Mrs. James family Case study
Mrs. James has a sore ankle that has been there for the past several weeks. It does not really hurt all that much, but she has been unable to get it heal. The cashier at the convenience store tells Mrs. James she should use butter to help heal wounds, because it keeps the wound moist and helps to enhance healing.
Mrs. James decided to follow the advice of her friend (the cashier at the convenience store) and has been applying butter to her wound for about one week. The wound does not seem to getting any better, in fact it looks a little worse, so Mrs. James stops the butter treatment. She knows she should get an appointment with her health-care provider, but when she calls to make an appointment, she is told that the physician she likes is out of the office on vacation for the next two weeks. She has heard about a nurse clinic at the Neighborhood senior Centre not far from her home, but has never been to the centre because she does not perceive herself to be old. Mrs. James decides to continue treating the wound herself. Mrs. James family Case study.
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Mrs. James’ wound continue to look progressively worse, it now a yellowish drainage and the skin around the wound has become red. Her foot also now hurts when she walks on it. She goes to the emergency room early in the morning. After sitting in the waiting room for four hours, Mrs. James tells the ER receptionist that she has better things to do than sit in a waiting room all day. She decides to go to the Senior Centre just this once to see if the nurse at the clinic will look at her leg Mrs. James family Case study.
At the Senior Centre nurse clinic, Mrs. James meets Karen, a geriatric clinical nurse specialist. Karen takes a short history and checks Mrs. James’s vital signs and glucose levels. Mrs. James is unable to recall all of the medications that she takes. After looking at the wound, Karen tell Mrs. James that she must see her physician. Karen makes an appointment for that day and arranges a ride for Mrs. James through the Senior Centre. Before leaving, Karen suggests to Mrs. James that she come back to see her next week and bring a list of medications that she takes. Mrs. James also learns from Karen that free lunch is served at the Senior Centre.
At her physician’s office, Mrs. James is told that her foot is infected and will require antibiotic treatment and dressing changes. The office staff arranges for Mrs. James to have a home care nurse make daily visits for IV antibiotic therapy and dressing changes for 10 days . The nurse and physician both note that her blood pressure and glucose level are somewhat elevated, but they assume the change is related to the infection and pain.
Mrs. James completes her 10-day dose of antibiotic therapy. The wound is no longer painful and is beginning to heal. She has a follow-up visit at her physician’s office and is instructed to continue with daily wound care. The office nurse talks with Mrs. James about the need for medication adherence to limit the effects of her diabetes. The nurse asks her if she has any problems with her medications. Mrs. James says she has no problems, she just doesn’t always take her medication. Mrs. James family Case study.
Mrs. James decides to go back to the Senior Centre nurse clinic to see the nurse because she likes Karen and wants to show her that her leg is healing. Karen checks her vitals and glucose level, noting that both are elevated. Karen looks at the leg and can see that the wound is healing. Mrs. James forgets to bring the list of medications she is currently taking, so Karen talks with her about how she obtains her medications and how she keeps them organized. Karen gives Mrs. James a diabetes and foot care brochure and asks her to bring a list of the medications she takes on her next visit. Mrs. James is in a Hurry to leave so she can get the free Senior Centre lunch.
Mrs. James was planning to go back to the Senior Centre this week to see the nurse, but she didn’t like what was on the lunch menu for that day. She is scheduled for another follow-up visit at her physician’s office, but elects not to go because it is raining hard on the day of her appointment and she does not want to be out in the weather.
Mrs. James is on her way out the door to go to the Senior Centre for lunch and to see the nurse when one of her cats gets out. She spends the next hour waiting by the window for the cat to come back. She is worried that the cat will be killed by a car or a dog and is mad that she is going to miss the lunch that day. When the cat comes back to the front door, Mrs. James is relieved and decides she needs to stay home the rest of the day to take care of her cats.
Mrs. James finally makes it back to see Karen at the Senior Centre nursing clinic. Her vital signs are checked (blood pressure, 126/92 mm Hg, blood glucose, 16 mmol/L), and Karen asks Mrs. James about her medication list (which she has not brought along with her). When examining Mrs. James’ feet, Karen notices that her shoes are in poor shapes, the edges of her shoes have been cut down and covered with cotton balls and tape. The nurse talks to her about the need for shoes that fit and suggests that she check at the senior Centre for help with obtaining properly fitting shoes. Karen also notes that the wound on her leg has almost completely healed. Mrs. James family Case study.
