Comprehensive Palliative Nursing Care: A Critical Analysis of Maureen’s Case

Students are required to review and critique the care given in a case study. You are not critiquing evidence, the CPG, or the standards. The critique of care is to be based on:

1) Contemporary evidence-based literature and

2) The End-of-Life Care Clinical Practice Guideline (CPG) and

3) The National Palliative Care Standards and

4) The Nursing and Midwifery Board of Australia (NMBA) standards OR the National Safety and Quality Health Service (NSQHS) standards.

A critique is not a description of care or the case study. A critique involves analysing the care, interpreting the care, assessing the care, identifying positives and negatives (what was done well and not so well and why) and offering suggestions for improvement.

Students are to critique four (4) episodes of care. These can be positive or

negative elements.

An “episode of care” is any time that care was provided. This could be an assessment, a nursing intervention, a referral to another service, or even an omission of care. Episodes of care can reflect themes, such as communication, assessment, symptom management, cultural/spiritual needs, family needs etc.

Case Study:

Background:

Maureen is a 76-year-old female, a native of Vanuatu, was brought up with two parents and her three siblings. Maureen’s upbringing was family orientated and she was fortunate to be well educated. Maureen is multi-lingual and is proficient in English, French, Bislama and Oceanic. Maureen completed her primary and secondary schooling in Luganville, Vanuatu. After secondary school, she was

awarded a scholarship to study in Fiji and graduated as a Community Nurse. Maureen worked as a school nurse in the local Presbyterian school when she returned to Luganville.



Social History:

Maureen met her husband, Peter Jones, an Australian National whilst working at the school in Luganville. The couple relocated to Australia after the birth of their first child Mark. Maureen and Peter had two further children, Karen, and Lisa. The family lived in the suburbs of Melbourne and made yearly trips back to Vanuatu to visit Maureen’s family. These family trips continued until the children were young

adults.



Spirituality:

Maureen is a daughter of a Presbyterian missionary and consequently was brought up with a strong Christian faith. Maureen and Peter brought their children up in the Christian faith and made sure their children practiced not only Christianity, but also Vanuatu culture and beliefs.



Cultural:

Like Australian Aboriginal narrative customs, the culture of Vanuatu embraces myths and legends. Storytelling, songs, and dances are important forms of communication and form these traditional tales. The story of Vanuatu’s history and landscapes are at the forefront. Art is a fundamental part of the social life and ritual celebrations. The Vanuatu culture respect the land and pay homage to the past and present custodians. Maureen, through inheritance remains a custodian of the land that her family once owned. This remains very important to Maureen.



Life in Australia:

Whilst the children were young, Maureen upgraded her qualification from Fiji that enabled her to hold Nursing registration in Australia. Maureen gained employment at the local Community Health Centre as a Community Nurse. Maureen initially found it difficult settling into life in Australia, being away from her family and her local Presbyterian community. Peter encouraged Maureen to engage in the church community in Australia. Maureen formed many friendships though the church in the Melbourne suburbs. Maureen was often volunteering her time at the local congregation by sharing her love of cooking especially sharing the traditional dishes of Vanuatu. Maureen’s love of cooking has been passed on to both her

daughters. When Maureen and Peter retired, they engaged in more voluntary activities in the Pacific region through charity organisations and would sometimes spend six months or more in Vanuatu. The couple funded and helped build a classroom block at the local Luganville primary school where they had both previously

worked. Throughout Maureen’s life, she has developed a large circle of friends, most of whom share her love of volunteering. In recent years, due to their age and increasing health issues, the couple reduced their holidays and travelling and only visited Vanuatu for special occasions such as family reunions and funerals.



