Case Study: Mr and Mrs Walters

BACKGROUND

When Ellen was hospitalized, Michael reported that prior to the stroke Ellen was becoming increasingly vague and was displaying short term memory deficits. Ellen had a lack of insight with regards to her physical and memory abilities and would often leave the house during the day – when Michael was at work he had received phone calls from Ellen stating she taken the bus to the main shopping centre but was not sure not sure how to get home.

Michael is semi-retired and works 2 days a week – during COVID restrictions he started to work from home and does not plan to return to the office. Michael feels that he needs to stay at home as he is concerned about Ellen’s lack of insight and her safety related to mobility (they have stairs in their house) and cooking. Michael is reluctant to ‘restrict ‘Ellen as she becomes upset if she feels people are treating her as a ‘child’.

Michael takes Ellen in for regular check-ups with the GP, as Ellen deteriorates, Michael has noticed the GP is talking more to him about Ellen’s condition than to Ellen directly. Something which Ellen can often notice – and this also upsets her. Michael worries that Ellen has not completely realised the extent of her own health situation.

Ellen is a non-smoker and does not drink alcohol. She has no allergies. Ellen walks with an heirloom walking stick and has as uneven gait, she was discharged with a 4-prong stick but does not want to use it as it as it ‘looks ugly’.

Her right hand and arm can become swollen if ‘dependent’ – Ellen also does not like to wear any supportive devices and finds the compression garment for her arm too restrictive, as a result her arm is often swollen and sore.

MOBILITY

Ellen walks with an heirloom walking stick and has as uneven gait, she was discharged with a 4-prong stick but does not want to use it as it as it ‘looks ugly’. Her right hand and arm can become swollen if ‘dependent’ – Ellen also does not like to wear any supportive devices and finds the compression garment for her arm too restrictive, as a result her arm is often swollen and sore.

HYGIENE

The bathroom has been modified with rails and the shower is sperate from the bath. A shower chair was supplied on discharge – but Ellen does not like to use it – she gets upset if she feels Michael is ‘supervising’ her in the shower as she wants to attend to her own hygiene.

Michael usually waits outside the bathroom door until Ellen is finished and comes in to assist with dressing – he has noticed that Ellen has had difficulty washing her hair and her genital area and he has occasionally noticed an unpleasant odour on her clothes and most of the time when he is attending to the washing. He has also noticed urine on her underclothing– but he has not felt comfortable discussing it with her as when he has previously tried to discuss this Ellen became very upset.

NUTRITION/EATING

Michael has taken over all the cooking from Ellen. He can make basic meals such as spaghetti bolognaise, steak and salad, but struggles to find variety, the meals are high in carbohydrates – which has not been good for his weight. This diet does not seem to make a difference to Ellen, who seems to have lost interest in eating.

Ellen did most of the cooking throughout their marriage and does offer advice, but this tends to make Michael flustered as he does not feel he is doing a good enough job.

LEISURE/SOCIAL LIFE

Ellen used to be quite active in her garden before her physical condition deteriorated and used to make preserves and chutneys with the fruit they grew. Ellen is also a devout Catholic and since her most recent admission to hospital she has received a monthly visit from her local priest. Her husband is not religious but knows how important Ellen’s faith is to her.

Ellen is a member of a local gardening club and often helped at a local community garden however she seems to have lost interest in this as well– as she is concerned about what other people will think about her and concerned that she won’t be able to do some of the activities she has done before.

FAMILY

Ellen and Michael have three adult children, Maria (35), Sarah (33) and Simon (29). Maria lives in the United Kingdom with her partner and her two children. Due to recent COVID restrictions they have not seen her for more than 2years. Sarah lives same suburb as Ellen and Michael and is a single mother with three children.

Sarah separated from her husband 3 years ago – the children have no contact with their father. She tries to help Michael with Ellen’s care as much as she can, but her time is limited. Simon works in the mines at Mt Isa as a fly-in-fly-out (FIFO) mining consultant. He is based in Townsville but again the COVID restrictions have limited visiting opportunities – Simon has a visit planned for his next break.

MICHAEL

Michael had a mild heart attack at 62. He takes Atorvastatin (80mg) at night, Metoprolol (100mg) twice a day and Aspirin (100mg) in the morning. Since taking over the cooking from Ellen, Michael has admitted he isn’t eating as well as he should be and admits to drinking several beers on a weekend.

