Question

Transcultural Nursing Case Study Worksheet Case Study Mrs. Dolores Hernandez is a 65 y/o obese, Cuban woman presented to your county clinic where you work as a FNP. She arrived to the clinic, with her grown daughter, Mariana, c/o weakness, lethargy, and fatigue x2 mos. She reports last week, while cooking at her daughter's house, she lost her balance and slipped on the kitchen floor. She denies LOC, and admits to only a mild bruise on her leg. She arrived in clinic with Mariana who insisted that she goes to the clinic for her persistent sxs. Mrs. Hernandez is widowed x4 yrs. Her husband died of a heart attack. She lives with Mariana since then. Mariana is 40 y/o. and employed FT as a supervisor at the local phone company. She also has a retail job, after work, about 3-4 times/wk. Mariana is divorced and has three children: Luis, 15, Carmen, 10 and Sophia, 7. Since moving to Mariana's house, Mrs. H has been managing the household while Mariana works two jobs. Mrs. H prepares the family's meals, attends to the children when they come home from school, and do light housekeeping chores. The family is originally from Cuba, has been living in SF for 12 yrs. Luis was born in Cuba, and the other two children in Miami. Mrs. H does not speak English. Although the children and Mariana occasionally speak English among themselves, the family's language at home is Spanish. Today, she was diagnosed with essential HTN and DM2. You prescribed an oral hypoglycemic med and advised Mrs. H to exercise daily and to limit her food intake to 1500 calories/day. Mrs. H is concerned as she usually prepares traditional Cuban meals at home and was not sure whether she could tolerate being on a diet. Besides she thought that her dishes are very "healthy." She added that her three grandchildren are all plump, nice looking, and healthy. You overheard Mrs. H tell Mariana that instead of buying the prescribed med, perhaps she should go to the botanica and obtain some herbs that would help her lower her blood sugar. Directions Complete the SOAP-Format Medical Plan for Mrs. H on page 2 of this worksheet. The following requirements apply: • You must apply Leininger’s theory and Change Theory as you complete the plan. • Your completed plan should be about 1-page in length. • You must use the SOAP format • Each of the following sections should only include information pertinent to that section: o The subjective part of SOAP note has been provided for you. o The objective part of SOAP note has been provided for you. o The assessment part of SOAP note should include: at least three medical diagnoses (not nursing diagnoses). Please note that the only items that belong in the assessment section of the SOAP note are diagnoses (e.g. 1. Broken femur; 2. Underweight; 3. Osteoporosis). o The plan part of SOAP note should include a plan for each of the diagnoses from the assessment section (e.g. 1. Cast, rest, pain medication prn; 2. Referral to dietician and increased dietary intake; and so on). SOAP-Format Medical Plan Subjective: 65 y/o obese, Spanish speaking, Cuban woman presented to clinic with adult daughter, Mariana with CC of weakness, lethargy and fatigue x2 mos. Reports lost balance and fell on kitchen floor last week, while cooking. Denies LOC. c/o mild bruise on leg. Pt with persistent sxs and Mariana has insisted on pt to go to clinic. PMH: Denies known history of (h/o) heart, lungs, DM, asthma or cancer (CA) MEDS: Herbs (unknown) NKDA FH: Widowed x4 yrs. Husband died of MI Lives with Mariana Takes care of 3 school-aged grandchildren SH: Denies ETOH, tobacco or illicit drug use ROS: (Abbreviated for this case study) Pulm: Denies SOB, DOE CV: Denies CP, heart palpitations Of note: Mariana interpreting for pt as requested by pt. Objective: VS: 37.8 – 88 – 20 – 140/80 – 98% RA 8/10 Constitutiional: A&Ox4, obese, NAD Skin: 2x2 maroon colored macula on RLE, otherwise intact HEENT: NCAT, PERRLA, Pulm: CTAB CV: RRR, S1S2, neg M/R/G. Skin warm & dry. GI: + bowels, round, obese, NT GU: defered Neuro: A&Ox4, CNII-XII grossly intact Assessment: Plan: (Please apply Leininger’s and change). Questions Answer the following questions after writing your SOAP-Format Medial Plan. Provide specific examples of how you would apply Leininger’s theory and Change Theory to this patient’s situation. The key is demonstrating that you can apply theory to a real-life situation. For example, it is not sufficient to write “I would provide culturally sensitive care”. State specifically what you would do, say, or recommend in order to provide that care and explain how your actions represent an application of the theory.

