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Introduction

The case study is of a 76-year-old female, a native of Vanuatu. Maureen and her husband, Peter, relocated to Australia after the birth of their first child, Mark. Maureen and Peter have strong Christian faith and brought their children up in the Christian faith and taught them to respect Vanuatu culture and beliefs. Maureen has a past medical history of peptic ulcer, stroke resulting in moderate left arm and leg weakness, Alzheimer’s disease and also experiences recurrent UTIs, osteoarthritis, and hypertension. Before her husband's death, Maureen was able to maintain a reasonable level of functional ability. Two elder children of Maureen Mark (50 years) and Karen (47 years) are married and used to live in their families. However, Maureen's youngest daughter, Lisa (43 years), who is unmarried and has no children now lives with Maureen. Lisa is her Financial Enduring Power of Attorney (EPOA) and primary carer. The current study will critique the care provided to Maureen by using high-quality evidence, the CPG, the National Palliative Care Standards and either the NMBA or NSQHS standards. Four identified episodes of care in the case of Maureen are: the first episode of care was appointing community nurses to assist her with showering and providing a walking stick, the second episode of care was assessing vital signs and medication, the third episode of care was to discharged home with daily community nurse support, and the fourth episode of care was to admitting Maureen to hospice for her end-of-life.

Main paragraph

Episode of Care 1

Maureen’s first episode of care was appointing community nurses to assist her with showering and providing a walking stick when she experienced a fall at home. As mentioned in the case study, Maureen has a medical history of shock, which resulted in moderate weakness in her left arm and leg weakness. Due to the stroke, the daily functioning of Maureen was affected; however, her husband Peter helped her to maintain a reasonable level of functional ability. The care provided to Moreen during the first admission was positive as she was in need of assistance to prevent further episodes of falls. During this first episode of care, the nurse was able to follow the NMBA standard 1.1. As nurses accessed, analyzed and used the best available evidence to provide safe, appropriate and responsive quality nursing practice (NMBA, 2023). However, in the current case study, Maureen did not follow Domain 1 of CPG, i.e., structure and processes to get safe and quality care (CPG, 2018). Appointing community nurses to provide assistance to Maureen was not satisfactory other members of the interdisciplinary team should be appointed

To maintain her functionality, nurses could have been provided with the discharge plan. Maureen could have been advised to visit a physical therapist for stroke recovery. A physical therapist could help her by creating a personalized exercise program to help improve strength, balance, and coordination in the affected limbs (Wasti et al., 2021). As mentioned in the case study, Peter assisted her in her daily living activities; instead, an occupational therapist could have been appointed to help her relearn daily activities like dressing, bathing, and eating. Adaptive equipment or techniques could be recommended to make these activities more manageable (Confronto et al., 2022). Further, incidents which were experienced by Maureen, like experiencing a fall at home, could have been prevented if proper rehabilitation had been provided during the first episode of stroke. To follow the NMBA Standard 6.1, nurses provided comprehensive and quality practice to identify and report potential and actual risks related to the patient (NMBA, 2023). In the case of Maureen, nurses could have identified the risks associated with Maureen's reduced functional ability, like disturbed performance of daily activity and increased risk of falls. By taking into consideration these risks nurses could have provided a discharge plan to achieve the agreed goals to follow standard 3 of the National Palliative Care standard (Palliative Care Australia, 2018).

Episode of Care 2

Maureen’s second episode of care was assessing vital signs and medication. Her admission two was a positive element of care as Maureen was in need of urgent medical care. The positive aspects include that Maureen received prompt medical attention after being found in the flood by her daughter Lisa. The quick response is crucial in the case of a fall, as it helps to address any potential injuries or underlying medical issues (Lach et al., 2023). Her vital signs were a matter of concern. Her respiration rate was high, her blood pressure was low, 115/68, and she had 13/15 GCS. The positive aspect was that Maureen's vital signs were assessed, and appropriate actions were taken to address her symptoms (Johnston et al., 2019). Integration of vital signs measurement into the fall risk assessment system have an enormous importance. Vital signs serve as a baseline for future comparisons. Regular monitoring of vital signs in the aftermath of a fall can help track the patient’s progress and determine the effectiveness of treatment and rehabilitation efforts. In the case of Maureen, the baseline vital signs provided essential information about her health status upon admission. The change in vital signs, particularly Maureen’s increasing temperature (38.9◦C to 39◦C), increased heart rate, and decreased GCS score, served as important indicators of a worsening condition. Following the identification of Leucocytes+++ and Protein+++ in the urine dipstick analysis, Maureen was stated on oral antibiotics.

