Russo And Sophia: Transfer Of Care And Based On Legislation And Ethical Concepts

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Question :

Assessment Task 2: Case Report

In this assessment task, you will be facilitating Joseph's discharge from hospital to his home.

Each student's report will be different as Joseph lives in the same suburb or town in which you reside (or if you wish the location of your most recent PEP). For example, if you live in Norwood, Joseph lives in Norwood, if you live in Sheffield, Joseph lives in Sheffield.  You will be exploring the services and options available in your local community.

This assessment requires you to demonstrate and apply the principles of shared transfer of care and the strengths-based approach to care. You will need to reconnect with the values of strengths-based care that you explored in CNA343.

Your strengths based nursing care (SBNC) should not only consider Joseph and his family but also the community strengths. In CNA343 you considered the construct that health and healing are influenced by patient strengths, family strengths and community strengths and how aligns with value 6 (Person and environment are integral), and this will be key to your plan. Another example is the right of Joseph not to disclose his admission diagnosis, which relates to SBNC value 5 (self-determination), which connects to the ethics of respect and autonomy.

This assessment task is not only focused on Joseph; as Joseph was his wife's carer prior to his admission you will need to consider what needs to be put in place to support Joseph and his wife.

This is not an essay, rather a report - which gives you the freedom to include images, tables, flowcharts, headings, forms etc. Please ensure your report has a logical flow.

You may write your report in the first or third person (however do not swap between the two, be consistent).

Joseph wishes to remain in his own home, he does not wish and will not discuss the option of residential aged care for himself or Sophia (Sophia feels the same). Joseph and Sophia will also not discuss respite care options or moving to a smaller house or unit - they want to stay in their own home.

This is an example, a previous student has kindly agreed to me sharing her work. Please note the case study and criteria have both changed since this piece was submitted.

This is another example shared by a student, this student has used clinical reasoning as a framework.

Please read the rubric  for this assessment task before you start.

Case Study

Joseph Russo was born on the 7th of July 1950 in Manarola, Italy. The youngest of six children, Joseph described his upbringing as ideal and he was very close to his parents and enjoyed school. At the age of 17, Joseph met Sophia and they married a year later. Joseph’s father encouraged him to move to Australia to work for his uncle who had emigrated 20 years previously.

Although somewhat reluctant, Joseph thought Australia sounded exciting and thought it would be a great start for both he and Sophia. Sophia was not as keen to move but wanted to do what would make Joseph happy.

They arrived in Australia in 1970 and were excited to find they were expecting their first child (Antonio was born in 1971, followed by a daughter Emma in 1972). Joseph was overjoyed to be a father and while still working for his Uncle started to explore the idea of starting his own smallgoods business. This happened quite quickly when a nearby shop became vacant. Joseph wanted to work close to home as he was worried about Sophia, since arriving in Australia she had only made a few friends in the Italian community and only spoke one or two words of English. Joseph tried to encourage her to learn English but each time she became frustrated. Joseph recalls that Sophia cried frequently after the children were born - he felt it was because she was homesick.

While he was concerned about his wife, he felt that they needed to remain in Australia as his small business was becoming hugely successful, customers would travel long distances to buy his smallgoods. He worked hard, sometimes over 80 hours per week. He was well known in the community as a happy, hard-working and very likable man. His hospitality was well known and the family home was host to many memorable events and parties. Sophia was an excellent cook and no-one ever went hungry, although she preferred to stay in the kitchen cooking and washing up, while Joseph entertained the guests with his stories and singing.

Sophia discovered in 1979 that she was pregnant again, although shocked she was excited; however the baby boy was stillborn at full term. Sophia felt deep sadness and a sense of failure, she lost her appetite (and as a result lost a significant amount of weight) and started smoking heavily (60 cigarettes per day). She rarely left the house. Joseph said little and instead worked harder and spent the remainder of his time in his shed, working on old cars.

In 1990 after dropping out of university Antonio decided to work for his father – for Joseph this was a defining moment as he now had a family business – this had been his dream and to celebrate he had the front of the shop repainted with “Russo & Son Family Butchery”. Joseph was content and his daughter completed her education and was awarded a Bachelor of Science and worked for a number of years as a research assistant. Emma started a family with her partner Steven. Emma gave birth to Thomas in 2006 and started to notice he was ‘different to other children’ at around the age of two. Thomas was diagnosed with ASD. Steven left shortly after his diagnosis and returned to work in the west.

