CASE STUDY #1 Mr. Jones is an 84 year old Caribbean male who has been referred to home care following discharge from the hospital. He is legally blind and has had a right lower limb amputation due to diabetes. He speaks and understands English although he has a thick Caribbean accent. He has five children, three of whom are scattered throughout the United States and the Caribbean; one of whom is incarcerated; and his youngest daughter, Marina who lives with him and is his caregiver. The other children have little contact with their father because they do not get along with Marina. No healthcare proxy was ever appointed by Mr. Jones and there are no advanced directives. Initially, he had been admitted from home to the hospital for respiratory distress. It was determined that he had pneumonia secondary to aspiration. He was admitted to the ICU, was sedated, placed on a ventilator and tube-fed. While in ICU his daughter Marina, challenged the health care team caring for her father. She questioned all interventions and used “Google” as her source of information. On numerous occasions, she threatened to remove the endotracheal tube and take him home by herself where she can feed him. At times her behavior was erratic and belligerent. Alcohol use was suspected but not confirmed. However, other times she demonstrated a calm and cooperative disposition. After one week, Mr. Jones was successfully weaned from the ventilator and underwent physical therapy in the hospital. He was discharged to home where he continues to live with Marina. On your initial home visit with Mr. Jones, you note that he is in bed and is somewhat lethargic. They live on the third floor of an apartment house with no elevator. Their living space is small and relatively clean, but smells of cigarette smoke. Marina seems guarded and provides little information as you attempt to initiate your assessment. She comments, “He doesn’t need home health care. He has me to take care of him.” CASE STUDY #2 Ms. Smith is a 61 year-old obese female who has been referred for home health care following discharge from the hospital. She lives alone in a house that she rents. Her limited Social Security disability barely pays for her monthly expenses. She was never married or had children, and she has no living siblings. The only relative she has is a nephew who lives nearby but rarely sees. She speaks to him on the phone a few times a week. She relies on public transportation whenever she needs to complete errands. Initially, she had been admitted to the hospital because she had fallen in her home. Her nephew could not reach her by phone and called for an ambulance. Upon arrival to the emergency department, Ms. Smith was unkempt and clearly had been lying in feces and urine at home. Her bilateral lower extremities were warm to touch, reddened and swollen. She had a temperature of 102.3 F. It was determined that she was dehydrated and septic secondary to bilateral lower extremity cellulitis. She was admitted to the ICU where she received intravenous fluids and antibiotics through a PICC line. During her hospitalization, the Social Work department contacted her nephew, Joseph. He and his wife both work demanding full-time jobs and are very involved in raising their three children. However, he stated that he had attempted to assist his aunt many times, but she would refuse his help. He informed the social worker that Ms. Smith had not permitted visitors to the home for many years, including himself. While planning discharge for Ms. Smith, the social worker investigated Ms. Smith’s living conditions. It was found that Ms. Smith was a hoarder and she was referred for psychiatric evaluation. She was transferred to the psychiatric unit for treatment, and was subsequently discharged to home. Arrangements had been made with her nephew for her home to be cleaned prior to her discharge. You have been assigned to deliver home care to Ms. Smith as she requires long-term antibiotic therapy. On your initial home visit with Ms. Smith, her nephew Joseph is there to welcome you, however, he seems anxious to leave. You note that although the home appears clean, there are a few small piles of clutter scattered throughout the home. Ms. Smith seems suspicious of you and asks multiple questions regarding your intentions in her home. She states, “I guess it’s ok for you to be here this time. But if you come back, I want Joseph here too.” CASE STUDY #3 John is a 22 year-old Type I non-compliant diabetic who has been discharged to home following a recent hospitalization for DKA. He was diagnosed at the age of 12. His mother, Evelyn had managed his diabetes until John turned 18. Since then, John has not kept his diabetes under control. Resulting from his non-compliance, he now suffers from diabetic neuropathy and gastroparesis. Joseph lives at home with his mother, Evelyn who works full-time as waitress. Joseph is unable to work and collects Social Security Disability. He has no siblings and his father died two years ago. Initially, John had been admitted to the hospital when his mother came home from work and found him confused and weak. He complained of abdominal pain and he had been vomiting. His blood sugar on arrival to the ED was 649. It was also noted that prior to admission, John had developed a wound on the bottom of his foot which was open and draining purulent fluid. He was placed on an insulin drip, antibiotics were ordered and he was transferred to the ICU where he spent three days. John has been hospitalized in the same facility numerous times and is well known to the staff as being difficult to care for. Once he is no longer acidotic, he becomes argumentative and refuses treatment. He demands to eat and drink and threatens to leave against medical advice. His mother is also well known to the staff as she calls the unit continuously asking for information regarding John’s treatment plan and condition. She tells the staff, “don’t tell John I called” and “don’t let him see you talking to me on the phone.” You have been