Mrs Elizabeth Green - Underlying Assumptions to Care - Case Study Example

Case World Scenario Name Tutor Institution Course Date Case World Scenario Introduction The focus of this essay is on a case study involving a patient Mrs. Elizabeth Green, a 78 year old woman. Mrs. Elizabeth lives alone in a single-storey unit. The patient was cleaning dishes at home and experienced 10 minutes of unrelieved chest and left shoulder pain. She was later admitted to the emergency department and after review by the cardiac team she was admitted for an angiogram, where stent insertion was recommended. As per standard protocol various medications and investigations were completed that included urinalysis, blood works, 12 lead EG and administered with IV morphine, GNT infusion and stat dose of PO 600mg Clopidogrel. A femoral angioplasty was performed and a blockage was found within her left anterior descending artery and was successfully stented. The patient underwent through the recovery process and was finally discharged and a cardiac rehabilitation process was recommended after her discharge. Accordingly, this essay will identify and discuss the potential barriers to effective planning for transition of care for Elizabeth. Case Analysis Evidence shows that the duration after hospital discharge is a susceptible period for patients. Therefore, as Elizabeth returns home from the hospital, it will be necessary to manage her health problems, treatment regiment and follow-up appointments as she continues to recover. Therefore, during planning of care should take into considerations many factors that will impact the patient after her discharge (Hesselink et al, 2015). Social determinants of health, that contribute to health disparities consist of socio-demographic, academic, cognitive, cultural and behavioural variables (Meyers et al, 2014). Therefore, a model including social determinant will be good at forecasting patient’s recovery. Health literacy is a vital social determinant aspect that impacts the ability of the patient to take the medications suitably, keep follow-ups, identify symptoms of deteriorating condition as well as identify when the symptoms occur (Hesselink et al, 2015). For Elizabeth, she is an elderly patient with low health literacy; therefore, it will be necessary for the nurse to ensure that a person is included in the plan who will be responsible for her after the discharge since in the hospital the nurse will be responsible for medication administration. The person responsible should be either her children since they have high health literacy (Hesselink et al, 2015). Moreover, social support from family or friends is an essential factor when planning for discharge (Meyers et al, 2014). Since Elizabeth lives alone, it will be necessary to ensure that she is moved to a place where she has social support, probably with one of her children. The family will be advised to ensure that Elizabeth receives friends often after discharge because this will offer important emotional and social support (Meyers et al, 2014). Social-economic status is also another factor that impacts health (Hesselink et al, 2015). However in this case, Elizabeth seems to be able to afford the required healthcare. But it will be emphasised on her children to ensure Elizabeth always has access to required dietary requirements since diet impacts on one’s health. Age factor will also be considered when planning for the patient’s care. Elizabeth is an elderly patient and hence has some unique needs, such as decline in cognitive function and hence she will need an individual to attend to her and guide her in aspects such as medication adherence (Hesselink et al, 2015). Generally, Social determinants of health will play a big role in the patient’s post-discharge outcomes. Understanding of potential barriers and underlying assumptions to care Underlying assumptions to care Individuals from culturally and linguistically diverse backgrounds are prone to discriminative acts during delivery of care (Selli et al, 2016). For example, a nurse may have negative attitudes towards a particular cultural group and this may hinder care delivery. For instance, in this case study, some nurses may be having ethnocentrism where they view their culture as superior to Elizabeth’s and this may hinder care delivery. It is therefore important for nurses to be aware of how potential discrimination and ethnocentrism can inadvertently impact their care delivery. Ageism is another underlying assumption that is likely to affect delivery of care to the patient. Elizabeth is an elderly person and evidence shows that aged patients often experience discrimination during care delivery. According to Williams (2009) just like any type of discrimination, ageism is fuelled by pre-conceptions rooted on fear and these fears during social situations and interactions turn out to be discriminative practices. Selli et al (2016) attribute the discrimination according to age to be the unspoken emotional reactions and beliefs to innate fears of physical decline, death and isolation. Therefore, a nurse may not deliver appropriate care to the aged patients basing on these perceptions. According to Simkins (2008) ageism is a major problem that has a direct impact on the patient mortality. Evidence shows that positive self-perceptions of aging have key impact on lengthening lifespan (Simkins, 2008). Evidence also shows that ageism indirectly impacts patient outcomes. For instance, if a nurse discriminates Elizabeth basing on her old age, this can result to her exclusion as well as her resisting treatment (Simkins, 2008). Williams (2009) supports this and explains that ageism is a prevalent form of discrimination that directly and indirectly affects patients. This indicates that discrimination due to the patient’s age could be a barrier to care delivery. Potential barriers to care transition According to Naylor & Keating (2009), transitional care includes wide range of services and settings planned to promote safe