You are a Registered Community Nurse who has been assigned to this new referral (as per the scenario supplied) as part of your caseload.

A part of your responsibilities is to prepare and present a case conference for this new referral to the Multi-Disciplinary Team (MDT) within your Local Health District.

Scenario: Vodka-loops

You pull the car up outside the new client’s house. It is a very small house from the outward appearance and is in disrepair. The yard looks poorly attended and an old car sits rusting and overgrows with weeds and grass in the front yard. Three small children of different ages played on the steps of the house. Three huge gum trees shade the house with some branches resting precariously on one section of the roof. The children looked dishevelled and unkempt. They played with no shoes on and you notice bruising on their legs. As you approach the house the children scatter, each racing off to hide near the massive tree or car body. You note that they are very young; approximately 3-9 years of age.

When you knock at the door and call for a few minutes; a large woman shuffles to the door to let you in. Mrs. Joan Bull had been expecting you as the local General Practitioner (GP) had set this referral up with her. She is an obese woman; dishevelled in appearance, wearing ill-fitting clothes and no shoes. She is very dyspnoea and steadies herself against the doorframe and at times gasping for breath. Joan is a 68year old female although looks much older and you note she has extreme difficulty in mobility. The history from the GP was that Joan has six children of her own and cares for a further 3 of her sister’s children; she lives without a partner. She has been divorced from her husband for two year. His occupation was a shearer and he rarely spent much time in the district due to the shearing sheds he followed being located in interstate.

Joan was recently diagnosed with Type 2 Diabetes 2/12 ago and was commenced on Metformin 500mg BD. She was diagnosed with hypertension 18/12 ago and was prescribed Metoprolol XR 200mg daily. Joan also has a history of alcohol abuse and has been brought to the attention of the local police by the neighbours on several occasions due to disruptive behaviour of the children. She has neither a motor vehicle nor a license.
“Sorry I was sleep. C’min”, she mutters as you enter.
“Were you at work last night?” you ask, thinking she might have been a shift worker.

The woman looks at you as if you have come from another planet. “No one ‘ere works even in the day luv”, the woman mocks. You feel small and foolish as you have not established a good rapport with Joan. You then notice the smell of stale cigarette smoke, and, as your eyes adjust to the dim light you can see a dishevelled state within the lounge area. The house is filthy and there is a significant amount of belongings everywhere. You attempt to navigate the track from the front door to what should be the lounge room and there is just enough room for you to stand and talk with the new client. 
Joan slumps back on to the couch and lights a cigarette.

“What’s all this then?” she asks pointing to your bag of nursing equipment as she coughs up a wad of phlegm, and spits it into a used coffee cup. 
“I am a community nurse, and I have been assigned to assist with your health needs and work with you in getting things organized”.
Joan looks you up and down; “Noth’n’ t’ do ’ere”, she splutters. 
“Have you been taking your medication Joan? I was advised that you had recently been commenced on some medication by tour Doctor”. “I believe you have six children that you care for Joan, is this correct?” Counting only three, you assume the others must be at school. 
“Yep,” Joan grunts, “the little rabbits won’t go to school though and the younger ones are following them, can’t get em to go…..and I‘ve been takin’ my medications if I remember. I haven’t bi’n feeling so bad lately and I don’t want to waste ’em”. 
“But you must take them twice a day”, you insist. “The GP had said that he had spoken to you about this”.

Joan shrugs with contempt and begins a tirade of abuse about the “useless good-for-nothin’ Doctor”. You attempt to regain the thread of the conversation…. “What have your blood sugar levels been like?” you enquire. 
“They’re fine. I b’in takin’ some ‘erbs me sista gi’me. She said they worked when she had sugar last time she was pregnant. I feel good and they’re cheap”. 
“But you seem to be very sleepy, and it is mid-morning”; you remark. “Can I check your blood sugar level now?”

As you take the blood sugar level you notice two of the children poking their heads around the door frame to see what was happening.
“Have the children had all their immunizations?” You ask Joan. 
“No,” Joan said dismissively. “No point is there with this ‘bola thing? Nothin’ll stop that and my sister said the ‘munisations can cause autoimmuneisum or somefink.”
“Autism?” you enquire with puzzlement.
“That’s the one. So there is no point is there”. “My kids, my rules”, Joan said with finality.

You are about to present an argument in favour of immunization, when Joan recommences her story of why she does not take her tablets regularly. She informs you that the children go to the chemist to pick the medication up, however, they open them before they arrive home and mix everything up so she does not bother to take them. 
In your assessment of the home you note that the front veranda has three steps up from the ground and six steps down off a back landing. There are no handrails to assist Joan in her movements from the house and the limited mobility Joan has could explain why she does not go to the chemist herself.

“The BLS is 23”, you inform Joan. “No wonder you are so sleepy Joan – What did you have for breakfast?” 
Joan pointed to a half empty bottle of vodka and a large opened packet of Fruit Loops on the coffee table. “Some of that”’, she said. “Vodka-loops”, she giggled to herself.

Marking criteria

1. Identify the patient as having complex needs:

• Provides a detailed summary of the complexity of the client’s requirements.
• Identified Informed consent of the client. (25 mark)

1. Participants in case conference

Identifies ALL members of the MDT who should be included in the case conference. (Not limit to follow)

• Social worker
• Diabetic educator
• Occupational therapist
• Physio- therapist
• GP
• Dietitian
• Immunization nurse
• Drug and alcohol specialist
• Psychologist
• DOC’s Department of social service
• Community service (transport, meal on wheels…) (20 marks)

1. Evidence for selection to the case conference

Provide the rational for the choice of the selected MDT members based on client assessment:

o Identifies the Social Determinants of Health.

o Identifies the primary Health Care principles.

o Identifies legal & Ethical issues relevant to this case (30 Marks)

Professional Portfolio

Why is normal saline used for wound care to post-op patients instead of using povidone-iodine? Which is more suited as best practice to prevent infection?

You will be required to identify a nursing problem or issue that relates to the specialty area of practice in which you are completing your clinical placement for this unit. (done. refer to question above)

Once you have identified a nursing problem/issue you will need to develop this into a question for exploration which is subject to approval by your LIC/Tutor. This question needs to be realistic in the context of your speciality clinical placement in relation to nursing practice. This question will lead you to contemporary literature.(this is done already)