assigned to deliver home care to John as he requires intravenous antibiotic therapy and close monitoring of his diabetes. On your initial home visit with him, Evelyn is present. She answers many of the questions you have asked John to answer. She interrupts frequently and voices her differing opinions regarding the plan of care you have laid out. Evelyn becomes distracted by a phone call and you take the opportunity to go over your plan with John alone. He appears to be interested and listens attentively. However, as Evelyn reenters the room, John’s disposition changes and remains quiet. As you prepare to leave, you tell John you will be back tomorrow. Evelyn states, “you can come at 3 pm when I get home from work”. CASE STUDY #4 Angelo is a 63 year-old who was admitted for acute shortness of breath directly from his pulmonologist’s office. He was admitted to the ICU for urgent chest tube placement and work-up to rule out lung cancer. Angelo has been a long-time smoker for 41 years and worked in construction until two years ago. He has a history of hyperlipidemia, but has been otherwise healthy until this admission. Angelo collects his retirement pension and lives with his wife of 35 years, Irene. Two years ago, Angelo’s son and daughter-in-law were killed in an automobile accident. Angelo and Irene are raising their two grandchildren, ages 7 and 9. Irene works full-time as a secretary and Angelo had been responsible for watching the children in the afternoons after school. During the hospitalization, it was confirmed that Angelo has lung cancer. He underwent a partial lobectomy and the plan was for him to have radiation and chemotherapy. Prior to his first treatment, Angelo respiratory arrested and was placed on a ventilator. After multiple attempts at weaning, Angelo was finally extubated and the chest tube was removed. He was sent to the medical-surgical unit and eventually was discharged home. He never received radiation or chemotherapy during the hospitalization. You have been assigned to deliver home care to Angelo as he is weak and debilitated. He was discharged home on continuous oxygen and is mildly dyspneic on exertion. The plan is for him to receive outpatient chemotherapy and radiation as soon as he becomes stronger. On your initial home visit with him, Irene and the two grandchildren are present. The children are very active, yet are well mannered. Angelo appears to derive much pleasure from the children’s company. Irene, however, appears extremely anxious and expresses concerns about Angelo’s prognosis and treatments. She also discusses the concerns she has about having to work full-time and the additional sole responsibility of two small children now that Angelo cannot care for them. As you outline your plan of care with Angelo and Irene, she begins to cry. She says, “This is overwhelming for us.” You begin to question what support systems are in place for them, but Irene continues to cry and tell you that they have no family close by. CASE STUDY #5 Stacey is a 27 year old with severe asthma who has been hospitalized several times since childhood. She has a close relationship with both of her parents and her one brother. Her mother has been extremely supportive in helping Stacey manage her asthma since she was diagnosed. Stacey graduated a local college and works as an accountant close to her home. Last year Stacey married her partner, Lisa who is getting ready to graduate a two-year nursing program. Initially, Stacey had been transported to the hospital via ambulance when Lisa arrived home from school and found her extremely short of breath and wheezing. On arrival to the ED, her blood gas revealed severe respiratory acidosis requiring mechanical ventilation, high dose steroids and admission to the ICU. Stacey remained intubated for one week and was subsequently given a tracheostomy as she had developed atelectasis and had difficulty weaning off the ventilator. After three weeks in the ICU, Stacey was finally able to breathe on her own and no longer needed ventilator support. Throughout the hospital stay, both Lisa and Stacey’s mother took turns sitting at her bedside. Quite often, Lisa would bring her nursing textbooks to the bedside and study. At times, both of them would stay in the room and seemed to be of support to each other as well as a support to Stacey. In the beginning of the hospitalization, Lisa would ask the nurses questions about Stacey’s care. As time went on, Lisa began telling the nurses how they were “not doing things right”. You have been assigned to deliver home care to Stacey as she requires asthma disease management in an effort to decrease her ED visits and hospitalizations as well as reduce time lost from work. On your initial home visit with her, Lisa and Stacey’s mother are both present. You notice that there is dust throughout the apartment and there are two cats sleeping in the corner of the room. As you begin to review your plan of care, you discuss triggers that may cause an exacerbation of asthma. Lisa immediately contradicts you and states, “Stacey’s last episode was triggered by stress, not the environment.” Stacey’s mother remains silent but appears to be agitated. She replies, “Lisa, why don’t you let the home health nurse teach us some things?” Questions for Group Activity 1. Based on the information provided, describe the following: a. Family needs b. Family structure c. Family strength d. Family functioning e. Nursing’s contribution f. Priorities of identified health needs 2. Provide two short-term goals and two long-term goals for this family. 1. 2. 3. Using family systems theory, how would you define this family? 4. What would be the purpose of using a family mapping (ecomap) technique to describe this family? 5. The nurse has 15 minutes to complete a family assessment. What are ways that the nurse can acknowledge the family’s strengths? 6. The community health nurse recognizes that illness can disrupt typical family routines. What is the aim of assessing rituals and routines for the family?
