Evaluation of a case study

Read the attached Case Study and the readings assigned for this week. Write a paper that includes the following elements:

1. A brief summary of the case, including a description of the subject (demographic and health data), social history, presenting problem(s)

2. Your professional recommendations

3. How you would feel and what you would want for yourself if you were in this circumstance

4. Compare #2 & 3 and discuss how you were/were not able to make these coincide

5. Describe how you would measure the outcomes of the actual plan as implemented

Martha Smith is a sixty-eight year old widowed, white female, who suffered a stroke in December, 2004. The stroke resulted in loss of several bodily functions. She lost her ability to swallow, requiring a feeding tube (PEG tube) to be inserted into her stomach for access to nutrition. She experienced loss of continence ability, resulting in the use of a Foley catheter and leg bag. Her balance is very poor, so she is now using a walker inside the home, and a wheelchair when she goes out. Due to the level of care required, Martha spent three months at the St. Lawrence Rehabilitation Center prior to being released into the care of her daughter, Susan Smith. She lived at home for two months, with ongoing assistance from friends, neighbors, and her daughter. By the end of May, 2005, it was mutually decided by Martha and the Smith family that Martha would move in with them. The family consists of Rich (Susanâ??s husband), Susan, and their two children: Justin (age: 10) and Courtney (age: 8). The family was initially supportive, but is currently experiencing stress related to the move.
Prior to the stroke, Martha had been home full-time. She retired from Macyâ??s in 2001, due to concerns about hypertension and stress. She rented a home at Spartan Village Mobile Home Park, about ten minutes from Susanâ??s home. She reports being â??particularâ? about certain things, and above all believes a home should be â??clean and orderly.â? She was used to taking care of things for herself, and has been doing so since her husband, Mike, died of a sudden heart attack in 1998. Martha admits to feeling like a burden to her daughter and family, but is fearful of being placed in a nursing home.
Since Martha moved in, the Smithâ??s have made a series of adjustments. The home is a three bedroom, ranch style home. Due to the lack of formal bedroom space, the dining room area has been converted into a fourth bedroom. It is an open space, so a room divider has been erected for privacy. Martha reports feeling â??exposed,â? and the Smithâ??s admit they miss having the space to use for entertaining. While not ideal, it is the best solution from the options they considered.
Martha has had a difficult adjustment to multiple changes in her life. Although retired, she previously enjoyed an active lifestyle. Since the stroke, her mobility has been restricted. She is limited in her ability to move around her home, and is somewhat embarrassed going out in a wheelchair. She has a leg bag for urine, and has experienced ongoing urinary tract infections due to the extended use of the Foley catheter. The feeding tube allows her to â??eat,â? but she misses the taste of food, and the social aspects of eating and preparing meals. While she is welcome to join the family at meals, she chooses not to stating it just depresses her.
Friendships Martha maintained for years have become a major loss for her. The distance from her old neighborhood to Susanâ??s is about ten minutes, but so far only two of her friends have come to visit. She recalls how they brought her candy, forgetting that she can no longer swallow. She misses the social times she once enjoyed with both friends and co-workers. She misses bowling â??with the girlsâ? on Tuesday mornings. Even telephone calls have basically stopped, since she moved in with her daughter. Martha questions why her friends have deserted her. No longer able to drive, Martha feels trapped and at the mercy of Susan and Rich. Even when they take her out, she worries about her catheter, use of the wheelchair, and whether she will get home in time for her feeding. One of the most embarrassing changes is the use of a cup to spit in when too much saliva builds up in her mouth. She is torn between wanting to get out of the house and the reality of what it is like when she actually does. The loss of social activities has resulted in feelings of depression.
Martha views herself as too young to be living â??like an old person.â? She follows her doctorâ??s, occupational and physical therapistâ??s orders in the hope that she will someday recover. Despite what medical providers have told her, she believes she can return to â??normal.â? She admits to thoughts of resentment about her situation. She also wonders whether if she had more money, or different insurance, there might be a different treatment that would help. Martha looks forward to the visits from her visiting nurse, Freda. Although she is not a friend, she has built a relationship with this service provider which is one of the only people outside of the family that she sees on a regular basis. She enjoys the chance to talk with someone outside of her family.