Mrs. James goes to the Senior Centre with the intention of getting lunch, but instead wanders into a leather craft class. She sits down and begins to work with the leather. She listens to some of the other women in the class and is annoyed at all their chatter, especially one lady named Mary Martin. She likes the leather craft activity, but does not like interacting with the women there.
Mrs. James gets a notice in the mail from the city, stating that the bushes in her front yard are encroaching on the street blocking the view. The notice states she has 30 days to cut back the branches or pay the city to remove the brush and potentially face a city fine. This makes Mrs. James very upset, because she knows she can’t just go out and cut down bushes at her age. She asks a neighbor to help her cut the bushes back. A few days later she sees a teenager in her yard doing the work, but Mrs. James does not go out to talk to him or thank him. She wonders if he is in a gang and is not sure he can be trusted.
Mrs. James runs out of her glucotrol, and when she calls the drugstore to get it refilled, she is informed that her prescription has expired. Mrs. James goes to the Senior Centre nursing clinic the following day to see Karen and explains her situation. Vitals and blood glucose are measured (blood glucose, 14 mmol/L). Karen calls the physician’s office , the nurse is able to get a list of Mrs. James medications and dosages, as well as the names of her cardiologist and gynecologist. Karen also sees that Mrs. James is still wearing the same shoes as the last visit.
Karen also talks with Mrs. James about her prescription drug benefits. Mrs. James indicates she received something in the mail some time ago, but did not understand what is was and threw it away. Mrs. James family Case study.
Mrs. James has become a regular at the Senior Centre on days the nurse is in the clinic. She has come to trust Karen and, in fact, considers her a friend. Over time, she has become more open to discussing personal matters. Mrs. James tells Karen in detail things about her cats and some of her neighbors’ . When questioned about her sons and whether they are available to help, Mrs. James explains that her sons don’t like her very much , but they would help if she needed them to. She goes on to mention that they are very busy and they know she does not need their help.
The Senior Centre is sponsoring a weekend trip by bus to a nearby provincial park. Although a fee is required, the cost is minimal. Karen (the nurse at the Senior Centre) tells Mrs. James about the trip and suggests that she go on the outing. Mrs. James tells Karen she has already seen all those parks before, and if she go on a bus trip she would have to listen to all the women chatter. She tells Karen, It’s bad enough to listen to them at lunch. I can’t imagine listening to them for days. Mrs. James also reminds Karen that she could never leave her cats alone for that length of time.
Mrs. James goes to the drugstore to get her prescriptions refilled. When she gets there, she is told that her co-payment for the prescriptions (Coumadin and digoxin) is $ 20. This makes Mrs. James very angry. She demands to know why the co- pay has changed and is told it is due to changes in the insurance plan. Although she has the money, Mrs. James decides not to pick up the prescription. Instead, she goes to the grocery store to buy a new carton of cigarettes anf then to the Senior Centre for lunch. She dreads it when she walks into the Senior centre and sees Mary Martin, the lady who talks too much. She glares at Mary as she walks past her and sits at a table by herself so she doesn’t have to listen to Mary talk.
One of Mrs. James’s cats dies this week. Mrs. James is so devastated that she does not leave the house for several days. She buries the cat in her backyard near the graves of her other deceased cats. She covers up the area with rocks to prevent a dog from coming along digging her kitty up.
On Tuesday morning, Mrs. James wakes up about 7 a.m. She does not feel right, but is not sure why. Her sight arm feels tingly and somewhat numb. She feeds her cats and decides to go back to bed. At 9 a.m. she wakes up again. When she tries to sit up, her right arm feels very heavy. When she tries to stand up, her right leg also feels heavy, making it difficult to walk, she can’t seem to get her leg support her.
Mrs. James wonders if the diabetes has caused her blood glucose levels to drop. She navigates to the kitchen and checks her glucose, noting it is 14. She decides to eat some breakfast, thinking she will better soon. Mrs. James begins to get worried when her symptoms don’t subside. At about 10:30 a.m. she calls her neighbor on the phone, explains the situation, and asks her to come over to help her. The neighbor tells Mrs. James to call 9-1-1 because she will have to pay for the ambulance; she decides to wait for her neighbor to take her to the hospital Mrs. James family Case study.