Joseph subdivided his very large block and built a house for Emma and Thomas next door. It was around this time that Sophia’s health started to deteriorate. Joseph spent more time at home helping both Sophia and Emma. Antonio took over the running of the business and convinced his father to expand the business by buying second shop. Joseph was incredibly proud and told everyone what a good business head his son had. However, Joseph was unaware that Antonio had a gambling problem and was taking large sums of money from the business. In 2008 during the global financial crisis, Antonio left Australia and Joseph and Sophia have not heard from him despite their efforts to trace and contact him. Due to the debts that Antonio accumulated in Joseph’s name, he lost the business and almost lost his family home.

Joseph now cares for Sophia full-time, she has COPD and heart failure. Joseph now cooks, cleans and provides Sophia’s personal care. He has declined all offers of assistance from healthcare providers, family and friends, as it is “his job to care for his wife not a stranger”. Joseph had planned a retirement in which they could both travel and enjoy their children and grandchildren – Joseph had saved hard for retirement but the debts from the business took all of their savings and they now rely solely on the pension. Sophia has not left the house in over a year. The financial struggles, losing contact with his son and caring for his wife have taken an emotional toll on Joseph.

In June of this year, Emma saw the lights on in her father’s shed and thought she would go and have a chat as her father seemed quite down in the past few months. As she approached the shed she saw him sitting in his beloved 1962 EJ Holden, at first she thought he was sleeping but something didn’t seem right, when she opened the car door she found Joseph unresponsive and ran inside to call 000.

When the ambulance arrived, Joseph was not responsive. He wasn't breathing but the ambulance officers could feel a faint carotid pulse. They inserted an oropharyngeal airway, intravenous (IV) cannula and provided ventilation with bag/valve/mask using 100% oxygen.

The ambulance officers reassured Emma who was distraught after finding her beloved father in such a terrible state. After calling the ambulance, she had turned off the engine and pulled her dad out of the car toward fresh air – this was a difficult task as Joseph is 171 cms tall and weighs 89kgs. Emma kept saying ‘I didn’t know what to do? How could I have saved him?’ They asked Emma to travel to the hospital with them, but she declined, as she was worried about who would look after her mum and son Thomas.

On arrival at the Emergency Department (ED), Joseph remained unconscious and was not breathing spontaneously. The ED Registrar, Dr Jaram, intubated Joseph so he could be mechanically ventilated. He was hypotensive despite 1.5 Litres of IV crystalloid, so an infusion of IV metaraminol was commenced with an aim of increasing his Mean arterial pressure greater than 65mm Hg. Joseph’s hypotension continued to be an issue, so Dr Jaram inserted a three lumen central venous catheter into Joseph ’s right subclavian vein using surgical aseptic non touch technique (ANTT). Inotropes in the form of IV noradrenaline was commenced and titrated to maintain MAP > 65. Joseph was transferred to the intensive care unit for ongoing care and close monitoring.

Emma arrived at the ED to see her father and was directed to the ICU. She was terribly frightened about how her father would be when she arrived. When she got the ICU, staff asked her to stay in the waiting room until Joseph was ready for visitors. It was over an hour before the nurse came to get her and during this time, Emma imagined terrible things that could be happening to her dad. She felt guilty for worrying how she was going to manage without Joseph in her life. Her mum Sophia’s health was worsening and she relied heavily on Joseph for all of her personal care and management of her medications. Emma’s son Thomas is now 12 and becoming increasingly challenging in terms of behaviours related to his ASD. Since her partner left, Emma has managed everything by herself, and it was becoming increasingly challenging to juggle the responsibilities of work, her son, her home and her parents alone. She felt so guilty that her dad had come to this desperate state and she had not recognised it.

When Emma finally walked into her father’s ICU room, she saw a pale, frail man who was attached to a breathing machine which made his chest rise and fall at a strangely regular rate. There were tubes everywhere, which were attached to machines delivering medications and a tube down his nose which delivered nutrition to his stomach. The intensive care specialist Dr Prince, spoke to Emma about Joseph’s situation. She said that Joseph was stable at the moment but he wasn’t breathing on his own and medications were keeping his blood pressure up. Dr Prince explained that they didn’t know how long Joseph had been exposed to the carbon monoxide from the car which can cause damage to the brain, and they would need to wait and see if Joseph gained consciousness over the next 24 hours.

Emma had to return home to her mother and son who were being cared for by a neighbour. She wished she could contact her brother Antonio. Despite everything he had done, he was still her brother and she desperately wanted to share the current pressures and responsibilities.

