Critical Analysis of a Second Selected Scenario from Caseworld

Introduction

The case chosen for the purposes of this paper is that of Elizabeth Rose Green, a 78-year-old woman living alone in her house. Elizabeth’s medical record is replete with diseases and surgeries, including gastro-oesophageal reflux disease, hypertension, hypercholesterolemia, osteoarthritis, diabetes mellitus type 2, and hysterectomy. Most recently, she was hospitalized with unrelenting chest pain and had angioplasty thereupon. The present paper endeavours to identify the potential barriers to effective planning for the transition of care for Elizabeth Rose Green. Before proceeding with the discussion of barriers, the author will briefly recapitulate Ms Green’s case. Basing further discussion on this brief synopsis of Ms Green’s case, the paper will assess the adequacy of information provided in the case study and identify what further information might be needed to develop an effective post-hospitalisation care for the patient. It will also explain in the process how assumptions about pathophysiological, psychological, cultural, spiritual and social processes held by nurses can influence the provision of care for post-angioplasty patients with long-term care needs in a community or extended care setting, drawing on the case of Elizabeth Rose Green. The bottom line is straightforward: information contained in the Elizabeth Rose Green’s case is descriptive enough to design an effective plan for the transition of care for the patient. Apropos the impact of assumptions held by nurses in the provision of care, it is little, yet not negligent.

Critical Analysis

Background

Before proceeding with a critical analysis of information contained in the patient’s case, it would be logical to briefly recapitulate it. Thus, Elizabeth Rose Green is a retired widow who dwells in a ground floor unit. She has two children and three grandchildren, all of whom are very supportive. However, they all live some distance away from Elizabeth and can visit her only on weekends. Elizabeth leads a generally sedentary, albeit not reclusive, life, as most people of her age are wont to do. Her children have hired a private cleaner to help Elizabeth with chores around the house once a week. She also uses a taxi for transportation. Elizabeth loves animals and she has a terrier cross named Matilda.

Elizabeth has a disturbing medical history, including gastro-oesophageal reflux disease, hypertension, hypercholesterolemia, osteoarthritis, and diabetes mellitus type 2. Moreover, she went through hysterectomy when she was 48 years old. What is more appalling, chronic disease seems to run in Elizabeth family. Her deceased mother had cardiac disease and her deceased father rheumatic fever, which triggered an array of health problems throughout his life. Her deceased sister had breast cancer. These medical records suggest, albeit inconclusively, that Elizabeth Rose Green may be also prone to chronic maladies. To the boot of that all, Elizabeth was an inveterate smoker, but she quit five years. Until recently, the patient reported good health, as for a person of her age, but nevertheless used a 5-point list of medications.

Prior to hospitalisation, Elizabeth experienced occasional episodes of chest pain, but they quickly lapsed. She was hospitalised after a long-lasting bout of excruciating pain in her central chest area and left shoulder that reportedly frightened her. On her way to the hospital, Elizabeth was given a loading dose of IV Morphine, and the intravenous glyceryl trinitrate (GTN) infusion was soon commenced. Upon her assessment by a cardiac specialist in the emergency department, Elizabeth was transferred to the Cardiovascular Investigation Unit for an angiogram plus or minus stenting. A femoral angioplasty was performed thereupon, stenting a blockage in Elizabeth’s left anterior descending artery.  The recovery process following procedure began immediately, according to the well-established 4-hour immobilisation rule, which is considered the best medical practice for angioplasty patients.

