NRNP 6831 Week 2 Complex Case Write-Up Example

Complex Case Write-Up: A 6-Year-Old With Down Syndrome and Five Services That Rarely Write to Each Other

Student Name

College of Nursing, Walden University

NRNP 6831: Management of Specialized and Complex Populations

Instructor Name

Month Day, Year

Complex Case Write-Up: A 6-Year-Old With Down Syndrome and Five Services That Rarely Write to Each Other

Ella is a composite 6-year-old girl with Down syndrome. She lives with her parents and a 9-year-old brother in a suburban town, and she attends first grade in a general education classroom with a paraprofessional for part of the day and speech therapy under an individualized education program. Her conditions are a complete atrioventricular septal defect repaired at 5 months, primary hypothyroidism diagnosed at 2 years, obstructive sleep apnea that persisted after adenotonsillectomy at 4, and mild bilateral conductive hearing loss. This write-up records her care in enough detail that later coordination papers can use it without reopening the chart.

Problems by Owner

The problem list is grouped by the service that holds each problem rather than by organ system, so gaps are visible.

Table 1

Ella's Problem List Grouped by the Service That Holds Each Problem

Three problems belong to no one. Constipation is treated in primary care, but toileting delay at school, which the teacher raises at every conference, has no clinical owner. Her body mass index has risen from the 70th to the 88th percentile in a year, and each service has mentioned it without any of them taking it on. Her last eye examination was at age 3.

Medicines, Equipment, and Prescribers

Prescriptions from several services are where conflicts and lapses hide, so each item is listed with the service that ordered it and where it is refilled.

Table 2

Ella's Medicines and Equipment With Prescriber and Refill Source

Two problems show in the table. The fluticasone appears on two services' lists with different start dates, so no one knows which prescription is current. The CPAP mask was fitted when she was 4, she has grown since, and her mother reports that it leaks and slips off by midnight, which may explain why her sleep study results have not improved.

Function in ICF Terms

The International Classification of Functioning, Disability and Health describes a person through body functions and structures, activities and participation, and environmental factors, rather than through diagnoses alone (World Health Organization [WHO], 2001). Used here, it puts Ella's school day and home environment into the record alongside her conditions.

Body functions. Her speech is understood by her family most of the time and by unfamiliar adults about half the time. Hearing is reduced by her conductive loss, more so when her ears are full of fluid. Her sleep is fragmented, and her parents describe her as tired most afternoons.

Activities and participation. She dresses herself with help for fasteners, feeds herself, and is dry during the day at home but has accidents at school two or three times a week. She takes part in class with a paraprofessional in the morning and joins a general physical education class. She is not yet reading.

Environmental factors. Her classroom is large and noisy. The remote microphone system that would carry the teacher's voice to her hearing aids was supplied by the district but is not used, because nobody at the school was shown how to pair it. At home, both parents work, her father on fixed shifts and her mother with some flexibility, which is why her mother attends nearly all appointments (WHO, 2001).

Surveillance Due

The AAP health supervision guidance for children with Down syndrome sets condition-specific surveillance by age (Bull et al., 2022). Table 3 turns that guidance into dates for Ella and marks what is overdue. It records what is due and does not prescribe anything.

Table 3

Down Syndrome Surveillance for Ella at Age 6

What the Family Carries

In the last 6 months, Ella had 11 appointments: two in primary care, one each in cardiology and endocrinology, three with speech therapy outside school, two with the equipment vendor for CPAP problems, and two laboratory draws. Her mother attended all of them except one laboratory draw. Because only three of the appointments shared a day, they used 9 weekdays, 7 of them unpaid for her mother. Her mother also keeps the only full medication list, carries a folder of cardiology and sleep study reports to each visit, and is the person the school calls about toileting. The burden of holding the plan together sits almost entirely with one parent, a pattern the AAP describes as common among families of children with medical complexity (Kuo et al., 2016).

Two Fragile Seams

Two handoffs look most likely to fail. The first is between sleep medicine and the equipment vendor: nobody owns the fit of Ella's CPAP mask as she grows, so a treatment that may be working on paper is failing at night. The second is between audiology and the school: the hearing aids and microphone system exist, but no one connects the clinic that prescribed them to the classroom where they are meant to be used. Both are left for the coordination plan in the weeks ahead.

References

Bull, M. J., Trotter, T., Santoro, S. L., Christensen, C., Grout, R. W., & Council on Genetics. (2022). Health supervision for children and adolescents with Down syndrome. Pediatrics, 149(5), Article e2022057010. https://doi.org/10.1542/peds.2022-057010

Kuo, D. Z., Houtrow, A. J., & Council on Children With Disabilities. (2016). Recognition and management of medical complexity. Pediatrics, 138(6), Article e20163021. https://doi.org/10.1542/peds.2016-3021

World Health Organization. (2001). International classification of functioning, disability and health: ICF.