NR 571 Week 8 Concurrent Problem Synthesis Example

Concurrent Problem Synthesis: How a Pneumonia-First Ordering Reversed Overnight in a Patient With Myasthenia Gravis, Traced Through Six Documents From the Term

Student Name

College of Nursing, Chamberlain University

NR 571: Complex Diagnosis and Management in Acute Care Practicum

Instructor Name

Month Day, Year

Concurrent Problem Synthesis: How a Pneumonia-First Ordering Reversed Overnight in a Patient With Myasthenia Gravis, Traced Through Six Documents From the Term

The Position

On the evening of admission I ranked community-acquired pneumonia first and myasthenia gravis second for a 72-year-old with generalized myasthenia, atrial fibrillation, diabetes, kidney disease and osteoporosis. I defended that order because the pneumonia caused the admission and was the trigger for everything else. By the next morning the order had reversed, and I now hold that the reversed order was right and that the original was right too, for the twelve hours it covered. What the term taught me is that in a patient with several conditions, the order of problems belongs to a time, not to the case.

The Ordering Moving, Moment by Moment

The first moment is in the case paper written on the admission evening. Its ranked list placed pneumonia first with the note that it would move down if the fever and oxygen need fell within 48 hours, and myasthenia second, to move up if the bedside breathing tests fell. Both of those conditions for movement were written before anything had moved.

The second moment is in the problem list on day 2 at 09:00. By then the one-breath count stood at 17 rather than 22, and the vital capacity had shrunk to 1.5 liters. The list put myasthenia first with a warrant that its worst outcome was now closer than the pneumonia's. The pneumonia stayed second, not because it mattered less, but because the team needed to know which numbers to watch first.

The third moment is in the competing treatment analysis. Once myasthenia sat first, the question became which treatment matched its clock. Raising prednisone would have helped over weeks and raised glucose now; immune globulin would help over days. The analysis chose immune globulin and named its price.

The fourth moment is in the rounds brief, which stated the ordering decision in a single opening sentence and asked the team one question: whether to hold the prednisone dose until the infection was controlled.

Multimorbidity as the Condition of the Case

Four conflicts surfaced in this one admission, and each crossed from one condition into another. Because myasthenia ruled out the pneumonia guideline's preferred antibiotics, the comorbidity brief turned to doxycycline, and that substitution brought a Legionella antigen into the plan that would not otherwise have been sent. A beta blocker is the reflex answer to a fast atrial rate, yet beta blockers sit on the list of drugs that can deepen myasthenic weakness (Sheikh et al., 2021), so the rate was left to fever control. Weak swallowing muscles meant that a weekly bone drug, irrelevant to the reason for admission, had to be stopped. And the steroid increase most clinicians would reach for first would have driven the glucose up during infection.

None of these four could be settled by reading one guideline at a time. In a hypothetical 79-year-old with five common chronic diseases, following each disease's guideline produced a regimen of 12 medicines with several possible interactions (Boyd et al., 2005). This admission showed a hospital version of that finding: the trouble was less the number of drugs than the fact that each guideline quietly assumed the other diseases were absent. The American Geriatrics Society's principles for patients with several conditions ask the clinician to read evidence in light of the whole patient and to balance benefit, harm and the patient's own priorities (American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity, 2012). On the ward, that came down to adding a qualifying clause to every recommendation before acting on it.

Where the Patient's Priorities Entered

The goals of care conversation on day 2 changed the meaning of the ranking. The patient accepted a breathing tube for a time if it led back to the garden, the grandchildren and the family table, and declined resuscitation for cardiac arrest. That answer made the myasthenia-first ordering more than a technical judgment: preventing crisis protected the outcome the patient said mattered most, while preparing for crisis respected the limits the patient set.

What the Term Did to My Defense of the First Order

I defended the pneumonia-first order on the admission evening as if it were a property of the case. The day 2 numbers showed it was a property of that evening. I do not think the first order was a mistake; the breathing numbers were stable when it was written, and the pneumonia was the active threat. The mistake would have been to keep defending it after the numbers changed. What I would change is the wording, not the decision. The first list should have said that the order was expected to change and named the numbers that would change it, which it did, but it should have also said when they would next be checked, which it did not.

What the Documents Did Not Capture

The documents record the ordering at fixed moments, and they miss the hours between. The first sign that the order should change did not appear in any of my documents. It was the night nurse's note at 04:00, recording that the patient's eyelids were drooping by the early morning rather than by evening and that the cough on sips of water was louder. That observation reached me only on morning rounds, four hours later. The bedside numbers confirmed it, but the nurse saw it first. A synthesis built only from my own documents would credit the reversal to the breathing tests, when the real first evidence was a nursing observation that no ranking of mine had asked for.

Recommendations for the Clinicians Who See the Patient Next

For the outpatient neurologist: decide, with the patient and outside an infection, whether this episode means the long-term regimen needs strengthening, since prednisone was deliberately held at 10 mg during the admission (Narayanaswami et al., 2021).

For the primary care clinician: record macrolides, fluoroquinolones and aminoglycosides as drugs to avoid, with the reason, in a place every future prescriber will see; restart alendronate once swallowing is normal; recheck glucose control now that metformin has resumed.

For any future admitting team: order this patient's problems by the damage each could do over the coming two days rather than by the reason for admission, note beside each entry what result would shift it, and expect the order to change. Ask the nurses which signs they would report first, and write those signs into the plan, because in this admission the earliest warning came from a nursing note at 04:00 rather than from a scheduled test.

References

American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity. (2012). Guiding principles for the care of older adults with multimorbidity: An approach for clinicians. Journal of the American Geriatrics Society, 60(10), E1-E25. https://doi.org/10.1111/j.1532-5415.2012.04188.x

Boyd, C. M., Darer, J., Boult, C., Fried, L. P., Boult, L., & Wu, A. W. (2005). Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: Implications for pay for performance. JAMA, 294(6), 716-724. https://doi.org/10.1001/jama.294.6.716

Narayanaswami, P., Sanders, D. B., Wolfe, G., Benatar, M., Cea, G., Evoli, A., Gilhus, N. E., Illa, I., Kuntz, N. L., Massey, J., Melms, A., Murai, H., Nicolle, M., Palace, J., Richman, D., & Verschuuren, J. (2021). International consensus guidance for management of myasthenia gravis: 2020 update. Neurology, 96(3), 114-122. https://doi.org/10.1212/WNL.0000000000011124

Sheikh, S., Alvi, U., Soliven, B., & Rezania, K. (2021). Drugs that induce or cause deterioration of myasthenia gravis: An update. Journal of Clinical Medicine, 10(7), Article 1537. https://doi.org/10.3390/jcm10071537