Barriers to Designing an Effective Post-Hospitalization Care Programme

Angioplasty is a generally harmless procedure that does not require complex post-hospitalization rehabilitation. Cardiac rehabilitation programme is recommended, but not compulsory (Morgan & Walser 2010). However, this does not mean that post-angioplasty patients should be left to fend for themselves without attention. In line with the generally accepted standard, Elizabeth remained in the cardiac care unit overnight for doctors to make sure that she was recuperating well from her recent surgery. Elizabeth woke up early in the morning and reportedly felt energetic and enthusiastic. Still, she had a shower with standby assistance because of slight dizziness. After a series of appointments and conversations with the hospital staff, Elizabeth was ready for her family to drive her home. It is in this context that the first and, perhaps, greatest barrier to transferring care for Elizabeth comes into place. Indeed, as mentioned in the case study, Elizabeth lives alone and her children can visit her only on weekends. She will not be able to fend for herself without the help of her children. Moreover, it is imperative that there should be someone beside Elizabeth all the time to control her physical activity. While this barrier has the potential to thwart the recovery process, it can be easily eliminated. Her children could take a leave or, alternatively, hire a house-sitter to attend to Elizabeth’s needs for a week. Even though the patient would be able to return to her previous physical activity or even outstrip it, she needs more than one week of attention, ideally (Morgan & Walser 2010). For example, even if she can delay her yard work for an indefinite period of time, her dog needs walking and grooming.

There are several other risks associated with Elizabeth being left alone in her house. It is recommended that the patient should be vigilant upon his/her release from the hospital. For example, it is advisable that Elizabeth should check her groin several times a day for any drainage from the catheterization site and her legs for redness, increased tenderness or hematomas (Moeini, Moradpour, Babaei, Rafieian & Khosravi 2010). As a matter of fact, some swelling at the tube insertion site could be observed in Elizabeth immediately after angioplasty. This means that the patient should be checked for other complications on a regular basis (Schmilowski & Swanton 2012). Likewise, the catheterization site should be checked for bleeding regularly, especially during physical activity (Moeini et al. 2010). While Elizabeth would hardly be able to measure her blood pressure or circulation in her legs, she would certainly have no problems with checking her heart rate, provided that she is willing to check it. This simple move could help her control her physical activity, thereby preventing any complications (Schmilowski & Swanton 2012). Also, it is possible that the woman would need assistance in dressing the wound site with a pressure dressing before performing activities.

Although Elizabeth is an old and responsible person, the absence of a caregiver could potentially lead to a situation where Elizabeth would forget to take her medicine, which is yet another potential barrier to her post-hospitalization and recovery (Schmilowski & Swanton 2012). The fact that she has been prescribed some new medications and the dosage of some of her old medications has been raised also amplifies the risk that she will forget to take them on time. This confusing welter of prescriptions and dosages has the potential to obfuscate Ms Green, so that she could either take a wrong dose of a particular drug or forget about it altogether. Another associated risk is that there will be no one who would drive Elizabeth to her cardiac rehabilitation programme in the hospital. However, bearing in mind that Elizabeth prefers to use taxi, as mentioned in the case study, this is a problem more phantom than real.

On the other hand, Elizabeth’s obstinacy and willingness to tolerate pain, as evinced by her previous chest pain episodes, is yet another potential barrier to transferring care for the woman. Indeed, it was not a rarity in the past that Elizabeth experienced episodes of chest pain, but did not report them to her cardiologist, because she knew the pain would subside in several minutes. However, now when she has to be extra-attentive to her condition, monitoring all the changes that take place, procrastination in reporting them may complicate her condition. The list of possible complications runs the gamut from myocardial infarction and arrhythmia to restenosis and beyond (Morgan & Walser 2010). Luckily for the patient, these complications are rare. Yet, given her age, the risks are higher (Morgan & Walser 2010). The patient needs also to be educated that a certain amount of bruising at the catheterization may be disregarded, but extensive bruising requires the patient’s attention (Morgan & Walser 2010). By the same token, the fact that Elizabeth may be blasé about the symptoms means that she would be reluctant to keep a recovery diary, where she would write down her experiences to share them later with her general practitioner.

