Course work

Page 1 answers are in the attachment

Case Study: Risk Stratification for Complex Patient in Case Management

Patient Overview:

• Name: Mrs. Evelyn Thompson
• Age: 68 years old
• Gender: Female
• Medical History:
• Type 2 Diabetes Mellitus (diagnosed 12 years ago)
• Hypertension (diagnosed 10 years ago)
• Chronic Obstructive Pulmonary Disease (COPD) (diagnosed 5 years ago)
• History of ischemic stroke (3 years ago, with mild residual right-sided weakness)
• Obesity (BMI = 34)
• Depression (diagnosed 2 years ago)
• Current Medications:
• Metformin 500 mg twice daily
• Lisinopril 20 mg daily
• Albuterol inhaler (prn)
• Fluoxetine 20 mg daily
• Aspirin 81 mg daily
• Primary Care Physician: Dr. Sandra Hayes
• Current Situation:
• Mrs. Thompson is hospitalized due to a recent exacerbation of COPD, which has led to difficulty breathing and increased use of her rescue inhaler. She also reports fatigue, weight gain over the past few months, and difficulty managing her blood sugar levels.
• Her hospital discharge is planned for tomorrow, and she has expressed a desire to return home, but she requires follow-up care to prevent further complications and re-hospitalization.

Clinical Information:

• Vitals on Admission:
• Temperature: 98.4F (normal)
• Blood Pressure: 150/92 mmHg (elevated)
• Heart Rate: 92 bpm (slightly elevated)
• Respiratory Rate: 20 bpm (within normal limits)
• Oxygen Saturation: 94% on room air (mild hypoxia)
• Laboratory Results:
• A1C: 8.7% (above target of <7%)
• Serum Creatinine: 1.2 mg/dL (within normal limits)
• Potassium: 3.8 mmol/L (normal)
• BNP: 300 pg/mL (elevated, possibly indicating heart failure exacerbation)
• Functional Status:
• Mrs. Thompson uses a walker for mobility but has difficulty walking more than short distances.
• She lives alone and has limited social support, with only a son who lives out of state.
• She struggles with managing her medications, particularly her diabetes management and inhaler use, and she has missed several follow-up appointments due to transportation issues and depression.

Nursing Considerations:

• Mrs. Thompson’s COPD exacerbation is currently stable, but she remains at risk for future exacerbations due to her non-compliance with maintenance therapy and poor self-management.
• Her diabetes is poorly controlled, contributing to her fatigue and overall decline in functional status. She is at risk for diabetic complications such as neuropathy and retinopathy.
• Mrs. Thompsons depression may impact her ability to engage in self-care, and her social isolation is a contributing factor.
• She has hypertension, which is not well controlled, putting her at risk for cardiovascular events such as stroke or heart failure.

Assignment Details:

You are a case manager assigned to coordinate care for Mrs. Evelyn Thompson upon her discharge from the hospital. Your task is to conduct a comprehensive risk stratification and critically think and discuss the following:

1. Clinical Risk Factors:

• Analyze Mrs. Thompsons medical history and current health status. Is she at risk for acute and/or Chronic complications?
• Are there any potential gaps in her care or medication management that you think needs addressed?
• Risk Stratification:
• Using the clinical data provided and the AAFP Risk stratification tool, classify Mrs. Thompson into a risk category for case management (e.g., high risk, moderate risk, low risk AND Levels 1-6) and explain why you have placed her in that risk category. IMPORTANT: Include your rating for both step 1 and step 2 and explain why you gave them that level.
• Identify the most critical factors contributing to her overall health risks.
• Psychosocial and Functional Assessment:
• Evaluate Mrs. Thompsons emotional and mental health status. Does her depression and social isolation affect her ability to engage in her care plan?
• Are there any other factors that might play a role in her successfully following the care plan?

Page 2

Target Population

Select one potential at-risk community or population that you are familiar with and is local for you, such as:

• Older adults
• Families with young children
• Rural communities
• Individuals with disabilities
• Individuals experiencing homelessness
• School-aged children

Infographic Requirements

• One-page infographic
• Audience-appropriate language (plain language, culturally sensitive)
• Visual format (Canva is recommended)
• May include icons, images, charts, or diagrams

Required Content

Your infographic must include:

1. Type of Emergency or Disaster that is at risk in your area

• Natural (e.g., floods, hurricanes, wildfires)
• Public health (e.g., pandemic, heat emergencies)
• Community-specific risks

1. Why This Population Is at Risk

• Social determinants of health
• Access, mobility, or resource limitations

1. Preparedness Strategies

• Prevention and readiness actions
• Emergency supply recommendations

1. Local Response Guidance

• What to do during an emergency
• When, where, and how to seek help must be specific and include real places in your local area

1. Nurses Role

• Education, advocacy, triage, coordination, or support

1. National Resources

• Emergency contacts, hotlines, websites, or agencies

Evidence & References

• Minimum of at least 2 credible sources, that will be checked for reference
• Sources should include CDC, FEMA, WHO, Red Cross, state or local health departments
• References must be listed in APA 7th edition (small font acceptable at bottom)
• Evidence accuracy is essential

Use of Artificial Intelligence (AI)

• AI tools may be used for idea generation or wording
• All information must be accurate and evidence-based
• AI-generated or fabricated references are not permitted