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Case Study #1

Demographic: Male

Comorbidities: Lumbago, Chronic Back Pain

Acuity: Medium

Patient has a Medtronic IT pump for pain management with a refill interval of 90 days. His nursing care includes the pump refill procedure, pump programming, monitoring, and therapy assessment. Telemetry review is completed with patient and/or caregivers and a comprehensive multisystem assessment is completed at every visit. A pain assessment is also completed to further evaluate the effectiveness of treatment. Alternative pain methods are discussed and reviewed. Vital signs are assessed at each visit. Bowel and urinary patterns are monitored. Teaching is provided related to skincare and wound prevention. Patient has diabetes, so discussions regarding food and lifestyle choices are discussed as needed. Safety and fall risk assessments are completed and any identified risks are addressed. Medical follow-up and reasons to seek follow-up when necessary are reinforced. Anxiety reduction is achieved with in-home refills as patient cannot drive further than 30 miles from his home. The home refill has decreased his anxiety greatly as he is about an hour away from physician office. The patient receives 30-day phone calls to assess for changes in status since previous visit, medication changes, MD visits or hospitalizations, and to address any issues or concerns. Calls to patient are also made prior to next scheduled refill visit to confirm day and time of appointment.

Case Study #2

Demographic: Male

Comorbidities: Cerebral Palsy

Acuity: Medium

Patient is a non-verbal 12 year old boy who is non-ambulatory and non-weight bearing. He has a Medtronic IT pump for management of tone and spasticity. He attends school and is learning methods of communication with an eye tracking device. He receives PT, OT, and speech services at school. He has an unstable living situation and receives Botox injections to arms and legs every 3 months. He receives a high dose of Baclofen and has an alarm date of 30 days. He is seen for IT pump refills approximately every 23-25 days. Patient has high anxiety regarding pump refills and requires restraint from parents or another nurse during procedure. He does not require monthly calls or stat visits. His refill visits include routine refill, pump care and assessment, multisystem assessment, medication reconciliation, assessment of vital signs, assessment of tone and spasticity utilizing the Ashworth scale, and monitoring of bowel and bladder habits. Education is included and reinforced at every visit with family and caregivers to include: Baclofen over- and underdose, identification and treatment for Baclofen emergency, fall prevention, skincare maintenance, identifying changes in tone and spasticity and possible causes. Phone calls are made prior to visits to confirm scheduled refill appointments. Patient is stable on his current ITB dosing and does not require interim adjustment visits.

Case Study #3

Demographic: Female

Comorbidities: Multiple Sclerosis

Acuity: High

Patient has MS and a Medtronic IT pump with Baclofen therapy for the treatment of muscle spasms and spasticity management. She is wheelchair-bound and requires assistance with her care. She receives support from her elderly mother who assists her with medication management and transportation. She has a refill interval of 62 days and is seen for refills approximately every 50 days. Nursing visit includes the pump refill procedure; pump programming, monitoring and therapy assessment. Telemetry review completed with patient and or caregivers. Scheduling is complex due to frequency of hospitalizations and memory impairment. She frequently cancels requiring rescheduling. Monthly phone calls are made by the nurse to assess for changes in tone and spasticity, changes in patient status, medications, or any hospitalizations. In addition to monthly calls visit confirmation calls are made 1-2 times week of scheduled visit. Nurse has gone to home day after visit was confirmed and patient does not answer the door because she forgot. Nursing visits include multisystem assessment, vital signs, assessment of pain, falls assessment and assessment of tone and spasticity utilizing the Ashworth scale. Physician communication as needed to assess therapy and need for adjustments or changes based on nursing assessment. Patient needs constant reminders regarding compliance with managing physician visits. Education is reinforced with every visit as patient is forgetful. Medication side effects, over and under dose symptoms reviewed. Ongoing education with visits and phone calls related to depression, skin breakdown, bowel management and urinary retention. Emotional support provided during visits and calls. Needs assessed for case management intervention referral as needed.