specialists and the primary care providers is not up to the mark. Therefore, the communication plan must be devised after considering the below mentioned factors-

  • Including a real-time communication approach that consists of a clinician-to-clinician communication must be featured as a part of the referral system (Piggott et al. 2019).
  • Designing and using the standard electronic referral templates which consists of both the free- text fields and structured fields.
  • The reason for the referral of the electronic capture must be enforced.
  • The specialists and the PCPs should be brought together to collectively develop the referral guidelines to be included in the electronic referral system.
  • The patient’s communication should be integrated into the electronic referral procedure.
  • Use of automation so that the patient related and the electronic referral requests can be pre- populated.
  • Inclusion of the capability of the electronic consultations which consists of the information-only referrals.
  • The performance of the electronic referral communication must also be monitored.

Develop collaborative care strategy for Liam’s monthly case conferences (including Liam and parents) every 2 months for 6 months

Collaborative care practice is used in the primary care as it improves the care for patients with chronic diseases. Various new collaborative-care models are also being created and implemented in primary care. As per the case study, collaborative care strategy design must provide conferences between the health care providers and the patient and his family members on a monthly basis while keeping the following factors in mind-

  • Common goals and commitment to meet these goals must be shared by the patient, the care team and his family members.
  • The Care-team members must be assigned with those roles which are suitable according to the individual’s area of expertise and education (Taylor et al. 2018).
  • A clear and full understanding of the role of various care- team member must be established to provide the best patient care.
  • A method for communication between the care- team members must also be established which may be for an instance, a shared care plan along with documentation which would be shared so that the team can access and use it when required (Scott et al. 2017).
  • It must also include the mechanism about the ongoing monitoring of the outcomes.

This plan helps the primary care providers to address the physician and the patient- specific factors which creates a barrier that limits the accessibility of the patient to get the required diagnosis and treatment (Bove et al. 2018).

Foster Liams’ independent management of both chronic conditions (with minimal parental supervision)

The self-management method in the given case study is considered to be the best standard in the achievement of optimum asthma control. It relies upon getting education related to the disease and getting well informed about the patient and health care provider’s partnership, the importance of day-to-day self-monitoring by the patient, the self-management for asthma as well as the following up of the physicians’ guidance which is mentioned in details in the self-management action plans (Bell et al. 2018).

The self- management for Asthma includes-

  • Environmental control such as avoiding pets, dust, exposure to other allergen or irritants present in the environment.
  • Adopting and practicing healthy behaviors such as avoiding smoking, alcoholic drinks and so on, which can trigger an asthma attack in patients (Scott et al., 2017).
  • Adhering to an asthma- controlling medication on a daily basis, and also during step- up as well as flare-up therapies along with an additional controller medication or bronchodilators.
  • Ensuring medical follow-ups on a continuous basis. 

 Even if the physicians focus on the role of self-management, the marked gap in between the self- management strategies practiced by the patients as well as the medical recommendations still exists (Piggott et al. 2018).

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. 

Lifestyle interventions is the key to live well in patients suffering with asthma. This may include increasing the fruit, vegetable as well as wholegrain intake and increasing the exercise levels which improves asthma (O’Beirne et al. 2018). The future recommendations for the patients may also consist of practicing yoga, meditation as well as massage like acupuncture and various other herbal therapies.

According to studies, a diet high in omega-6 fatty acids and saturated fats is correlated with inflammatory mechanisms while on the other hand, a diet consisting of high intakes of fruits, vegetables, omega-3 fatty acids as well as dietary fibers has been associated with anti-inflammatory pathways. Since asthma falls in the category of chronic disease which is driven by inflammation, it is considered to get improved by consuming anti-inflammatory diet while reducing the tendencies of Hypertension (DASH) in asthma.

Studies on physical activities showed that the adults and children suffering with asthma are less inclined towards exercising as compared to the non-asthmatic people (Argintaru et al. 2019). It is also correlated with poor asthma control, reduced impact of medicines and medications on the patient, frequent exacerbations as well as decreased quality of life in patients.

Psychological interventions can also help people suffering with asthma mentally. Studies have examined various distinct therapies and also monitored the various physical as well as psychological outcomes for the results. Researchers are still studying the effects of psychological interventions on larger number of people with and improved plans and designs to determine its effectiveness in enhancing the physical health outcomes of asthmatic patients.

Nursing skills used to cope up with barriers in patient care

Nursing skills are extremely relevant in the provided case since proper formal as well as informal care can only make Liam’s condition better.

First of all, a nurse must ensure that environmental interventions revolving around Liam does not trigger his condition. The nurse must make sure that the patient knows their asthma triggers well and must assist him to eliminate these triggers by ensuring that the patient’s room is free of such triggers.

Career stress issues and mental health is another aspect where nursing skills can help the patient. It may happen so that Liam’s inability to do a certain work may lead to mood swings or depression and anxiety (Menzies-Gow et al. 2018). It is important for the nurse to recognise the symptoms and take necessary steps to deal with it, for example, psychological interventions.

An arthritis patient often suffers from frequent chronic joint pain, sleep disturbance, fatigue, limited mobility and altered moods. The nurse must be persuasive and encourage Liam to follow a sleep routine and indulge in comfort measures whenever required. 

Unstable living environment plays a significant role. Living in an unstable living environment causes a patient to be more prone to health issues and makes them isolated too. This can also lead to anxiety, stress or depression. Therefore, the nurse can help by talking to the patient regarding his problems which will help him to deal with stress more effectively.

Long- term maintenance of plans is also an important aspect in such cases. Liam is observed to be actively changing health behaviors but he has difficulties maintaining the plan. Since the patient is in a very vulnerable stage at this point, the nurse associated with his case must also look into the fact that Liam is well-versed with his ongoing situation so that in any emergency case, he is able to deal with the situation. In this way, he may also feel independent. 

Nursing strategies used to cope up with barriers in patient care

In case of Liam, assessing and managing the acute and chronic pain in arthritis could be done by the cognitive behavioural strategies used by nurses. Cognitive behavioural therapy (CBT) is a technique where the patients are engaged in a talk therapy which helps them in identifying and developing skills in order to change their negative behaviour and thoughts. Thus, by using this technique the nurse can help in changing the negative thoughts and behaviours of the patient and developing better skills to cope up with the pain.

Another strategy that a nurse may use is collaborative care which aims at improving the patient outcomes by using inter-professional cooperation. It includes primary or tertiary care teams which work together with the other healthcare professionals like dieticians, mental health professionals, physiotherapists or medical specialists. In order to implement this strategy, nurses must ensure effective communication. Nurses can lead the care team as they are specifically trained to have good communication skills, adaptability and empathy. Nurses can also offer an effective patient- focus care plan as they are engaged in caring for the patient around the clock and therefore have a better view of any care that should be provided. This will improve the quality of patient care.


The self- care plans have proved to be the most efficient in controlling arthritis and asthma. Following the devised self- care plans, monitoring the health regularly as well as lifestyle interventions like physical exercise and psychological interventions are crucial to a healthy lifestyle. The case study of Liam presented in the study provides a clear example of how to deal with complications associated with asthma and arthritis. The study also reveals the significance of communication in Liam’s given situation. Moreover, nursing skills and strategies involving methods like maintenance of airway patency, dealing with complications have also been highlighted in this study. The effects of these should also be monitored in order to redesign the plan, if required.

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