CULTURALLY COMPETENT CASE STUDY

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Case Presentation for Cultural Competence

Race and Gender of a patient with Sickle Cell Crisis

History/ Case Scenario

The client is a 23-year-old Afro-American male with Sickle Cell disease. He has visited the Emergency Department requesting for pain medicine for his sickle cell crisis. Never before has he ever come to this medical center but has always been going to the one across the street since his childhood. He feels that the doctors in that hospital have failed to bother about him, and they ever give him the best pain medicine. The client states that it is a 15/10 scale when asked about his pain level.  He is writhing and suffering in pain. Assessment of the patient clearly shows his need for medication to control his pain by looking at his face.

  1. Symptoms review

No fever, no respiratory distress. No pain in the chest but has painful extremities.

  1. The Past Medical History

At the age of 9 months, the client was first admitted to the hospital, and he had a diagnosis of joint crisis, chest crisis, and infections. He underwent blood transfusions after that including routine medications to a point where he was on hydroxyurea. There was no hospitalization for three years. At the age of four, he started missing classes because of the sickle cell anemia crisis. He continued with the hydroxyurea treatment which helped the doctors and parents monitor his blood level regularly and gives him the right does. He has also been having a follow-up for the doses of titrating. Thus, the treatment has helped him grow into a twenty-three-year-old man that he is now. The patient was diagnosed with NKDA allergy at the age of 17 and pneumonia at 12.

  1. Family History

The patient’s mother suffers from hypertension, and his father has the sickle cell trait.

  1. Social History

He does physical exercises at a local recreational community center

  1. Physical EXAM

Temp: VS: HR 110, T: 98.6ºF, BP 136/81, RR, 20

 General: the Patient displays pain and discomfort

 ENT: Clear TM, PERRL, EOMI.

Cardiovascular: normal S1/S2, no gallops, rubs, or murmurs. Presence of Sinus tachycardia

Lungs: bilaterally CTA

Neuro: Intact

 Extremities: Presence of pain all over the body, no cyanosis/ clubbing/edema

 Abdomen: diffusely tender, non-distended, soft

  1. Include a cultural assessment

Questions for patient

What is your living will?

Patient: having to live for the past 23 three years with sickle cell disease, I believe that I grow old to testify that I can overcome the condition. I know of my uncle who is now 68 years and he was diagnosed with sickle cell disease at a young age just like me.

What barriers do you face when seeking care for this condition?

Patient: the pain challenge I face is the untreated pain. The physicians I have always been visiting from a young age do underestimate the level of pain I feel. They have now prolonged giving me my pain doses or give me the IM medicine so that I do not ask for more pain medicines. They fear that taking lots of opioids will create a cross-over effect and addiction to illicit drug use. Also, I feel as an African- American, most physicians in the ED mistrusts me since they are not African American. I do not have a private physician to manage my pain.

What health diets do you take for your health?

Patient: I do take high-calorie foods with dense nutrients, adequate fluids, omega3 fatty acid supplements and mineral and vitamin supplements.

What is the healthy diet to you?

Patient: a healthy diet is one that comprises of all nutrients ranging from vegetables, fruits, lean meat, chicken, fish eggs, tofu, beans and low-fat dairy and nuts. I also take plenty of calcium-rich foods such as yogurt, green leafy vegetables, cheeses soymilk and orange juice.

What I eat when ILL

Patient: When ill, I usually have problems with my appetite, but orange juice and plenty of water helps me sometimes going with slices of bread.

Do you have any health risk behavior?

Patient: No. I do not smoke or take alcohol

Do you use any recreational drugs?

Patient: No

Do you exercise each day?

Patient: I do exercise thrice a week but not on the days; I am in pain. I do acrobatics and swimming frequently and cycling.

Precautions to prevent HIV and STI

Patient: I use condoms in every sexual encounter.

C: 4 nursing diagnosis of the client

 What actions should I take to avoid stereotyping the patient?

I have to treat the patient just in the same way as any other patient. I will take sufficient time to do a physical exam and the good history of the patient.

What are the main medical issues for this case?