1. How did you apply Leininger’s theory to this patient situation? [Type response here]

2. How did you apply the Change theory to this patient situation? [Type response here]

3. What are some actions you would take to address cultural competency in this type of situation? [Type response here]

Answer 1

SOAP format Medical Plan -

Subjective and Objective part is already provided. We will move to assessment plan.

Assessment - She has been diagnosed with hypertension and diabetes mellitus. Her fasting and post prandial blood values should be checked so that dose of oral hypoglycemic drug can be decided. An ECG and X ray chest is advised to see if hypertension is longstanding. Lipid profile is advisable considering weight and other risk factors of blood pressure and sugar problem. HB A1C needs to be checked to see average blood sugar value of last 3 months.She is obese. So her BMI needs to be assessed. Weight management plan should include periodic weight reduction goals. She complains of weakness,lethargy and weakness. Need to evaluate her for hypothyroidism,so her T3,T4,TSH needs to be assessed. Her Hb level needs to be assessed to rule out anaemia.

Plan - Here we will apply Leininger's theory.

Q1 - Applying Leininger's theory means providing culturally congruent care by through congnitive based assistive,supportive acts which are tailored in such a way that it suiys particular individual or group's cultural values and beliefs. Here the family is from Cuba and staying in SF. Her cooking style is traditionally Spanish. She also believes in botanical herbs to control sugar instead of medicalization. She herself is obese.

My plan would include to keep her cultural values intact. I won't ask her to leave her traditional cooking habits entirely. I will tell her to make few changes which she can adopt easily. Like making salt restricted diet. Use less spice and butter. Avoid sweets. While making food for children also,she needs to restrict spices,butter as kids are plump. Physical exercise is advised. At least start with 20 mins walk daily. I will tell her that her belief about botanical herb's use for lowering sugar is without any clinical evidence. If that was the case,several oral hypoglycemic drugs wouldn't have been used globally. I will tell her to have faith in doctor's advice. Her concepts of healthy food need to be reworked. I will tell her that Cuban food is good food but we need to make certain changes to make it more healthy like limit calories, avoid yellow bulk of egg,avoid butter,spices etc. This way we won't her cultural beliefs but will customise it to suit her health requirements.

2. Change theory - To make changes, first the patient should realise that change is needed. Secondly, there should be willingness to go ahead with change. At this stage patient may have some doubts. Thirdly, patient should be ready for implementation. Here the patient wasn't ready to go to clinic and her daughter brought her to clinic. As a nurse, I would do her counseling about her health condition. I will tell her briefly about illness and tell her that with simple medication,diet and exercise ,she can control it. If she has anxiety about making her diet compliant to health requirements, I will tell her to follow simple things,instead of changing whole diet. Like no sweets. Salt restrictions. Avoid butter. Have small frequent meals. Go for daily walk of 30 mins. She doesn't want to go for medication for lowering sugar,but wants to use some herbs. I will advise her to go for medication as use of herbs in lowering sugar has no clinical evidence. I will also boost her confidence so that she will adopt these changes.

3.To make sure cultural competency, I will first analyse the beliefs which are carried by patient. She cooks traditional Cuban food which she thinks is healthy. Her grandchildren are plump and healthy. She believes in botanical herbs to lower sugars. I will counsell her first so that psychologically ,she is comfortable to accept change. Being plump is not healthy. She is also obese and has blood pressure and diabetes. So instead of changing whole cooking habits,I will simply tell her to make small changes like reduce salt,spices. No sweets in diet. Restrict butter in cooking. Use brown rice and bread. Have small frequent small meals. Go for daily walk. This way she doesn't have to leave her traditional cooking style which she loves. It is just some small changes which she can easily adapt. Also I will tell her to use oral hypoglycemic agents to lower sugar instead of botanical herbs as for botanical herb's use,there are no clinical evidences but for oral hypoglycemic drugs,there are proven results.

Psychological counseling is required to make lifestyle changes. She needs to do exercise and walk. She needs to accept that the illness is present and she can overcome it with simple measures.