Like the nurses administered paracetamol and for the treatment of UTI antibiotics and Panadol were continued. According to the NMBA Standard 1.1, nurses should access, analyze and use the best available evidence, which includes research findings for safe quality practice (NMBA, 2023). This standard was followed by the appointed was registered nurses they recognized the need for a urinalysis and started Maureen on oral antibiotics when the UTI was diagnosed, indicating a commitment to addressing her medical conditions. During this episode of care the actions taken by the registered nurse were appreciable as she tried to identify who Lisa is and promote Lisa's involvement in her care (Sattar et al., 2019).

However, some improvements could have been made in this second episode of care, like Maureen becoming agitated when she was speaking a different language (Bislama). There were possibilities that the RN faced difficulties in understanding her language. So, the healthcare providers could have appointed the RN who can understand the Bislama language to ensure cultural competency in her care plan (Cerveny et al., 2021). Despite medical attention and treatment, it was noted that Maureen’s capacity for functional improvement plateaued during her admission, and she continued to require assistance (Dorsch et al., 2019). More attention needs to be provided to maintain her functional ability, like appointing a physiotherapist instead of just providing assistance (de Sousa et al., 2019). Maureen's episode of care also highlights the negative aspect of cognitive decline. Her agitation, incoherent speech, and confusion about her caregivers is indicative of her deteriorating cognitive function. The nurses should have followed the NSQHS standard 8 to ensure that Mauren’s acute deterioration was recognized promptly and appropriate actions were taken (NSQHS, 2018). As mentioned in the case study, Mauren has a medical history of Alzheimer's disease and later the diagnosis of vascular dementia, indicating appropriate actions were not taken by the healthcare team. The RN should follow the NSQHS standard 4 to comprehensively conduct assessments and provide a clear and appropriate care plan (NSQHS, 2018).

Episode of Care 3

The third episode of care was to be discharged home with daily community nurse support. However, the third episode of care appeared to be negative as after two weeks of being discharged at home, Maureen fell when Lisa was at the grocery store. This time, the fall results in some severe consequences including neck of femur fracture (#NOF). The third of episode of care included the discussion about the surgery to repair Maureen's #NOF. Respecting and honouring a patient's wishes and values is a fundamental principle of patient-centred care. As mentioned in the case study, Lisa found an Advanced Care Directive that stated that Maureen did not wish to have invasive measures or surgery if she fell or declined. Unfortunately, a similar incident happened when Mauren needed surgery to repair #NOF. The care provided to Maureen during her third hospital stay was positive. Firstly, the registered nurses did not conduct the full pain assessment and assumed the pain was related to Maureen’s #NOF. Although the RN gave her paracetamol and contacted the doctor to seek an order for additional analgesia, but it could not be considered as the proper care. When Lisa requested for surgery the healthcare team respected and honoured Maureen's Advanced Care Directive by declining the surgery. Lisa’s surprise and difficulty in comprehending Maureen’s condition and prognosis of Alzheimer’s disease may be seen as a negative aspect. It indicated a gap in communication and support in helping family members understand and cope with Mauren’s condition (Dixon et al., 2019).

