Question

Ms. Ritter is a 32-year-old woman who visits the medical outpatient clinic to discuss her treatment options for breast cancer. She is married and has one child, a daughter, who is 6 years old. She and her husband hoped to have another child in the near future but now wonder if that will be possible. She shares with the nursing staff her concerns about the future and how cancer will affect her and her family. Identify two follow-up care plan components that would be important when considering Ms. Ritter's role as a wife and parent. 3. Ms. Ritter tells her nurse, “This chemotherapy has made me feel so tired, and there are many nights when I can't sleep very well. I'm looking forward to this ending.” What is an appropriate response the nurse might give Ms. Ritter? Cultural Awareness Ms. Jackson is a 44-year-old overweight woman who was diagnosed with diabetes 2 years ago and is now insulin dependent. In 2012 the company she worked for downsized, and Ms. Jackson lost her job. As a result she was unable to pay her mortgage and became homeless. Since then she has been staying with various family members and friends because she has not been able to afford her own apartment. She has been working as an office temp from time to time but has not been able to find full-time work. She arrived at the emergency department (ED) with a blood sugar of 322 (normal range is 80 to 120) and a hemoglobin A1C of 11% (normal is approximately 5%). Sam is a 23-year-old nursing student assigned to care for Ms. Jackson. After Sam reads Ms. Jackson's chart, she notices that she has come to the ED on several occasions over the past 6 months with the same issue. She also notices that health care providers who took care of Ms. Jackson during the previous visits documented that she verbalized an understanding of how to manage her diabetes but has been nonadherent with her treatment plan. After Sam conducts a cultural assessment using an explanatory model with questions, she learns that Ms. Jackson fears that she will eventually die because her mother died of diabetes. She also learns that Ms. Jackson cannot get her medications filled because she doesn't have health insurance. After obtaining this information, Sam consults with a social worker, who tells Sam about a community health center within eight blocks of the place where Ms. Jackson is currently living. This health center has a diabetes management program and can offer ongoing support to Ms. Jackson. Sam spends time with Ms. Jackson explaining that people do not die from diabetes if they manage it effectively. Sam also discusses with Ms. Jackson some realistic ways to manage her diabetes given her challenging circumstances. In addition, she escorts Ms. Jackson to the social worker's office so they can discuss possible housing and unemployment resources. Sam realizes that there is an opportunity for her to learn more about the social determinants of health that affect Ms. Jackson's ability to manage her care. She also realizes that by gaining skills in cultural competence she will be more confident in providing culturally competent care to her patients. 1. List some of the social determinants of health that Sam most likely discovered while conducting a cultural assessment with Ms. Jackson. 2. On the basis of a cultural assessment, Sam discovers that Ms. Jackson believes that she may die. Select the C-LARA communication mnemonic listed in this chapter and plot a discussion that might help Ms. Jackson understand that diabetes is a manageable chronic illness that does not have to result in death. 3. Ms. Jackson is discharged and returns to the ED several months later because she is having difficulty managing her diabetes again. You are assigned to care for her. How will her weight, history of nonadherence, and past visits to the ED possibly affect your treatment? How could these factors trigger biases and assumptions that will get in the way of providing quality care? How could self-awareness help you reduce the effect of bias on the quality of care you provide?

Answer 1

1.aMs. Ritter needs psychological support and counselling to relieve her fears and anxiety.

• After a woman has completed treatment for breast cancer , she may surely consider having children. Disease and prognostic concerns, age, fertility and infertility issues, social , ethical and financial issues should be considered.Most women are advised to wait for 2 years before conceiving .
• Eventhough cancer treatments can cause fertility loss in women , nowadays there are plenty of treatments available to preserve fertility such as embryo freezing , ovarian protection techniques, oocyte freezing, ovarian tissue cryopreservation followed by auto-transplantations ,ovarian tissue preservation,etc.
• Ms. Ritter being a mother of a 6 year old may need to balance between her needs and child needs. Being a patient undergoing chemotherapy she may be feeling drained, but Ms. Ritter has to find ways to keep her daughter and family happy. She can keep a make to do list , in which she can prioritize her goals and expectations leading to make herself emotionally fit and stable.

b. There are side effects for chemotherapy and it can be managed so well with women continuing their daily work and routine schedules.

• Fatigue related to cancer and insomnia , anxiety, nausea are common complaints in people with cancer treatment. These may alleviate or decrease in the coming months after the completion of treatment.
• Family support, socialization, practicing healthy lifestyle like moderate exercising , carrying out household routines , balanced diet may keep up her pace and mental stability in overcoming all the barriers in the way.

2. a .Ms Jackson has lost her daily earning due to loss of job and no home. She donot have insurance too. For living a quality life she needs housing and also necessary financial resources but she lacks all these. It is also possible that she does not have a primary care provider. Ms. Jackson's limited access to economic resources, Sam may also discover that Ms.Jackson may not have any chance to receive healthy food in her neighborhood. Often homelessness lead to difficulty affording or gaining access to health care. Ms. Jackson's unstable housing situation is hindering to prepare meals that would allow her to better manage her diabetes. Her overweight is perceived as non-adherent, Ms. Jackson may experience suggested or clear cut  bias from her health care providers. Her race and ethnicity could also have an impact on how her health care providers view her.

b. The communication pnemonic was given by an organisation .I have listed the pnemonic which is in the chapter.

C - Calm - calm yourself down, take a deep breath, check pulse
L - listen - to the patient and family's perspective
A - affirm - express connection when something is shared(feeling,perspective)
R - Respond - to what is said. Answer the question
A - Add - share additional information (to educate or clarify )

I have given a sample discussion between Sam and Ms. Jackson:

Sam: Ms. Jackson, Through the chart I come to know that you have a history of diabetes in your family.
Ms. Jackson: Mmm, Yeah .My mother had diabetes.
Sam: Oh. Is she with us now.
Ms. Jackson: No, she died from diabetes.
Sam: I am sorry . Losing a parent is never easy as she would have been your support. (affirmation)
Ms. Jackson: I miss my mom a lot. If she was there ,she would have done something to help me out., especially after I lost my home , I was really feeling very emotional.
Sam: I can get the picture of it. Ms. Jackson, I'm thinking how your mother's struggle with diabetes have affected your perception of diabetes as killer . It must be alarming to think that you have the same illness that led to her death. (affirmation)
Ms. Jackson: Yes, Im terrified whenever I get to think that. Every time when I visit the emergency department, I feel like she is waiting for me .
Sam: That makes a lot of sense to me. (affirmation) Diabetes is hereditary but through self-care activities,nutritional management, exercise you can overcome it (RESPONSE). Same time, diabetes can decrease the quality of life  . I would like to spend some time to acknowledge you about ways to manage your diabetes more effectively (add). I would like to introduce you to a diabetes educator, who can help you to find out more solutions to the challenges you face and empower you to overcome the situation. (add).

c. Every person has a unique belief and value system that has shaped at least in part by his / her cultural environment.Being a culturally competent nurse knowing the particular history of patient nurse should avoid imposing a personal value system knowing about patient's different point of view. Provide her psychological support and managed care. She can be referred to a social worker to improve her quality of life.