Transcultural Nursing Case Study Worksheet
Mrs. Dolores Hernandez is a 65 y/o obese, Cuban woman presented to your county clinic where you work as a FNP. She arrived to the clinic, with her grown daughter, Mariana, c/o weakness, lethargy, and fatigue x2 mos. She reports last week, while cooking at her daughter’s house, she lost her balance and slipped on the kitchen floor. She denies LOC, and admits to only a mild bruise on her leg. She arrived in clinic with Mariana who insisted that she goes to the clinic for her persistent sxs.
Mrs. Hernandez is widowed x4 yrs. Her husband died of a heart attack. She lives with Mariana since then. Mariana is 40 y/o. and employed FT as a supervisor at the local phone company. She also has a retail job, after work, about 3-4 times/wk. Mariana is divorced and has three children: Luis, 15, Carmen, 10 and Sophia, 7. Since moving to Mariana’s house, Mrs. H has been managing the household while Mariana works two jobs. Mrs. H prepares the family’s meals, attends to the children when they come home from school, and do light housekeeping chores. The family is originally from Cuba, has been living in SF for 12 yrs. Luis was born in Cuba, and the other two children in Miami. Mrs. H does not speak English. Although the children and Mariana occasionally speak English among themselves, the family’s language at home is Spanish.
Today, she was diagnosed with essential htn and NIDDM. You prescribed an oral hypoglycemic med and advised Mrs. H to exercise daily and to limit her food intake to 1500 calories/day. Mrs. H is concerned as she usually prepares traditional Cuban meals at home and was not sure whether she could tolerate being on a diet. Besides she thought that her dishes are very “healthy.” She added that her three grandchildren are all plump, nice looking, and healthy. You overheard Mrs. H tell Mariana that instead of buying the prescribed med, perhaps she should go to the botanica and obtain some herbs that would help her lower her blood sugar.
Complete this worksheet and submit it to Canvas.
As a health-care provider, utilizing Leininger’s theory and the Change theory, implement a medical plan for Mrs. H. Please submit a one page summary of your plan for Mrs. H’s visit today. Please use a SOAP format. If you are unclear how to write a SOAP note, please see the following reference: http://fcm.unm.edu/education/physician-assistant-program/docs/template_clin_soap_note.pdf
- The subjective part of SOAP note should include: chief complaint (CC), history of present illness (HPI), allergies, social history, and medications. It should include information pertinent to this section, and not include information that belongs in a different section of the SOAP note.
- The objective part of SOAP note should include: vital signs, BMI, HEENT, Pulmonary, CV, GI, Skin, and Point of Care Testing. Not all of the information that you will need for the objectivesection of the SOAP note is provided in the case study, so you will need to make up the information (generate the information). For example, you will need to make up the patient’s vital signs. You should make up data that it is congruent with the information provided in the case study. For example, if the patient in the case study was described as “underweight”, you would make up a BMI that reflected an underweight patient (< 18.5). You will also need to make up information about your physical exam and point of care testing. It should include information pertinent to this section, and not include information that belongs in a different section of the SOAP note.
- The assessment part of SOAP note should include: at least three medical diagnoses (not nursing diagnoses). Please note that the only things that belong in the assessment section of the SOAP note are diagnoses, e.g., 1. Broken femur; 2. Underweight; 3. Osteoporosis
- The plan part of SOAP note should include a plan for each of the diagnoses (from the assessment section) e.g., 1. Cast, rest, pain medication prn; 2. Referral to dietician and increased dietary intake; 3. XX
After writing your SOAP note, answer the following questions. Provide SPECIFIC examples of how you would apply the theory to this patient’s situation. It is not correct to say “I would provide culturally sensitive care”. You need to state specifically what you would do, say, or recommend in order to provide that care, and explain how your actions represent an application of the theory.
The key to this assignment is demonstrating that you can apply theory to a real-life patient situation.
- How did you apply Leininger’s theory to this patient situation?
- How did you apply the Change theory to this patient situation?
- What are some actions you would take to address cultural competency in this type of situation?