The patient’s age merits special attention when discussing barriers to post-hospitalization care. Thus, although angioplasty is a minimally invasive procedure, it nevertheless can bring about some unpleasant symptoms and sensations in patients, as mentioned before. In this context, it is important that the patient should be able to distinguish symptoms that are normal during the recovery process and symptoms that signal complications (Morgan & Walser 2010). Whereas light tiredness is inherent in the recovery process, rapid onset of weakness is a warning signal (Morgan & Walser 2010). It is a matter of conventional wisdom that human energy wanes as the years wax, meaning that Elisabeth could have commonly experienced such symptoms even before angioplasty. Thus, Elizabeth’s age can serve as a barrier, preventing her from differentiating between different symptoms. Although the case study provides a great deal of information about the state of Elizabeth’s health before her recent angioplasty, it does not mention a word about her “threshold of tiredness”. Nonetheless, it is generally accepted that post-angioplasty patients who are above 75 years, have diabetes and problems with the cardiac pumping function are at higher risk of complications (Antoniucci 2009). Elizabeth has all these symptoms, which, therefore, pose an additional barrier to designing an effective post-hospitalization care programme for her. Additional precautions might need to be taken to ensure Elizabeth’s recovery post-angioplasty.

Interestingly, unhealthy food slows down the post-angioplasty recovery process (Lilley, Collins & Snyder 2014). Conversely, a healthy diet has the capacity to accelerate the recovery process, albeit not very substantially. Designing an effective personalized diet plan that would exclude particular foods is the responsibility of the general practitioner, but the ultimate responsibility for the efficiency of this plan rests with the patients, for they need to adhere strictly to the designed plan (Lilley, Collins & Snyder 2014). Evidently, for Elizabeth to be able to comply with her personalized diet plan, if any, she would need somebody to bring groceries and control her protein and fat intakes. Again, the fact that she lives alone may pose additional obstacles to transferring care for her.

One possible implication of angioplasty is that the patient may lose his/her appetite (Lilley, Collins & Snyder 2014). It is not stated in Elizabeth’s case study if she has had any problems with appetite following her angioplasty. Thus, additional information about Elizabeth’s appetite is needed to design an effective post-hospitalization care programme for her. If she has lost her appetite, measures must be taken to stimulate it. As an alternative, the patient should be encouraged to eat in small helpings throughout the day (Lilley, Collins & Snyder 2014).

As important as the previously discussed aspects are for Elizabeth’s post-hospitalization care, they recede into background relative to designing a healthy angioplasty exercise plan for Elizabeth. It is imperative the person in charge of designing a post-hospitalization care programme for Elizabeth should strike a delicate balance between immobilisation and physical exercise for Elizabeth, for both components are needed for her speedy recovery (Frontera, Slovik & Dawson 2006). The generally accepted rule is that the patient should gradually increase his/her physical activity. The importance of gradual increase in activities after angioplasty should not be underestimated. Once angioplasty has been performed, the patient’s heart has “a much better blood and oxygen supply”, and the patient feels stronger and more energetic (Bath, Bohin, Jones & Scarle 2009, p. 50). However, to increase fitness and preclude potential risks and problems, activities should be performed gradually. Thus, post-angioplasty patients are encouraged to avoid strenuous exercise, such as heavy lifting and most sports, for five to seven days.

For older people, the recommendation is that they should avoid strenuous exercise for about one month (Frontera, Slovik & Dawson 2006). Likewise, it is recommended that such patients should not overtax themselves during bowel movements to prevent haemorrhage at the catheter insertion site. At the same time, it is evident that post-angioplasty patients should not stay in bed all the time. They should take walks and engage in other similarly easy activities, because gradual exercise helps develop the strength of the heart. This is the reason why slight arm movements are encouraged by all doctors immediately after angioplasty, even though patients are required to stay in bed for several hours in accordance with the early-mobilisation rule (Frontera, Slovik & Dawson 2006). Clearly, a healthy angioplasty exercise plan for Elisabeth Rose Green should not be demanding, so that it would not strain her circulatory system and, therefore, would not invite further complications. While the information contained in Elizabeth’s case study is sufficient to set an angioplasty exercise plan for her, the absence of caregivers beside the patient may stultify her recovery progress.

