This case study is a home visit with Ms. Sallie Mae who is an 82-year old widowed female patient, who lives alone and was recently discharged from the hospital for exacerbation of her congestive heart failure (CHF) with breathing difficulties, weight gain of 8-pounds, and pain in the chest. Ms. Sallie also has a diagnosis of irregular rapid heart rate and high blood pressure for which she takes medications for. Four problems with substantiating evidence will be addressed in this case study after the patient has been assessed, also medical and/or nursing interventions would be discussed with rationales that will improve the patient’s overall health.
Problems Identified
The problems identified are a risk of fall and potential for injury at home, depression related to loss of a loved one and loneliness, impaired social interaction or lack of support system, non-compliance with prescribed oxygen therapy, and medication system risk related to absent medication reconciliation before discharge, polypharmacy and multiple medication adverse effects.
Non-Compliance to Prescribed Oxygen Therapy
Ms. Sallie Mae’s discharge instructions include home oxygen therapy at 2 liters via nasal cannula as needed, to be delivered by the medical equipment company and company to educate the patient on how to use it. However, the patient declined this treatment because she does not know that with heart failure, her heart muscles might be weak and not able to pump blood the way they normally would which means that her body doesn’t get the oxygen it needs leading to damage to her heart and brain. She thinks that she takes a lot of medications already and she also voiced concerns over the cost. Ms. Sallie Mae will need to be educated on her medical diagnosis, signs and symptoms, and treatment.
By making sure that Ms. Sallie has adequate information on her disease process and management strategies, she may be more compliant with her care (Gulanick & Myers, 2011). The collaboration of care with the oxygen supplier after obtaining patient permission would help to reestablish this care plan. A home follow-up visit with the nurse to evaluate compliance and provide support after one week is recommended.
Impaired Social Interaction or Lack of Support System
Ms. Sallie Mae is widowed and lives alone since the death of her husband whom she misses so much. She does have a daughter who is busy with her family issues and work, so her support system is very limited. Social support is one of the social determinants for overall health in the general population, and there is a higher chance of depression diagnosis among people that lack social support (Grav, Hellzèn, Romild, & Stordal, 2012). Because of Ms. Sallie Mae’s lack of support system, a home health aide/weekly nursing home visit is recommended to assist with ADLs, medication check and adherence, meal preparation, other light duties, and psychosocial support.
Risk of Fall and Potential for Injury at Home
A patient is an elderly person who lives alone with multiple medications to be taken. There is a mess in her house with some papers on the floor and uncomfortable furniture placement that can put the woman at risk of fall and injury at home. She has evident troubles while navigating the room in her intentions to open the door. According to Laflamme, Monárrez-Espino, Johnell, Elling, and Möller (2015), medication use remains one of the modifiable risks for falls among older people, especially, if there is no specific control from a professionally prepared nurse.
She does not even inform her nurse about new drugs being bought by Sallie Mae’s daughter and added to her treatment plan without doctoral approval. Finally, she denies taking oxygen therapies because of personal unwillingness to do it thus promoting fall risks due to dehydration and the lack of oxygen.
Depression Related to Loss of a Loved One and Loneliness
Sallie Mae feels lonely during a certain period after she lost her husband who was a good friend of hers. The unexpected death of a loved person is usually characterized by the development of depression symptoms which are hard to recognize because they resemble grief (Keyes et al., 2014). As the patient lives alone, it is impossible to identify symptom duration. Sallie does not like to accept support and continues living with depression isolating herself and avoiding communication even during her regular assessments. She does neither clean up in the room and nor see her friends. She feels normal not to follow recommendations given to her by a healthcare professional but admits that she has some health problems that bother her. In other words, she understands that something goes wrong but is not ready to deal with it, proving her depression and loneliness.
Scripted Dialogue
Nurse (N): Good morning, Sallie Mae, my name is INSERT THE NAME, and I will be your nurse.
Sallie Mae (SM): Good morning, INSERT THE NAME, I am glad to see you in my home.
N: It is my pleasure to assist you in dealing with your current health condition. As far as I see, you experience depression problems, congestive heart failure with breathing difficulties, weight gain, and chest pain.
SM: Oh God! Is it really dangerous and I can see my dear husband soon?
N: Sorry to admit, but God does not want this meeting to happen soon, and I am here to postpone it as far as possible. Hope you are ok with such a plan.
SM: I guess I am…
N: Do not worry, your treatment is not too complex, and it is easy for you to cope with several tasks. First, can you tell me if there is anyone who can stay with you and assist for some time?
SM: I think I do not have such a person after my husband’s death. He was a good and kind person, and I miss him so much. We have a daughter, but she works hard and spends a lot of time in the city.
N: Ok, then, I will develop a plan with a nurse being your main support. We have a great team of healthcare experts who are ready to cooperate with you if you do not mind.
SM: I would like to try this type of cooperation.
N: First, the task is to stabilize your physical condition, and, to achieve this goal, you should follow the already prescribed oxygen therapy. The recommended amount of oxygen has to be received every day to avoid serious heart complications or even fatal outcomes. The nurse will follow you taking at least two liters per minute during the next several months.
SM: Ok, no excuses for missing oxygen therapy. It is high time to find someplace in the room for a balloon.
N: By the way, about your place. The nurse is not responsible for cleaning up the house, and it is your responsibility to keep order at your place. Sallie Mae, dear, you have enough powers to take several simple steps and find the necessary place for all the stuff around. You may be visited by your friends and healthcare workers, and it is not quite right to meet them under such conditions. In addition, it is a good physical exercise that can help you deal with your current problems.
SM: I understand, but it is so difficult for me to complete this work. I am not motivated enough, and I do not think anyone can visit me within the next several weeks.
N: You have to move and do something. Therefore, these “cleaning” exercises are for you to try your skills and abilities, and the nurse will check your achievements. The next step is to take medications carefully. All discharges have to be approved by a doctor. It is quite dangerous to make independent decisions in your case because side effects and misuse can be lethal.
SM: Agree, hope the nurse will help me deal with that mess on my table.
N: Of course, she does. Finally, your appetite. No canned food is allowed. It is time to buy some fruits and dairy products. You can watch TV and observe a variety of products available to modern people. Options are impressive, and healthy eating is one of the main recommendations I can give at this moment. It helps improve your heart-related problems and control weight with time.
SM: Oxygen therapy, healthy eating, no extra medications, and physical exercises under nurse control.
N: You are correct. Hope this plan will change the situation soon. I will visit you regularly to report on your latest achievements. At this moment, we are done with the plan. I hope for your cooperation. Have a good day. Goodbye.
SM: Thank you, bye.
References
Grav, S.1., Hellzèn, O., Romild, U., & Stordal, E. (2012). Association between social support and depression in the general population: The HUNT study, a cross-sectional survey. Journal of Clinical Nursing, 21(1-2), 111-20. Web.
Gulanick, M., & Myers, J. (2011). Nursing care plans diagnoses, interventions, and outcomes (7th ed.). Web.
Keyes, K. M., Pratt, C., Galea, S., McLaughlin, K. A., Koenen, K. C., & Shear, M. K. (2014). The burden of loss: Unexpected death of a loved one and psychiatric disorders across the life course in a national study. American Journal of Psychiatry, 171(8), 864-871. Web.
Laflamme, L., Monárrez-Espino, J., Johnell, K., Elling, B., & Möller, J. (2015). Type, number or both? A population-based matched case-control study on the risk of fall injuries among older people and number of medications beyond fall-inducing drugs. PLOS ONE, 10(3), 1-12. Web.