I fear that the sickle cell diseases is affecting other body organs such as the vascular, pulmonary, liver, gall bladder, spleen, the skeletal and the central nervous systems. The four main nursing diagnoses are the intrapulmonary conditions such as infection, infarct, embolism, and shunting. The patient can also have hepatic infarct or secondary hepatitis from a blood transfusion. The third one is that he may be suffering from gallstones and finally the hematuria condition.

D: Identify outcomes/planning goals for /with the client

The planning goal is to recommend the patient for lab test on the arctic count and CBC, electrolytes, ABG baseline to determine chronic hypoxia and U/A. Other beneficial radiographs can include a CXR to determine the presence of pulmonary symptoms and films of bone to locate the pain. To find out the presence of gallstones, bowel infarct, abscess, appendicitis, and pancreatitis the patient will have an abdomen CT and U/S. A head CT will also be undertaken to determine if the patient suffers from neurologic symptoms.

  1. E. Outline nursing interventions giving attention to safety, best clinical expertise, patient values and preference, clinical context and health teaching

 Best clinical expertise

The physician had to order an IV and promptly ordered IV morphine. The nurse administered these medications to control the pain adequately that the patient was experiencing. In the first two-hour stay at ED, the pain was adequately controlled. The physician did not order any x-rays or lab test.

The pain management is symptomatic. It involves ensuring the patient receives a hydration through either the IV or oral with normal saline boluses. Analgesia treatment begins with a push of morphine IV followed by a morphine drip and later constant boluses of morphine. Another physician can recommend ketorolac and promethazine to help patients. Also, the PCA can sometimes be needed. In providing the best care, it is appropriate for the physician and nurses to determine the needs of the patient so that they can admit the patient or send him home. Therapies for outpatient services can include Percocet or Vicodin and also the non-steroidal anti-inflammatory drugs (NSAIDS)

 Safety concerns

Giving the patient with sickle cell crisis of pain with high doses of opioid can cause cross-over effect of using illicit drugs or addiction to these drugs. It is also crucial to know whether or not the patient is overestimating the pain because of his addiction and the need for more medicine.

 Patient preferences and values

The patient beliefs that his earlier doctors were not giving him adequate medication and that they have failed to care for him. He feels that he has to empathize the level of his pain so that the nurses and doctors provide him with enough medicine to relief his pain. He also prefers that the factors and nurses to be of his ethnicity/ race so that they would understand his pain.

 Clinical context and health teaching

As a physician, I have to be aware of the community such as the presence of stereotyping in the society. I have to understand and learn more about treating pain and its acute exacerbation and understand that it may not necessarily lead to addiction (Zempsky, 2010). As a physician, I also have to have the cultural discrimination/disparities knowledge such as reasons why the Afro-Americans feels discriminated much in this country. This view makes most Afro-American patients fail to have complete trust in the medical profession (Clark, 2009). I have to treat the patient in the same way as I treat another patient. Take time to do a thorough physical exam and obtain his history. I will also communicate in the best way with the client by informing him that I intend to give him the best care and to ensure that his pain is in control. I will involve the patient in making his treatment goal and acknowledge the fact that we can reiterate through easing the pain and not eliminate it.

  1. Evaluate the care
  2. My Knowledge: In this evaluation I have demonstrated my knowledge in cross-cultural clinical care by recognizing the patient’s severity of pain relating to the vaso-occlusive crisis due to the sickle cell disease.
  3. Patient care: I showed appropriate and compassionate care with providing mutually beneficial outcomes of controlling pain in an adequate manner.
  4. Professionalism: I have demonstrated sensitivity to the distress felt by the patient, and I did not make assumptions or stereotype his behavior of seeking drugs.
  5. Communication and Interpersonal skills: I was able to generate an effective exchange of information with the patient, and this helped me to validate the genuine symptoms felt by the patient

References

Clark P (2009). Medical Profession’s Prejudice. Racism, sometimes overt,  subtle, that continues to plague US health care. Health Progress, Sept-Oct 84(5):12-23

Zempsky W. (2010) Evaluation and Treatment of Sickle Cell Pain in the Emergency Department: Paths to a Better Future. Clin Pediatric Emergency Med. 2010 Dec 1; 11(4): 265–273.



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