Finally, it should be mentioned that lack of moral support for Elizabeth may also hinder her recovery process. Anxiety and stress increase risks of complications (Antoniucci 2009), so some sort of meditation as well as psychological consolation, conversations with relatives and other related sources of moral support are needed. On the positive side, Elizabeth has a pet, which can offer at least a certain amount of emotional consolation to her in times of distress.

The Impact of Assumptions and Stereotypes on the Quality of Care

From the perspective of pathophysiology, information contained in the case study is generally sufficient to design an effective post-hospitalization care program for Elizabeth. However, whereas the case study covers the ongoing medical treatment of Elizabeth, it offers little information about the psychological, cultural, socioeconomic and spiritual domains. When such information is scarce, some nurses may resort to commonly held assumptions, thereby creating additional hurdles to the transition of care for the patient – hurdles that are difficult to overcome. Indeed, there is a wealth of research that shows how stereotypes can influence the provision of care for patients (Koutoukidis, Stainton & Hughson 2012; Berman, Snyder, Kozier & Erb 2014). For example, health beliefs vary from culture to culture, thereby making cultural sensitivity crucial for designing an effective post-hospitalization care programme for people belonging to different cultures (Berman et al. 2014). Consequently, it appears that assumptions based on stereotypical or outright erroneous understanding of cultural differences can affect the quality of nursing care. The same can be said about psychological, socioeconomic and spiritual domains of healthcare.

However, it is difficult to determine whether nurses responsible for the development of the post-hospitalization care programme for Elizabeth Rose Green are likely to make assumptions about her. Judging by the information available at her case study, it appears that Elizabeth quit smoking five years ago when she was 73. However, it is not indicated in the case study when she began smoking. Also, it is stated that she weighs 80 kilograms. Considering that her height is 155 centimeters, that weight is somewhat excessive. On the face of things, it seems that some nurses have grounds to make assumptions about Elizabeth based on the commonly held stereotypes about overweight and addictive people. For example, nurses could perceive Elizabeth negatively because of the popular stereotype, albeit not completely without grounds, that people are always responsible for their health (Blonna, Loschiavo & Watter 2011). In doing so, they would blithely ignore the role of social, structural and other factors. Yet, even the most assumption-prone nurses who eagerly revel in stereotypes and indiscriminately attach stigma to patients would probably make a reservation about Elizabeth’s age. Indeed, it may be a veritable ordeal for a person of her age to control weight, and most nurses must understand this.

Other than that, however, there is a paucity of information in the patient’s case study that could help to understand which assumptions about Elizabeth nurses are likely to make. Indeed, it is not stated in her personal details if she is white or black. Similarly, her socioeconomic circumstances are unclear. At the same time, this uncertainty combined with some facts from the case study could give way to new assumptions. For example, latching onto the fact that Elizabeth is visited by a private cleaner only once a week, a nurse could assume that she is pecuniarily embarrassed, while in fact she may have simply been able to do other tasks on her own until she was hospitalized. This assumption would be especially dangerous in the context of designing a healthy angioplasty diet for Elizabeth, as nurses could try to fit it to her perceived “pecuniarily embarrassed” circumstances. Conversely, assuming that a person is richer than he/she in fact is may also stultify setting of a healthy angioplasty diet, as nurse may fail to consider socioeconomic factors that limit the choices of the patient.

Conclusion

On the whole, the present paper has shown that information contained in Elizabeth’s case study is detailed enough for nurses to be able to design an effective post-hospitalization care programme for her, including an angioplasty exercise plan and personalized diet plan. Among the most evident barriers to designing such programme and, hence, to Elizabeth’s recovery may become the hermetic atmosphere in which the patient is forced to live. Indeed, Elizabeth’s recovery process would depend largely on the presence of some of her relatives or, at least, other caregiver to offer her psychological support, monitor her condition and control her compliance with the designed care programme. Some minor details that need to be clarified to improve a post-hospitalization care programmed for the patient are her pre-hospitalization “threshold of tiredness” and her current appetite.

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