Some of the improvements that have been identified in the case study is to conduct proper pain assessment. Conducting a pain assessment is the first step in effectively managing a patient’s pain. It allows healthcare providers to understand the nature, intensity, location, and triggers of pain, which are essential for selecting appropriate pain management strategies (Dixon et al., 2019). The RN should have conducted a pain assessment to tailor interventions according to the patient’s unique needs and to ensure personalized care. Effective pain management is associated with significantly improved outcomes, while poor pain control predisposes patients with hip fractures to delirium. As Lisa was surprised and facing difficulty in comprehending Mauree’s condition and prognosis. Proper education and support should be provided to Lisa and other family members to help them understand and cope with Maureen's condition (Dizdarevic et al., 2019). Maureen requested to speak to her church minister, the healthcare staff should have allowed her to meet the church minister. The involvement of her church minister could have ensured cultural competence in the care plan and provided spiritual support to her (Kaihlanen et al., 2019). The RN should have followed the NMBA Standard 2.1, which states to engage in therapeutic and professional relationships. By using this standard, RNs can show respect to Maureen's culture, values, beliefs and rights (NMBA et al., 2023).

Episode of Care 4

The fourth episode of care was to admitting Maureen to hospice for her end-of-life palliative care. As mentioned in the case study Maureen’s children were in conflict to make decisions for her care plan. Maureen's daughter, Lisa, wanted to continue to care for Maureen at the family home and agreed for extra services to be put in place to support her. However, his elder son Karen was highly opposed to Maureen being discharged home. The fact that Karen opposes the surgery for Maureen's #NOF, while Lisa requested it, highlights a family disagreement. Family conflicts and differences of opinion can be challenging and may negatively impact the decision-making process (Laryionava & Winkler, 2021). The act of not involving Maureen and her son Mark indicates a breach of Standard 2 of National Palliative Care Standards (Palliative Care Australia. (2018). According to this standard, healthcare professionals should provide up-to-date information to the patient and their family to support informed participants in care planning and decision-making. However, when healthcare professionals conducted the family meeting to resolve the family meeting, Maureen and her other son, Mark, were not involved (Singh et al., 2023).

Improvements were required in the fourth episode of care to promote Maureen's engagement in advance care planning. This involves discussing and documenting their preferences regarding medical interventions, end-of-life care, and other important decisions. The RN should follow Standard 6 of NSQHS, i.e., use effective communication and documentation to support continuous, coordinated and safe care for patients (NSQHS, 2021). By using effective communication skills, the RN should foster open and honest communication with Maureen. Provide her with clear and understandable information about their condition, prognosis, and available care options and encourage her to ask questions and express their concerns (Becqué et al., 2021). The RN should follow and develop a plan by using assessment data and the best available evidence. The RN should consider Maureen's cultural, religious, and spiritual beliefs and incorporate these values into the care plan and involve relevant spiritual or religious leaders as desired by Maureen. The RN should offer emotional support and counselling to help Maureen and her family to cope with the emotional challenges of palliative care (Singh et al., 2023). According to Standard 7 of the National Palliative Care Standard, to promote the effectiveness of palliative care, social workers, psychologists, or palliative care specialists could have been appointed (Palliative Care Australia, 2018).

Conclusion

It can be concluded that all these four episodes of care can overlap and vary depending on the specific medical condition of Maureen. These episodes of care highlight the different phases in Maureen's healthcare journey, from preventive and chronic disease management to acute care, transitional care, and ultimately, end-of-life care. The implication of NMBA and NSQHS standards demonstrates the importance of delivering safe care, the significant role of the family, and the challenges in making care decisions for Maureen. 

The involvement of patients and their family members can support informed decisions about the care plan. Family involvement in the current case study of Maureen is a positive aspect, as it reflects a desire to provide care and assistance to the patient (Sattar et al., 2019). According to the NMBA Standard 1, nurses should access, analyses and use the best available evidence, which includes research findings for safe quality practice (NMBA, 2023). This standard was followed by the appointed was the registered nurses they recognized the need for a urinalysis and started Maureen on oral antibiotics when the UTI was diagnosed, indicating a commitment to addressing her medical conditions. During this episode of care the actions taken by the registered nurse were appreciable as she tried to identify who Lisa is and promote Lisa's involvement in her care (Sattar et al., 2019).

References

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