First, I would thank Ms. C’s son for bringing up his concerns. Without the input of family and loved ones, how would we know of Ms. C’s need for support? Because he spoke up for his mother and asked for help, we can provide the family with tools and support to help Ms. C achieve the best possible outcome.
I would sit with Ms. C and talk with her about how she is doing. By first building a rapport with her, and showing her that I am someone she can rely on to care for her, she is more likely to be open with me about her feelings, concerns, and ability to cope. Being a nurse she feels she can trust will also allow her to feel more comfortable being candid with me, especially about her symptoms and compliance with her treatment plan. In listening to her express her feelings about her current situation, I can pick up valuable cues about her communication abilities, preferences, and possible barriers. Any language or hearing/visual barriers can be remedied by offering the appropriate assistance (interpreter, hearing aid use or adjustment, other assistive measures).
(5)I will want to know if Ms. C understands her diagnoses, treatment plan, and who she can turn to for help. An informed patient can better care for themselves, and is more likely to follow her care plan. (7)Due to the complexity of the case, it will be necessary to use an interdisciplinary approach to managing her care.
With the above handled, we can move on to talking about her medications. Does she have her medications? If not, we can make sure she has whatever assistance she needs to ensure uninterrupted access to them. Social services can provide help with finding financial resources and programs to provide medication delivery.
Ms. C has been diagnosed with rheumatoid arthritis, symptoms of which include joint inflammation, swelling and pain. Are these symptoms interfering with her ability to open medication bottles, administer any insulin injections (if she is prescribed insulin), or perform finger stick blood sugar tests? If so, an occupational health consult is needed to help Ms. C identify problem areas and offer assistive devices. If opening medication bottles is an issue, contacting the pharmacy to request arthritis-friendly caps is an option (provided there are no children in the home that could access the medication).(2)If she has her medications, we need to review together how they are being taken now, and she is following the instructions for each. If vital sign measurement is required before taking a drug? Some drugs are only to be taken if specific vital signs fall within certain parameters. For example, beta blockers require blood pressure and apical pulse readings before taking, and the dose is held (not given) if the pulse and BP are above a certain range set by the prescriber.
If pre-dose vital signs are needed, be sure the patient has the ability to perform measurements correctly, is in possession of the needed equipment (BP cuff, stethoscope), and knows how to correctly measure and record these measurements. It is crucial the patient is given an up-to-date medication list that includes instructions for taking each. We also need to make sure each provider who cares for Ms. C has a copy of this list.
Having more than one provider increases the chances that the patient may be prescribed new medications that may be a duplicate of a current medication, or a drug that will cause the patient harm if taken with another on her current list. If Ms. C is taking multiple medications and is having difficulty managing on her own, or if she is experiencing side effects or adverse reactions, we will want to talk to the social worker or case manager about enlisting the help of a clinical pharmacist.
The clinical pharmacist is educated and trained in direct patient care environments, including medical centers, clinics, and a variety of other health care settings. Clinical pharmacists are frequently granted patient care privileges by collaborating physicians and/or health systems that allow them to perform a full range of medication decision-making functions as part of the patient’s health care team. These privileges are granted on the basis of the clinical pharmacist’s demonstrated knowledge of medication therapy and record of clinical experience. This specialized knowledge and clinical experience is usually gained through residency training and specialist board certification. (1)If she is not taking one/some/all of her medications due to side effects, we will talk about what side effects she is experiencing, what impact they have (minor, major, hazardous) on her life, and which drugs may be causing the side effects.
With the help of the clinical pharmacist, we can include all providers in optimizing her medication regimen. It may be possible to eliminate some, reduce the frequency of doses (using extended-release formulations, for example), or perhaps change scheduled medications to PRN (as needed) when appropriate. Combination pills, also known as polypills, “improved medication adherence with small improvements in systolic blood pressure and LDL cholesterol.” (3)(4)We can also review her diet, use of non-prescription remedies, use of illicit substances, and alcohol consumption, all of which have an impact.
For minor side effects, we can include non-pharmacological methods to relieve discomfort. Major side effects and adverse reactions will require immediate attention. Not only will I need to document these, I need to contact the appropriate provider right away to report the situation and get new physician orders as the provider deems appropriate. Once we have managed to make all necessary accommodations above, we need to make sure Ms. C is able to continue following her treatment plan, making updates and ensuring follow up appointments and scheduled treatments are completed. Making sure her care team communicates regularly with each other and Ms.
C will help her maintain long-term compliance, as well as maintaining the highest level of health, function, and independence achievable.