The neighbor arrives at Mrs. James’ home at about 10:50. By this time, Mrs. James is talking, but not making any sense. The weakness on her right side has become even worse, to the point at which Mrs. James is unable to walk. The neighbor (believing Mrs. James called 9-1-1) is hopeful the ambulance will show up soon. By 11 a.m., the neighbor decides to call 9-1-1 and ask about the ambulance; she learns that a previous call was not made. An ambulance arrives shortly thereafter and takes Mrs. James to neighborhood Hospital. She arrives in the emergency room about 11:35. She is treated by Dr. Gordon, who determines that she is having a stroke. Mrs. James is admitted to the medical-surgical unit.
Mrs. James remains at the Neighborhood Hospital. She has had a difficult week. Because of swallowing difficulty, a feeding tube was placed, and tube feeding was initiated. She has ongoing issues with nausea and abdominal fullness. Additionally, she has been experiencing diarrhea; she has had two episodes of fecal incontinence because she was unable to get the nursing staff to answer her call light. She is unable to ambulate independently at this time. Mrs. James family Case study.
Mrs. James also develops an elevated temperature and confusion before anyone notices that urine in her Foley bag is cloudy. A urinalysis (UA) and culture and sensitivity (C&S) test confirm that she has a urinary tract infection
She has become very depressed and has taken a very passive role in her care; she wants the nurses to just take care of all of her needs. She continues to experience expressive aphasia and is embarrassed about the way she sounds. Mrs. James’ son, Brian comes to see her at the hospital this week. She barely speaks to him the entire time he is there. He only stays for a few days to take care of few things at her home. Brian leaves his contact information with the nursing staff in case the need to contact him for anything. Mrs. James feels angry about the entire situation, and she is unhappy with the general inconsistency in the care she has received. One of the nurses she really does not like is Bobby. She does not find him to be nice or caring at all.
This week, Mrs. James is transferred to the Neighborhood Rehabilitation Centre. Because of ongoing swallowing difficulties, a percutaneous endoscopic gastrostomy (PEG) tube is inserted for continued tube feedings shortly before she is transferred.
At the Rehabilitation Centre, she works with physical, speech and occupational therapists. She continues to have little to no motivation for improvement. Mrs. James is pleased when Karen (the nurse from the Senior Centre) comes to visit her. She tells Karen what a horrible experience this has been. Karen, who is aware that Mrs. James has been very passive, tells her she needs to work on getting better so she can go home to take care of her cats. If she fails to improve, she might be placed in a nursing home. Mrs. James tells Karen that the cats are probably all dead by now and that there is no point in going home. Karen assures Mrs. James that her son, Brian, placed them in a boarding facility and that they are being well cared for. This information provides a spark in Mrs. James, and she now has a reason to get better; her cats need to be rescued from inhumane treatment they are probably receiving at the boarding facility. Mrs. James family Case study.
Mrs. James remains at the Neighborhood Rehabilitation Centre. She is making excellent progress and has regained much of her mobility. She continues to work with the staff to regain her ability to independently carry out activities of daily living (ADL) skills.
Mrs. James remains at the Neighborhood Rehabilitation Centre and continues to progress in her mobility speech and swallowing.
Arrangements are being made for Mrs. James to be transferred home. Because of her ongoing care needs, her son, Brian, has agreed to spend up to a month with his mother in the role of caregiver while she makes the transition home.
Brian James has returned to the Neighborhood and spends several days making the necessary arrangements for her discharge. Among the arrangements are making home modifications ( such as rails and seat for the shower), obtaining equipment (wheelchair, walker, and grab bars) , making appointments for follow-up physician visits and ongoing outpatient physical therapy, and figuring out her medication regimen. Because Mrs. James has prescriptions from several physicians, it takes Brian several days to figure out which are current and which are not. Additionally, Brian finds a box of medications in her home; it seems that Mrs. James hoarding medications for years. Brian throws all the old medications away and buys a pill box to help his mother keep her medications organized. Mrs. James family Case study.
Mrs. James is very glad to come home and thrilled to see her cats. She is so thankful that Brian rescued them. Although she is glad Brian has come to help her, she immediately begins to criticize many of the things he has done. She really did not want those ugly bars placed in the shower; he should have asked her first. She is also angry when she learns that he threw her box of medication away and that her won’t buy her cigarettes. At the same time, Mrs. James does not understand why her sons have ignored her for so many years.