Past Medical History:

Although Maureen maintained a healthy lifestyle, she was diagnosed with a peptic ulcer just after Karen was born (1973) for which she was prescribed a combination of antibiotics, H2 blockers and proton pump inhibitors (PPI’s) for a 2-month period. This treatment appeared to work in subsiding Maureen’s symptoms. In 1990, Maureen was hospitalised with a recurrence of the peptic ulcer and is now taking a PPI indefinitely to assist with this condition. In 2012, Maureen had a hospital admission following a stroke. The stroke resulted in moderate left arm and leg weakness. With Peter’s support, Maureen maintained a reasonable level of functional ability when discharged from having the stroke. Six years ago, Maureen was diagnosed with Alzheimer’s disease and was still in the care of Peter. Maureen also experiences recurrent UTIs, osteoarthritis and hypertension.



Current Social:

Peter died 2 years ago, following a cardiac arrest. Mark, now fifty (50) years old, trained and worked as a policeman, however a motor accident three years ago has left him physically impaired, and wheelchair bound. Mark lives with his wife Beth and their two sons, in the same suburb as the family home. Karen, the older daughter and second child is forty-seven (47) years old and lives in Perth with her husband Ross and their three children. Karen also has two young grandchildren who reside in Perth. Lisa, the youngest daughter of Maureen and Peter is fortythree (43) years old, un-married and has no children. Lisa now lives with Maureen and is her Financial Enduring Power of Attorney (EPOA) and primary carer.



Admission One:

Four months ago, Maureen had a fall at home, resulting in a two-week hospital admission. She was discharged into the care of Lisa, with community nurses visiting twice a week to assist with showering. Maureen was also provided with a walking stick.



Admission Two:

Five weeks ago, Maureen was admitted to the St Patricks General Hospital after Lisa found her on the ground in front of the toilet. Lisa had indicated that she was unsure how long Maureen had been on the floor. On admission (1400hrs)

Maureen’s vital signs were:

RR: 22, HR: 60, BP: 115/68, SaO2: 97% on RA, GCS: 13/15, Temp: 38.2

The registered nurse (RN) looking after Maureen administered paracetamol. Two hours later, Maureen became agitated and started calling out for Lisa and speaking in a different language (Bislama). Maureen was also incontinent of urine, needing a

two-assist to mobilise and change her. The RN provided some reassurance for Maureen, however Maureen continued to call out for Lisa. Observations were

repeated at 1800hrs:

RR: 24, HR: 70, BP: 120/70, SaO2: 97% on RA, GCS: 12/15, Temp: 38.9

Observations were repeated four hours later (2200hrs):

RR: 26, HR: 72, BP: 120/70, SaO2: 97% on RA, GCS: 12/15, Temp: 39.2

At hand over, the afternoon RN reported Maureen’s vital signs to the night RN. The afternoon RN also indicated that Maureen was calling out for ‘Lisa’ but the RN didn’t know who ‘Lisa’ was. At this time, the night RN contacted the on-call doctor to request a review. The night RN obtained a urine sample and did a dipstick analysis which identified Leucocytes+++ and Protein++. The night RN reported this

to the on-call doctor, who requested a formal urinalysis and commenced Maureen

on oral antibiotics. The night RN reviewed Maureen’s admission information and identified Lisa to be her carer. The night RN called Lisa to update her on Maureen’s condition. The following day Lisa arrived at the hospital to provide support to Maureen. The urinalysis identified a UTI. Antibiotics and Panadol were continued. Maureen’s temperature began to fall into normal range and her agitation reduced. During Maureen’s admission it was noted that her cognition was declining, as she was sometimes not orientated to person/place. Further investigations identified that

Maureen had vascular dementia. Maureen’s capacity for functional improvement plateaued during her admission and she continued to require 1-2 assist with all activities of daily living. Lisa indicated that she wanted to continue to care for Maureen at the family home and agreed for extra services to be put in place to support her. Karen, however, expressed concerns that Lisa had not been coping well and considering this was Maureen’s second hospital admission in the past six months, it was now time for Maureen to enter Residential Care. Karen was highly opposed to Maureen being

discharged home. After Lisa and Karen had some discussions (without communicating with Maureen’s son Mark), it was agreed that Maureen would be discharged home with Lisa with second-daily community nurse support.