and prompt passage of patients across care settings. For elderly patients with chronic condition like Elizabeth, high-quality transition care is very important for the patient and the family caregivers as well. Evidence indicates that poor “handoff” of the elderly people and their home carers from hospital to home is associated with adverse events, low satisfaction with care as well as high rate of re-hospitalisation (Naylor & Keating, 2009). According to (Nishita et al., 2008) there are several barriers associated with gaps in care during critical transitions. Some of the factors include poor communication, incomplete information transfer, insufficient education of older patients and their careers, poor access to crucial services, as well as lack of a single point individual to make sure there is continuity of care. Naylor & Keating (2009) adds that language and health literacy aspects along with cultural differences exacerbate the problem. In this case study, there are various factors that are likely to be barriers to successful transition of care. For example, incomplete and imprecise patient medication lists for Elizabeth may hinder successful transition of care. According to Hubbard & McNeill (2012) hospital personnel report several complexities that healthcare providers face in assembling a precise list of every patient’s prescription medication on a prompt and cost-effective basis. Therefore, in case the patient in this case is handled incomplete and inaccurate list of medication lists this could be a hindrance to successful transition. This is because the patient as well as care givers may understand the required mediation which can even lead to poor adherence to medications. In addition, the patient has been living alone and this may further worsen her adherence to medication. As a result, it would be necessary to ensure that the patient no longer stays alone and have sources of support who can be reminding her when to take her medications as well as attend the required rehabilitation programs. Elizabeth is an elderly adult and hence her cognitive function maybe declining and hence she needs a family care giver to manage her medications (Hubbard & McNeill, 2012). Nonetheless, as Hubbard & McNeill (2012) provide, not all patient have family carers who are close at hand and dedicated to care-giving and hence this can be a barrier to successful transition. It is therefore important to ensure that even through Elizabeth stays with a family member after discharge, a transitional care team continues to offer education and motivation after she leaves the hospital. This is supported by Zamanzadeh et al (2015) who explain that hospital is not the most effective place to educate patients and carers regarding medication management, because hospitalization experience might have weighed down both the patient and carers. Therefore, it is appropriate to ensure transition team follows up Elizabeth to educate her and her caregivers about medication management. Another potential barrier is difficulty scheduling opportune follow-up visits with primary care healthcare providers or community based specialists for the patient. This is because discharge planning and transitional care programs normally prioritise scheduling during patients’ hospitalization (Zamanzadeh et al, 2015). Appointment with patients’ primary care providers that happens soon following the discharge does not indicate how soon the visit supposed to occur. For instance, in this case study, there was no indication when Elizabeth would be visited by the primary care provider and this poses a potential barrier to successful transition. Evidence indicates that scheduling the first follow-up visits can be complex, due to the shortage of primary healthcare providers as well as the heavy workloads that community-based healthcare providers face (Cebeci & Çelik, 2008). This therefore results to pressure to find alternative means of reviewing patient’s medication fast, if need be, for example via more easily accessible clinicians. Elizabeth is underwent a complex medical procedure and hence needs careful monitoring from the primary healthcare provider (Cebeci & Çelik, 2008). Accordingly, the possibility of lack of the primary healthcare provider to follow up Elizabeth is a potential barrier to successful care transition. Lack of adequate education and counselling to the family caregivers is also a potential barrier to successful transition. According to Zamanzadeh et al (2015), family carers play an important role in supporting older people during their hospital admission and particularly after discharge. It is therefore important to ensure that the family carers are consistently engaged during decision making regarding discharge plans and quality of their preparation for the next phase of care. Evidence shows that this has been poor and therefore this presents a major barrier to Elizabeth’s successful care transition (Fredericks, 2009). In addition, even though care-giving can be gratifying, it also enforces burdens of family carers. The stress associated with care-giving has a likelihood of exacerbating during events of acute illness. Therefore, in case there are no nurses and social workers to attend to the emotional needs of Elizabeth’s carers during care transition, this can result to negative experiences as well as the carers not being able to adequately support their loved ones (Zamanzadeh et al, 2015). Finally, there is a barrier of lack of enough resources to ensure successful cardiac rehabilitation for Elizabeth. According to Mampuya (2012) cardiac rehabilitation is important in ensuring monitoring for the safe return to physical activities for the patient. The multidisciplinary strategy focuses on the patient education, personalised exercise training, adjustment of the risk factors as well as the overall wellbeing of the patient. Cardiac rehabilitation has been shown to be an effective means for the care of patients with heart disease (Bainbridge & Cheng, 2017). Elizabeth is