On day two, Joseph had not regained consciousness. He was not opening his eyes, although he was moving his limbs spontaneously but not with any purpose. Joseph ’s temperature was documented at 38.8 degrees Celsius, with an increased heart rate and he remained hypotensive. On assessment, the insertion site of his CVC was very red and warm. No other site of infection was found so a diagnosis of Central Line Associated Bloodstream Infection (CLABSI) was made. A swab was taken from the site as well as peripheral and central blood cultures. A new CVC was inserted into the Left internal jugular vein under strict surgical ANTT and the suspected source of the infection, the original CVC was removed. Broad spectrum IV antibiotics were commenced and then changed when sensitivities were available.

On day four, Joseph regained consciousness. He opened his eyes to voice, responded to requests to move his arms/legs appropriately. He had reduced limb strength but there was equal and purposeful movements. Joseph was weaned from the ventilator and extubated. Nasal prong oxygen was administered to maintain SPO2 > 93%. Joseph’s blood pressure continued to be reliant on inotropes, so he remained in the ICU. Emma was relieved her dad didn’t seem to have brain damage. She tried to talk to her father about what had happened but he refused and would avoid eye contact whenever she brought the subject up. He did not ask how Sophia was, which surprised Emma.

On the evening of day five, Joseph suddenly became agitated and restless and persistently tried to remove tubes and lines. When he wasn’t demonstrating this behaviour, he appeared withdrawn, apathetic, avoiding conversations and eye contact. Nursing staff suspected he was experiencing delirium, and implemented non-pharmacological protocols in an attempt to reassure Joseph and re-orientate to the environment. Interventions included encouraging communication and repeated reorientation, ensuring visible daylight, consistency of nursing staff, mobilisation activities and range of motion exercises. When Emma visited Joseph in the morning, she was very distressed, thinking that Joseph had terrible brain damage. Nursing and medical staff reassured Emma and informed her of the strategies they were putting in place to support him during this period of delirium. During this period, Joseph's CVC became occluded, this was managed without having to remove the CVC.

On day eight, Joseph was no longer reliant on inotropes and was mentally alert and orientated. He transferred to the medical ward to continue IV antibiotics and follow up with the psychiatric team. On admission to the medical ward staff noted an intact fluid filled blister on Joseph 's left heel, measuring 3 cm by 3 cm.  

Five days later, Emma met with the Psychiatrist and Joseph’s physician who informed her that Joseph was ready for discharge. Joseph was keen to be discharged from hospital however he refused to participate in any discussions around residential care for either Sophia or himself. Emma wanted her father to return home but acknowledged that additional services were required and Joseph agreed to this request. Joseph's CVC line was removed prior to discharge.

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Answer :


Transfer of care is a continuous process where the patients are shifted from one type of care setting to that of other. It is vital to manage the transfer of care in appropriate manner as it may further lead to cause further issues in health of the patent and even increases the overall treatment cost. The research findings also suggest that the transfer of care always involve a team effort where if there is an inadequate coordination may lead to unwanted consequences. The poor coordination includes incomplete patient education, poor discharge, poor medication chart and inappropriate transition etc. Because of the involvement of such issues, most cases leads to readmission in the hospital and increases the stay in hospital as well. In countries like Australia, there has been a significant effort taken for providing a positive and efficient transfer of care. Transfer of care allows the care expert to make a team and facilitate a smoother transition process. The scope of this report will discuss about the case study involving Mr. Russo and his wife Sophia. Mr. Russo will undergo transfer of care and based on the legislation and ethical concepts, the strength based care process will be suggested to Mr. Russo. The care process will be culturally appropriate and will be provided in a home setting. 

Establishing goals –

Before establishing a goal for the patient, a brief about his health history will be descried. Mr. Russo is a happy and hardworking man living with his family in Sheffield, Australia. He is being suffering with several co morbid conditions since several years and both his physical and mental health found to be deteriorating. Recently, he was diagnosed with hypotension in hospital and in the later part it was discovered that he has been suffering from delirium as well. As reported by his daughter Emma, the nature of the patient has been completely changed after his wife Sophia’s health started deteriorating. Most of the time he got involved in providing care for Sophia, Emma and Antonio, and because of this the business was completely lost. While he was getting discharged from the hospital, he has also developed pressure ulcer of 3x3 cm. As suggested by the clinicians, Mr. Russo was alert mentally, however, he needs more mental support and will need a regular follow up until a complete recovery is achieved. Mr. Russo demanded a home based care setting instead of living in the community. Intercare service limited based in Sheffield will be contacted for providing home based care to the patient (Falvey et al., 2016).  Both Sophia and Mr. Russo will be given care and will be helped towards improvement of their mental health. The other goal is to provide a better intervention for hypotension and pressure ulcer to reduce the chance of re hospitalization of the patient (Renke and Ranjio, 2015)-

Goal 1-

The primary objective is to provide an efficient transfer of care from hospital to home for Mr. Russo with the help of Intercare service limited, Sheffield. 

