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Immune thrombocytopenic purpura

ITP

NMSU Grants

Patient

Information

14 yo

Female

Jill

Hopkins

Walk-in at local clinical for uncontrollable nose bleed

Diagnosed with ITP 4 months ago

Assessment

  • A&O x 4
  • Petechiae in mucus membranes
  • (2) 2 cm bruises --left clavicle, 3 cm bruise distal r. elbow
  • Bilateral discoloration of LE's
  • w/ ecchymotic areas around ankles

Vitals signs:

T 98.9

HR 78,

BP 124/76,

RR 18,

SpO2 97% (RA)

Pain 2/10

Assessment

Chem 7

Na: 138 CO2: 25

K: 4.1 BUN: 18 Bgl: 93

Cl: 101 Cr: 1.0

Coagulation

CBC

Labs

PT: 13.4

PTT: 28.5

INR: 0.9

Hgb: 13.8

Hct: 43

Platelet: 26.3

WBC: 8.1

Labs

Care and Priorities

Chronic

Acute

Prevent bleeding

Priorities:

Priorities:

Platelets: >30

Patient teaching

Stop bleeding, prevent falls, hemodynamic stability

Care Priorities

&

Interventions

Treatment:

Transfusions,

Treatment:

Steroids and/or transfusion

TRA, rituximab, splenectomy

IgG

Considerations:

lifestyle changes, adherence

Considerations:

Reoccurrence, hemorrhage, death

Psychosocial

Psychosocial

Mental Health

Risk for imparied social interaction r/t anergia

Interventions:

  • Assess interaction with family, friends, and peers

  • Identify Jill’s feelings that lead to poor social interactions

  • Encourage the client to keep involved with lower activity sports such as in the debate team

Religious

Risk for spiritual distress r/t religious affiliation’s refusal of transfusion

Interventions

  • Assess history of formal religious affiliation and desire for religious contact

  • Display an understanding and accepting attitude

  • Structure nursing interventions in terms of the patient’s belief system

  • Provide information that does not interfere with the patient’s beliefes and demonstrate respect for the patient's individuality

Family Considerations

Altered family process r/t nearest hospital located 45 minutes away

Interventions

  • Assess the family members perception of problems, taking into account health literacy and usual medical practices

  • Provide opportunities for the family to express concerns or answer questions

  • Assist family in setting realistic goals

Ethical Considerations

Law

Policy

Ethical

Considerations

The Affordable Care Act (ACA)

The Affordable Care Act (2010) strengthens prevention and wellness efforts.

§24-7A-6.2 NMSA 1978 … Consent for Certain Minors Fourteen Years or Older (homeless youth or parent of a child)

Beneficence

Nonmalifecence

We must not cause harm to the patient. Potential for ethical dilemma if patient refuses treatment due to religious beliefs.

Autonomy

Fidelity

Veracity

Being completely truthful with our patient/the pt's family about her condition and the benefits/risks of treatment or refusing treatment. 

Justice

Those in rural areas such as our patient might not have access to the same healthcare services that are offered in metropolitan

Systems of Care

Systems

of

Care

Small rural clinic acts as primary care clinic for community.

Out of Pocket care model used unless client has insurance or Medicaid/Medicare coverage.

Pro:

Rural Clinical

Con

Meets most basic primary urgent care needs at fraction of cost without insurance compared to hospital 45 minutes away.

  • Secondary and tertiary care are limited, which may become necessary in managing Jill’s ITP long-term with hematologists, special medications, or possible surgical intervention (splenectomy).

  • Lack of technological advancements.

Hospital acts as primary, secondary, and tertiary care for Jill.

Cons:

Pros:

Hospital

For-profit hospital – increased costs, may run battery of tests to gain profit.

Failed to adequately teach Jill and family about Medicaid/insurance options during visit in May, leading to increased medical debt for family.

Farther from Jill’s home – increased costs to family like gas and meals as well as physical/emotional strain.

  • Meets care management needs of ITP.
  • Open 24 hours while clinic may only have business hours.
  • Emergency Medical Treatment and Active Labor Act (EMTALA) in ER.
  • Technological advances more prevalent.

Small Rural Clinic

Hospital 45 minutes away

Homeopathic Remedies

Community

Resources

Lack of Available Community Resources

Family has working-class finances, was not properly educated on applying for Medicaid or SCHIP, and already incurred possibly avoidable medical debt.

Economic

Considerations

Interventions

  • Addressing unlimited needs with limited resources (Giddens, 2017).

  • Small rural clinics often have limited supplies, resources, technology, and staff.
  • Cost-effectiveness may play a role in whether up-to-date protocols, interventions, and procedures are performed over outdated options (Giddens, 2017).

Assessing health literacy regarding Medicaid/SCHIP/insurance options

Providing patient education on Medicaid/SCHIP/insurance options based on family income, racial/ethnic group, and state requirements.

Small clinics usually have.....

Difficulty staffing

Lack of funding

Patient teaching can be harder

Care

Evaluation

Patient teaching

Out of date practices and protocols

Populations at risk

Median age >50

Improvements in Patient Care

How Can This Improve?

Consistency in health care availability

Professional boundaries

Cultural considerations in health care delivery and patient education

Considerations for patient populations with increased health care disparities and poverty

Education on how politics plays a role in available health care

Surveys and community outreach

References

Bolin, J. N., Bellamy, G. R., Ferdinand, A. O., Vuong, A. M., Kash, B. A., Schulze, A., & Helduser, J. W. (2015). Rural Healthy People 2020: New Decade, Same Challenges. Retrieved from https://onlinelibrary.wiley.com/doi/full/10.1111/jrh.12116.

Giddens, J. F. (2017). Health care economics. In Concepts for nursing practice. (2nd ed., pp. 519-524).  St. Louis, MO: Elsevier.

Nelson, W., Pomerantz, A., Howard, K., & Bushy, A. (2007). A proposed rural healthcare ethics agenda. Journal of medical ethics, 33(3), 136–139.

US Census Bureau. (2016, December 30). New Census Data Show Differences Between Urban and Rural Populations. Retrieved from https://www.census.gov/newsroom/press-releases/2016/cb16-210.html.

Thank

You

Thank You

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