Mrs. James’ son remains at her home caring for her, taking her to her various appointments, and enduring a constant barrage of criticism. He is highly motivated to get his mother back to functional independence so he can go home.
Mrs. James has become accustomed to having her son Brian help with things around the house. He literally takes care of everything for her, and she has come to expect him to do everything for her. Although she is very appreciative of his efforts, Mrs. James has a hard time openly acknowledging this and usually praises him through the eyes of her cats. You are a very good cat master, she tells him.
Mrs. James has finished her outpatient physical therapy. Brian tells his mother that he will be leaving soon, but before he goes, he wants her to prove to him that she is safe living on her own. Brian levels with his mother and tells her that, if she is unable to do so, they might have to consider assisted living options. Mrs. James is furious with this and is determined to show Brian that she is capable of living on her own and that she does not need him.
Mrs. James, accompanied by her son Brian, walks to the grocery store to do some shopping. It is her first time to the store since her hospitalization. Brian evaluates her ability to get to the store, make purchases, and get home from the store. He is impressed by her determination and stamina, despite changes in mobility. Mrs. James decides not to even try to buy the cigarettes she craves; she figures Brian will be leaving soon enough. Nest, they go to the drugstore to get fresh refills on all of her medications.
At home, Mrs. James makes all three meals for several days in a row, takes care of all the household chores, and is able to get to the toilet, get dressed, and bather herself without any assistance. She has learned to keep her medications organized and checks her glucose twice a day. During this week, she gives hints to Brian that he could help out, but he just sits and watches her. Mrs. James wonders aloud how she ever raised such a lazy son.
Brian heads home this week after the long stay with his mother. Mrs. James is deeply saddened to see him go, but keeps a stiff upper lip when he leaves. She tells him she is tired of having him there and wants the house to herself now; she has many things to do. Brian knows his mother all too well and gives her a hug as he goes out the door.
Mrs. James readjusts to her new life. She is able to do most things, but it takes her longer. She finds the house quiet and lonely since Brian has left, although her cats keep her company. Mrs. James has avoided going to the Senior Centre because she believes everyone will talk about her. Her son Brian calls her to ask how things are going; she tells Brian she just fine and doesn’t need anything Mrs. James family Case study.
Mrs. James decides to go see Karen, the nurse at the Senior Centre. She is glad no one is with the nurse when she arrives. Karen measures her blood pressure at 120/78 mm Hg and her glucose at 12 mmol/L. Mrs. James enjoys visiting with her for 15 minutes before being interrupted by a stupid old man who wants to see Karen. Mrs. James wanders out to the main room and finds a group of ladies playing cards. They invite her to join them. Mrs. James tells them she can only stay for a few minutes because she has other things to do, but ends up staying for the entire afternoon. They suggest she join them again the following week
Mrs. James decides not to join the ladies at the Senior Centre for cards, but she goes for lunch twice this week. She wonders why she has not heard from Brian lately and decides to call him. They talk for a short while, and Mrs. James tells him about the ladies asking her to join them in card games. Brian encourages her to join them again sometime soon.
Mrs. James sees Karen at the Senior Centre again this week. She is annoyed when Karen asks her about her medications and glucose measurements because she just wants to visit. However, because she is self managing her disease better, Mrs. James is able to recall her medications and her most recent glucose readings. She isn’t sure when she should be going back to see her physicians, however, Karen checks her blood pressure and finds it to be 118/82 mm Hg; glucose is 11mmol/L. Mrs. James family Case study.
Mrs. James sees the card-playing ladies at the Senior Centre this week and is again invited to join them, She spends most of the afternoon playing cards and finds that she can beat them easily because they spend all their time talking to one another as opposed to paying attention to the cards in their hands.
Mrs. James is invited to spend a week at the home of her son Brian and his family. Brian has offered to drive to her home, board her cats in a kennel and then drive her to his home several hours away. Mrs. James is reluctant to leave her home and her cats. However, because it has been years since she last visited her grandchildren, she is anxious to see them. Mrs. James agrees to visit Brian and spends the rest of the week getting ready to go.
Mrs. James is out of town visiting her son Brian this week. Mrs. James family Case study