The change in level of independence extends to areas of personal hygiene and modesty. In order to shower and dress, Martha requires assistance. Susan helps her in the morning with dressing and showering. The use of a shower seat has eased the physical challenge for them, but the psychological challenge of being undressed in front of her daughter is still uncomfortable for both of them. In order to allow Susan to be home in the daytime, she changed shifts at work and is now gone from 2:30 p.m. until midnight. Susan provides custodial services in a long-term care facility. In the evening, Rich is responsible for helping Martha change into a nightgown, emptying the leg bag, and starting the feeding tube pump. While he is willing to help, both Rich and Martha share an uncomfortable feeling about this. Role reversal with the same gender parent and child has proven easier for them than role reversal of in-law/son-in-law of different gender role reversal. Rich tries to avoid looking at Martha as much as possible during changing, but the more he does this, the more uncomfortable Martha feels.
During the evening, Rich is also responsible for Justin and Courtney. Justin has been diagnosed with Attention Deficit Hyperactivity Disorder and needs help remaining focused during homework. During the last month in school, Justinâ??s grades dropped considerably. Rich is worried that it is partly due to the lack of time he has available to spend with Justin. He is also concerned that Justin told him he never wants to get old if â??this is what life is like for old people.â? Aware that their children are learning about aging from this experience, both parents are concerned that it will have a negative impact on how they view elders. In the back of their minds, the parents are also concerned that when it is their time to possibly need help, their children may not want to take on the added burden.
Courtney is very close with Martha and enjoys having â??Nanaâ? living with her. However, she has been using Nana to avoid helping with chores around the house. When told by her parents to do a task, she frequently goes to Martha and tries to get out of the work by offering to keep her company or read to her. Susan pointed out what she think is happening, but Martha undermined her by saying â??she is just a little girl; donâ??t be so hard on her.â? When things are calm, Courtney enjoys listening to stories about when her Nana was a little girl. She especially enjoyed having her grandmother attend an Awards Ceremony at her school. They have developed a close bond, which simultaneously pleases and worries Susan. She is afraid of what will happen to Courtney if they reach a point of no longer being able to care for Martha at home. Susan confided in a friend that she has been talking to a social worker at her job about the possibility of moving her mother into long-term care in the near future. Currently, there are no Medicaid beds available at the facility. Susan only feels comfortable with the facility where she is employed, because she thinks the staff would treat her mother well knowing that Susan is an employee there. At this point, she has not discussed this option with Martha. One can only guess that Martha will be upset not only about being placed there, but also having arrangements made without consulting her in advance. This loss of control over options in her life, is another stress for Martha.
The stress of full-time work, caring for Martha, parenting, and tight finances has caused the family to fight more than normal. Rich and Susan have very little time together, and they are exhausted when they do. Although not directly stated, Susan believes Rich is angry at her for the lack of sexual intimacy they once enjoyed. Susan feels uncomfortable â??being romanticâ? with her mother down the hall. Rich recently started making comments to Susan about resenting the entire situation of caring for Martha. He would like to see Susanâ??s brother, Pete, shoulder some of the responsibility. Pete is divorced and living with a paramour in Florida. He expressed that he cannot help at this time, but does occasionally send small checks to help with the costs. This causes resentment and anger in the family, and results in Martha feeling more like a burden.
Martha uses her time to think about her life situation. She feels helpless, and lacks purpose. She perceives herself to be a burden to her daughter and family. While she does not want to live there as a burden, she is fearful of being placed in a nursing facility. Although not financially successful, she saw her life as a success prior to the stroke. She enjoyed activities with family and friends. She entertained in her home, and made time to help others. These things gave her purpose. History indicates that she has been able to cope with the loss. After the death of her husband, Martha continued her life by finding other social activities to fill her time. She learned to cope and found enjoyment in different things. If she is assisted in finding purpose in her life, she can go forward with hope. Without this, she will likely remain depressed, and resentful. The negative impact will have a ripple effect throughout her family.