At Home:

When at home Lisa found an Advanced Care Directive that Maureen had completed when Peter was still alive, which stated that she did not wish to have invasive measures or surgery if she fell or declined. Two weeks after being discharged home, Maureen fell, while Lisa was at the grocery store, and sustained a #NOF.



Admission Three:

Maureen was admitted to hospital. On admission, Maureen appeared to be in pain and was requesting to speak to her church minister. The RN looking after Maureen gave Maureen paracetamol and contacted the doctor to seek an order for additional analgesia. A full pain assessment was not conducted as the RN assumed the pain was related to Maureen’s #NOF. Lisa requested surgery to repair Maureen’s #NOF. Karen was opposed to this. At this point the interdisciplinary team coordinated a family meeting, including Lisa, Karen, and Mark, to discuss Maureen’s prognosis and future care. The team recommended that Maureen be discharged to hospice care due to her cognitive decline and increasing need for assistance of one to two people to aide with core tasks associated with daily living. During the family meeting, Lisa appeared surprised to learn about the prognosis of Alzheimer's disease and had difficulty comprehending that Maureen’s condition would deteriorate further. Lisa admitted that she was having some trouble caring for Maureen and that Maureen would also frequently start talking in Bislama. Through the family meeting, it was agreed that Maureen would be admitted to hospice for her end-of-life palliative care.



Paragraph Instructions

The Written Assignment should follow the below paragraph structure:

Para 1 - Introduction: Briefly introduce the case and the condition. Indicate that you will critique the care provided against high-quality evidence, the CPG, the National Palliative Care Standards and either (not both) the NMBA or NSQHS standards. Identify the four (4) episodes of care you will discuss in your assignment and the sequence of information to be presented – so the reader knows what to expect in your assignment.



Para 2: Identify the first episode of care you will critique. Indicate if it was a positive or negative element of care. Identify why it was positive/negative referring to high-quality nursing related/focused evidence, the CPG, the National Palliative Care Standards and either (not both) the NMBA or NSQHS standards.



Para 3: Identify improvements that could have been made in relation to the first episode of care (what should have been done instead and why?), referring to highquality nursing related/focused evidence, the CPG, the National Palliative Care Standards and either (not both) the NMBA or NSQHS standards.



Para 4: Identify the second episode of care you will critique. Indicate if it was a positive or negative element of care. Identify why it was positive/negative referring to high-quality nursing related/focused evidence, the CPG, the National Palliative Care Standards and either (not both) the NMBA or NSQHS standards.



Para 5: Identify improvements that could have been made in relation to the second episode of care (what should have been done instead and why?), referring to high-quality nursing related/focused evidence, the CPG, the National Palliative Care Standards and either (not both) the NMBA or NSQHS standards.

Para 6: Identify the third episode of care you will critique. Indicate if it was a positive or negative element of care. Identify why it was positive/negative referring to high-quality nursing related/focused evidence, the CPG, the National Palliative Care Standards and either (not both) the NMBA or NSQHS standards.



Para 7: Identify improvements that could have been made in relation to the third episode of care (what should have been done instead and why?), referring to highquality nursing related/focused evidence, the CPG, the National Palliative Care Standards and either (not both) the NMBA or NSQHS standards.



Para 8: Identify the fourth episode of care you will critique. Indicate if it was a positive or negative element of care. Identify why it was positive/negative referring to high-quality nursing related/focused evidence, the CPG, the National Palliative Care Standards and either (not both) the NMBA or NSQHS standards.



Para 9: Identify improvements that could have been made in relation to the fourth episode of care (what should have been done instead and why?), referring to highquality nursing related/focused evidence, the CPG, the National Palliative Care Standards and either (not both) the NMBA or NSQHS standards.



Para 10 - Conclusion: Summarise what you have discussed in your assignment (the key points) and provide your overall critique of the care provided in the case.