a heart disease patient and hence for there to be successful transition of care it would be necessary to ensure that there are all available resources for successful patient’s recovery (Mampuya, 2012). Effective cardiac rehabilitation ensures the patient regains independence as well as improving on regular physical activities. In this case study, Elizabeth was recovering well even though she had increased breathlessness whenever she participated in physical and exercise activities. For there to be successful transition of care, it would be necessary to ensure that Elizabeth successfully regains normal breathing (Bainbridge & Cheng, 2017). More importantly, the cardiac rehabilitation program needs to ensure that all the modifiable risk factors are controlled. Elizabeth is on several medications and hence there will be need to ensure that there is optimization of all the prescribed medication as well as therapeutic education that stresses the significance of the measures of therapeutic life changes (Bainbridge & Cheng, 2017). Lack of enough resources can hinder presence of therapeutic education which needs to be a structured educational program through workshops to teach patients and their carers regarding their conditions. Such a program can ensure Elizabeth and her carers become responsible and autonomous for their treatment and lifestyle changes as well. In addition, lack of availability of professionals to manage the patients and carers psychosocial problems can hinder successful transition of care. Psychiatric problems such as anxiety are common after coronary procedures and are allied to fatigue and reduced quality of life (Chunta, 2009). Therefore, it would be important to ensure that the patient is availed with the appropriate psychosocial practitioners to help she learns stress management and additional self-control tools which consequently affects the control of the risk factors. Community resources According to Cowie et al (2012), effective long-term care is important for good outcomes for patients who have had an event of acute heart failure. This can be achieved through availing the appropriate resources to ensure a seamless transition after discharge from hospital. To ensure effective transition for Elizabeth, it would be necessary to ensure that Elizabeth has access to an effective disease management program; GPs and community nurses are available to follow up the patient following her discharge; availability of other practitioners to ensure the patient adopts appropriate self-management behaviours and that the patient and the family receive effective education and support (Cowie et al (2012). For Elizabeth, it should be ensured that there is a multidisciplinary healthcare team with a nominated coordinator available with the cardiac rehabilitation centre within the community for delivery of cardiac rehabilitation services (Kim et al, 2012). It should be ensured that Elizabeth is referred to such a cardiac rehabilitation program after her discharge and it should be functional with a fully trained healthcare provider. The available healthcare providers should have certification in medicine, physiotherapy, occupational therapy, psychology, social work, nutrition and even pharmacy to ensure that the patient receives multidisciplinary care services. The patient should also be referred to various support groups within the community. The support groups will help Elizabeth in coping with her condition because support groups consist of survivors and patients who are going through the same and hence they encourage each other (Zimmerman & Dabelko, 2007). This will be very important for her successful and smooth recovery. In addition, Elizabeth will receive encouragement regarding various factors she needs to modify in order to reduce the risk to heart attack. Of equal important is referring Elizabeth to counselling and physical activity programs within the community. Counselling will assist her emotionally and hence she will be better placed to cope with her condition (Zimmerman & Dabelko, 2007). In regard to physical activity programs, it will be necessary to ensure that she is supervised by a healthcare professional and aspects such as heart rate, blood pressure, respiratory rate and symptoms are monitored accordingly. Healthcare providers supervising the physical activity programs are supposed to have the most recent cardiopulmonary resuscitation certification (Zimmerman & Dabelko, 2007). Conclusion The essay focused on Mrs. Elizabeth, a 78 year woman who underwent femoral angioplasty. During the patient’s care planning, social determinants of health will play an important role her recovery. How factors such as health literacy, age, social-economic status will affect her recovery post-discharge has been discussed. In addition, potential barriers to care delivery will have been discussed as well as assumptions that may hinder delivery of effective care. Some assumptions include ageism where at times nurses have been discriminative towards aged patient. Elizabeth is an elderly patient and hence this is one factor that may hinder care delivery in her case. In conclusion, it would be necessary to refer Elizabeth to appropriate community services that will help her in her recovery. Reference List Bainbridge D & Cheng D, 2017, Current evidence on fast track cardiac recovery management, Eur Heart J Suppl, 19 (suppl_A): A3-A7. Cebeci F & Çelik S, 2008, Discharge training and counseling increase self-care ability and decrease post-discharge problems in CABG patients, Journal of Clinical Nursing, 17(1), pp:412-420. Cowie et al, 2014, Improving care for patients with acute heart failure: before, during and after hospitalization. ESE Heart Failure. 1(2), pp: 110–145. Fredericks S, 2009, Timing for delivering individualized patient education intervention to coronary artery bypass graft patients: A Randomized Controlled Trial, European Journal of Cardiovascular Nursing, 8(2),pp: 144-150. 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