Michael has taken on most of the household work; however, he has arthritis in his hips and finds the burden of housework, maintenance, and his home business quite demanding. Lately he reports he has started to experience some chest pain and he wonders how much longer he is going to be able to look after Ellen.

FINANCIAL

Ellen used to work as an administration officer but retired at after her initial dementia diagnosis. Michael is an electrician and owns his own business: he has two employees. Since Ellen’s condition has worsened he has considered selling his business to one of his employees to free up some cash and make more time to care for Ellen. Michael knows that as Ellen gets worse there may be more health bills in the future.

Though he knows his business is in reasonable financial health, he isn’t sure it is enough, and he worries where the extra money will come from. They have not quite paid off their mortgage and have started to draw on Ellen’s modest superannuation fund. Ellen and Michael also contribute to the rent of their daughter Sarah, who can only work part time

HOME ENVIRONMENT

Michael and Ellen live in a four-bedroom two storey house with an internal staircase. The carpeted bedrooms and tiled bathroom are on the top floor, with the kitchen, living, dining, office, and laundry on the ground floor.

Outside there is a concrete walkway up to the front door that has settled unevenly over the years. There are no home modifications at present. The bathroom has a bathtub and stand-up separate shower.

The house sits on a quarter acre block with a mature garden. Michael tries to keep the grass down but it’s getting harder to find the time maintain the garden. Snakes are a common occurrence in the area during summer and Michael is concerned that this is a dangerous situation – given Ellen likes to work in the garden and the grandchildren visit regularly.

Topic Learning Outcomes

LO1: Build on knowledge of pathophysiological, psychological, cultural, spiritual, and social processes to develop long term person – centred care plans.

LO2: Formulate mechanisms to evaluate the self – management knowledge and skills of a person with complex care needs.

LO3: Formulate mechanisms to utilise technology to provide evidenced – based care and promote person – centred – self management strategies

THE ASSIGNMENT

Part A you will have the opportunity to demonstrate the general knowledge you have gained through the topic, regarding the following concepts,

Chronic conditions and complex needs and the link to hospital avoidance
Structural (biopsychosocial) enablers and barriers to people living well at home
The role of the nurse in supporting person-centred self-management in the home

Part B you will apply this knowledge to a specific case Mrs & Mr Walters – identifying person-centred care needs that may support them to remain living well at home

TASK 1

Chronic conditions / complex needs and hospital avoidance

Discuss your understanding of the link between chronic health conditions, complex needs, hospital avoidance and living well at home.
Consider the perspective of

o Person centred / self-management
o Australian healthcare system

Support your critical thinking with health statistics and current evidenced based research publications – hint National strategic framework for chronic conditions (2017)

TASK 2

Biopsychosocial barriers

• Identify and one ‘sociological’ barrier to hospital avoidance and person- centred self– management in the person’s home.

o Briefly describe – in your own words, your understanding of the sociological
concept of ‘structure & agency’

o Choose either Ageism or Social Capital

Briefly describe the chosen sociological concept – do not use a direct
quotation – you can give general examples to assist your explanation.

Describe how this sociological concept can lead to ‘structural’ barriers
that can impact the ‘agency’ of people living with chronic conditions.

o Support the discussion with current evidenced based resources – use
sociological resources (hint: they are in the readings list) to reference the
discussion

TASK 3

• Describe the role of the Registered Nurse working in the community in supporting people living with chronic conditions to live well at home.

• Include your understanding of person -centred care and critical allyship (hint: the resource is in the reading list)– make appropriate links to the NMBA RN Standards of practice

You are the RN working in a general practice in that Mrs & Mr Walters attend. They have come to the practice asking for support. The GP asks you to speak with them both to identify what their person-centred self-management needs are. You are asked to then develop a plan that will allow them both to remain living at home and highlight some of the community support options available to them. Mr & Mrs Walters have given consent for you to use their first names.

TASK 4

Identify 2 person-centred support needs for the case person and their family that will promote self-management in the home.

o Discuss the rationale for the chosen support needs

o Briefly discuss some of the barriers to person centred self-management in the home for Mrs & Mr Walters

o Discuss how these support needs can be enabled including which
(organisational & or multidisciplinary) resources need to be engaged – for this
case person

o Support the discussion with current evidenced based research publications
(required)