Goal 2-

The secondary objective is to provide a strength based approach for Mr. Russo and his family in order to recover fully from their condition. 

Legal and ethical issues involved during the transition of care-

While transfer of care from the hospital to home based setting, there are several legal and ethical issues involved in it. In the care practice, these issues may have certain ethical implications. The patient with certain mental instability generally lack the awareness and the capacity of taking any decision and therefore they are not able to give their full consent on any type of care process decided by the caregiver. In later stages, it may create certain ethical conflicts between patient and the care givers. Confidentiality of information is also important to be maintained while taking any decision on care regimen. The case further gets complicated when the patient demands their diagnosis must be kept confidential and must not be shared with anyone. Although they generally demands it to safeguard themselves from social stigma and unwanted social isolation, however, this may have a long term implication on the health of the patient. The patient don’t want to feel awkward in front of the care giver and on the other side of the coin, if the complete detail about the health history of the patients are not shared then it may lead to disruption of the care proces (Ensing et al., 2015). 

Strength based approach for recovery-

According to the value 5, environment and the person are integral. The patient and their family are highly affected by their environment, both socially and physically. One of the environmental condition may take out the best from a person and the other one will be associated with their vulnerabilities. The people thrive and grow when there is a goodness of fit associated with their environment. For instance, Mr. Russo was quite friendly, happy and hardworking person and was having a good rapport with the community. It means that the interaction with his community takes out best from him. The business was single handedly taken to a newer height and because of his sharp business ethics and knowledge, he was liked by most of the people. The business is completely stopped now  but his core strength was his business mind and ethics. He can collaborate with his community members and start a consultancy service to help grow their business. It will make him more engaged in work and earn money to re establish his family (Kangsara et al., 2016). Such kind of environment will help Mr. Russo to draw on the strength he has and provide opportunities for their development and healing. The nurses of Intercare limited are aware about the interaction of people with the environment. They observe people multiple time during crisis and often understand that a simple gesture of kindness from the friends, relatives and neighbors may give a compassionate touch to the patient.  As Mr. Russo was happy and extrovert person, he will be allowed to interact with people and live natural life that he use to do when he came to Sheffield (Feltner et al., 2014). 

 (Miller et al., 2016). 

Self determination is another important aspect towards the strength based approach for mental health recovery. The nurses also support the self knowledge and choices of value of a person and enable them to act according to the situation that go previously affected by predisposition and ill circumstances. The exercise of self determination will allow the patient to make a choice of living and giving a response to a specific limitation and stay within the context of healthcare intervention that is being undertaken. The role of the nurse here will be to listen to the patient in order to elaborate, explain, clarify, provide suggestion and information and then connect them with the resources and people. In case of Sophia and Emma, they both can support each other and help Antonio to grow and help father for his health. Sophia is a good cook and have that talent that can help to live her life in a better way. She can guide Emma to become a good cook and even Emma can start her own food business with the help of her mother. Emma also can learn some skills of cooking and help the community member by providing food services. Emma, Sophia and Mr. Russo can start their own business of home based restaurant by providing food at lower cost to the people in community (Davies et al., 2015). 

Along with all these, the physical fitness of Mr. Russo is also important after getting discharged from the hospital. An appropriate nursing intervention will be taken on his diet and his pressure ulcer will be treated using appropriate medical intervention. 

Culturally safe care –

The intercare health service provides culturally appropriate care to the patient even at high acuity and stressed scenario. The service providers will be having an optimum knowledge about the cultural diversity of the Russo family. The nurses will be aware about the primary origin of the family and will try to facilitate care on the basis of that. Sophia was not good in English and therefore care must be provided to her in a way that it must not get affected by the language barrier. For a proper knowledge dissemination, the nurses can take help from Mr. Russo and Emma who will be there around with Sophia all the time (Shah et al., 2016). 


.The research findings also suggest that the transfer of care always involve a team effort where if there is an inadequate coordination may lead to unwanted consequences. The poor coordination includes incomplete patient education, poor discharge, poor medication chart and inappropriate transition etc. Because of the involvement of such issues, most cases leads to readmission in the hospital and increases the stay in hospital as well. The strength based approach for the mental recovery for Mr. Russo can be vital. In this case, out of eight values, Self determination and integrity of Mr. Russo with the environment will be very important.