A case study report requires students to analyse a case, in order to address specific aspects of the case through responses to focused questions.
Arnhem land is an area of approximately 100,000 square kms in the north-eastern corner of the Northern Territory (NT) in Australia. It is home to the Yolngu people; the Indigenous custodians of the land who have lived there for at least 40,000 years and continue to engage in many traditional cultural practices. However, the health of the Yolngu and other Aboriginal people in this region is generally poor, with people experiencing a high burden of preventable ‘lifestyle’ diseases that are clearly linked to poverty, poor infrastructure and disadvantage4,5. Babies from this region are often born underweight; children are at risk of infectious diseases, pneumonia, otitis media, skin diseases such as scabies and Rheumatic Heart Disease; and adults are at risk of chronic conditions such as diabetes and cardiac disease.
Mae Roberts is a 45 year old Yolngu woman from Yirrkala in East Arnhem. Yirrkala is a small, very remote town 900kms east of Darwin; where 13 clan groups speak different dialects of local language and live between Yirrkala and the surrounding homelands8. According to the 2016 census, the population is 809 people who are mostly Aboriginal and/or Torres Strait Islanders (83.1%) and mostly young with a median age of 26 years9. Low educational attainment and high unemployment are common, and most people live in family groups with children, in houses with an average of 6.6 people.
Mae Roberts grew up in a traditional household in Yirrkala; living in a two-bedroom house with her mother, two aunties, an uncle and four siblings. Mae speaks and understands a little bit of English, but her native language is Yolŋu Matha. Mae’s mother was a stolen generation child who was taken from her home in Yirrkala at the age of 7 to work on a mission in Milingimbi some 1,434km away from Yirrkala. As a consequence, Mae’s mother was often sad, drank too much and sometimes wouldn’t leave the house for days. Mae doesn’t remember anything about her father.
Mae recalls always having a sore throat and itchy skin sores most of her childhood and remembers a number of horrible experiences where she was given very painful injections into her bottom. Her Aunty took her for these injections as it was too upsetting for her mother, but Mae remembers screaming and running away from the nurse because the injections hurt so much. Mae experienced terrible treatment from health providers when she was a child, as they either blamed her mother or Mae herself for not coming to the clinic for ‘them injections’ and said it was their fault for ‘livin all together in that dirty house’. Mae and her family rarely understood what was expected of them given the language barrier, but they did understand that they were treated poorly and never really understood much about ‘her sickness’. Mae remembers feeling terrified of ‘that nurse’ and her family feeling sad and angry for those ‘hurting injections’, which they told Mae she could stop having. Mae now lives in Yirrkala with two sisters, her brother, two of her siblings and four of her grandchildren (10 people in the home).
Current Medical History
Mae has felt quite unwell lately, finding it harder and harder to get her ‘wind’, especially when she’s trying to ‘do things’ (dyspnoea worse on exertion). She has told her family that she is tired all the time with ‘short wind’, has ‘racing one’ in her chest and feels ‘a dizzy one’ in her head (extreme fatigue, palpitations and light-headedness). Mae has such ‘short wind’ and ‘racing one’ in her chest that she has to sit down most of the time.
Mae sees the doctor at the local medical service who examines her, does an ECG and explains she needs to see a cardiologist urgently and needs to fly down to Royal Adelaide Hospital. Mae is alarmed (as is her family) as Adelaide is 3,332 km from Yirrkala, and ‘a long, long way off country’ as Mae says. Mae has never been ‘off country’ or away from family for any length of time, and is terrified about going to hospital so far away. After much discussion Mae understands she is very unwell and the doctor organises to access funding for her sister to fly with her. Mae’s sister asks other family to ‘look after the kids’ because she and Mae usually care for the four grandchildren. Mae’s doctor commences her on Penicillin and tells her that this is to ‘prevent any further damage to her heart’.
Mae’s provisional diagnosis is Mitral valve stenosis, secondary to Rheumatic Heart Disease.
Past Medical History
- Acute Rheumatic Fever (ARF) at 6 years old post Group A streptococcal throat infection
- Chronic tonsillitis as a child and adolescent
- Rheumatic Heart Disease (diagnosed 2011)
- Multigravida (2 live births)
Family Medical History
Coronary Heart Disease, Alcoholism, Depression, Type 2 Diabetes Mellitus (T2DM) (Mother died at 44 years from cardiac failure?); Father unknown;
- Ramipril 10mg/day
- Pravastatin 40mg/nocte
- Panadol 1g/PRN
- Benzathine Benzylpenicillin G (BPG or Bicillin) injection every 3-4 weeks
Considerations And Preparation For Hospital Admission And Discharge
Please respond to all the following questions described under Each Heading. Utilise relevant, peer-reviewed, evidence-based literature to support all responses
Reflect: Epidemiology of Rheumatic Heart Disease
Refer to current health data about Rheumatic Heart Disease (RHD) in Australia to identify the prevalence and pattern of disease in Indigenous people. Critically analyse how this relates to Mae in relation to her risk factors and the social determinants that have impacted on her health to contribute to the development of RHD.
Reflect And Respect: Prevention and barriers experienced by the patient Acute Rheumatic Fever with progression to Rheumatic Heart Disease is preventable. Explore some of the barriers Mae experienced to treatment and management for this condition.
Communication And Advocacy: Cultural Safety
Critically analyse the implications for Mae travelling to Adelaide so far off country and being away from her family and community. How might this affect her? How can health care staff advocate for Mae whilst she is in hospital to ensure she understands what is going on and feels culturally safe?
Safety And Quality; Communciation And Advocacy: Collaborating for safe, quality care
A new medication regime and cardiac rehabilitation might be ordered for Mae for when she leaves hospital. Describe how health providers in Yirrkala might collaborate with other health and community service providers to ensure Mae can improve her health. Include how Mae be supported to take her medication safely and regularly.
Please read the case study carefully, so you have the background information regarding Mae’s health and current medical condition.
Additional information obtained on admission to hospital
Mae is given a provisional diagnosis of Mitral valve stenosis, secondary to Rheumatic Heart Disease.
- Mae appears anxious.
- RR – 22bpm
- HR – 110 (regular)
- BP – 110/64
- Temp – 36.9
- O2 Sats – 94% RA
- FBE (Hb – 13.2 g/dL, Hct 0.40, WBC count – 5 x 109/L, Plts – 250 x 109 /L)
- UEC’s (K = 3.5, Mg =0.85 mmol/L; Urea and Creatinine within normal parameters)
- LFT’s (within normal parameters)
- Pathophysiology of Diagnosis
Describe the pathophysiology of Rheumatic heart disease and discuss how Mae’s past history of Rheumatic fever (as a child), may have progressed to this current diagnosis of mitral valve stenosis. What do the results of the above investigations tell you about her current presentation and prognosis?
- Focused Physical assessments and Medications.
Please note that this question consists of two sections (Assessment & Medications)
- a) Assessment
Identify two relevant focused systems assessments that you would perform on Mae and provide a rationale for your choices. Describe TWO abnormal findings you may note on performing these focused systems assessments (please include TWO abnormal findings per body system).
- b) Medications
Mae has been prescribed two new Medications (Digoxin and Carvedilol) by the Cardiologist. Discuss the action, indication and common side effects of each of these medications; and identify the nursing considerations involved in their administration.
- Complications and Clinical deterioration
Identify and discuss TWO potential complications associated with Mae’s diagnosis. What are THREE clinical cues (signs and symptoms) that would indicate deterioration in Mae’s condition.
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