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CRITICAL ANALYSIS OF A SELECTED SCENARIO FROM CASEWORLD

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The case chosen for this paper is that of Jessica White, a girl five years of age, living with her brother and parents in her maternal grandmothers house. Jessica was born prematurely at 33 weeks gestation and was diagnosed with eczema and asthma shortly thereafter. Jessicas condition is complicated by a variety of other factors, both environmental and genetic. The present paper attempts to identify the potential barriers to the effective planning of the care transition for Jessica. To this end, it critically reviews the adequacy of the information provided in the case study and identifies what further information might be needed for the development of an on-going post-hospitalisation care for Jessica. In the process, it also explains how pathophysiological, cultural, and social factors affect the provision of care for the asthmatic patients that require a long-term care in a community or extended care setting, drawing on the case of Jessica White. Overall, the information provided in the case study seems sufficient for the clinical treatment but is not enough for developing an effective post-hospitalization care programme for Jessica.

It would be wise to begin the paper with a critical analysis of the information provided in the case study. When Jessica White was hospitalized with asthma, she was five years old, weighing 20 kilograms and standing at 104 centimetres. Despite the fact that she was born prematurely, namely four to five weeks early, her parameters suggest that she is developing in accordance with the normal patterns. Some research shows that the premature newborns may develop at a slower pace, according to the miss developmental timelines, or exhibit evident developmental problems (Bukatko & Daehler 2011). The most common problems that the new-borns experience are underdeveloped heart and lungs, awkward movements, unsteady brain development, and problematic sleeping. Jessicas parents report that, save for her respiratory maladies, she does not have any other symptoms that may suggest any developmental problems. However, although Jessica has a penchant for studying and is enthusiastic about starting school, she has experienced some learning difficulties. Moreover, in the case study, it is stated, Jessica was able to respond to questions of the nurses with single words. It might be another hint to her learning difficulties. While an accurate explanation of Jessicas learning problems can be given only upon a closer examination, it is possible that her premature birth might be one of the key factors. As to the impact of the premature birth on the newborns lungs, it can hardly be the cause of the development of asthma in Jessica, but it could worsen her condition. While the genetic causes of asthma are the most persistent and difficult to treat, they do not pose a barrier to effective planning of the care transition for Jessica as significant as the other factors do.

The home environment in the White family is one of the most evident barriers. Despite reassurances from Jessicas parents, her life does not run in an ordinary groove, as for a five-year-old girl. She is living with her mother (42 years), father (45 years), brother (11 years), and grandmother (75 years). Jessicas father abuses alcohol and drugs. Because of this fact, violence within the home environment is common. To the boot of that all, Jessicas brother is mean to her. The whole experience is unnerving to Jessica, and further erodes her emotional well-being. There is nothing strange about it. Indeed, Research has shown significant evidence of harm to children who live in homes where there has been domestic violence (Marsolini 2006, p. 159). Apart from being sorry for their parents, such children may live in a constant fear for own lives. Likewise, it is possible that the domestic violence in the White family had started even before Jessica was born. While it cannot be taken as an axiom because of the lacking information in the case study, the mere possibility of it being true may also shed some light on the girls case. According to Marsolini (2006), 6% of pregnant women are battered causing injury to the mother and potentially her unborn child (p. 159). Pickup, Williams, and Sweetman (2001) argue that one of the implications of the violence against pregnant women is premature birth. Whether Jessica was born four weeks early because her father beat her mother or not, one thing is sure: harsh domestic environment in the White family may militate against Jessicas convalescence and should be considered in designing the post-hospitalization care programme for her.

Asthma self-management is one of the lynchpins of the post-hospitalization care for children with asthma. At the root of all asthma self-management programmes, there lie three principles. First, asthmatic children can live healthy and active lives. Second, asthma can be controlled by drug therapies, as well as education and environmental regulation. Among these instruments, drug therapy stands out as the most important and efficient one. The third principle of any asthma self-management programme presumes that the asthma episodes are easier to prevent than to treat. In order to prevent the asthma attacks and exacerbations, the patient should strictly adhere to the therapeutic programme designed specifically for him or her. Apparently, self-care should be nurtured in the asthmatic children from the early age; nevertheless, in Jessicas case, a hostile domestic environment can have a negative impact on the girls asthma self-care development. Because of a complicated atmosphere in the household, the girl may feel a lack of family support and disregard the principles of the asthma self-management.

Children may feel frustrated when asthma exacerbations disrupt their daily routines. It is imperative that they are educated about what measures to take in order to prevent the asthma episodes. They also require constant reassurances from their family members that they can cope with the disease and live a full life if they learn how to do it. Although Jessicas mom is sincerely worried about the condition of her daughter, the unsettled domestic environment in the family may thwart her efforts in educating the girl or obstruct the already made progress. Moreover, in the case study, it is stated that Jessicas father has received an occupational injury and could not continue working. Jessicas mother, on the other hand, has to earn money for the family while the daughter spends more time with her problematic father. From the information contained in the case study, it appears that Jessica does not like her father and brother as much as she likes her mother. When her father and brother visited Jessica in the hospital, the girl was sad and even anxious and asked when her mom would come. This situation cannot but have a deleterious effect on the girls asthma self-care efforts. Indeed, for the child to be able to cope with asthma effectively, all the family must involve in the process. The possibility of a crisis necessitates a great deal of parental vigilance and attention in the form of educational sessions, sleepless nights, and occasional visits to the hospital. Therefore, a post-hospitalization care program should include recommendations about the education for parents. Alternatively, though not as productively, the nurse could assume the role of a moral supporter by providing education and moral reassurances for the child.

What is more important, a disruptive atmosphere in the White family may result in a situation where Jessica will neglect her daily asthma medication regimen. Sometimes, when there are protracted time lapses between the episodes of asthma, children tend to think that the disease will vanish on its own and abandon the regimen altogether. The ever-growing body of literature on the topic suggests that indeed, the condition often disappears before adolescence (Harver & Kotses 2010; Austen & Lichtenstein 2013). However, there is an important prerequisite for such a favourable outcome: a strict adherence to the asthma self-management programme and asthma medication regimen. The failure to recognize the importance of it may have the far-reaching health implications for the patient. The nurse, as a prime caregiver, is mandated to report any neglect or complete abandonment of the treatment regimen. Nevertheless, the most essential task of the nurse is to discourage such behaviour in the asthmatic patients through education, reassurance, and support.

The information contained in the case study does not say anything about the ethnic origin of Jessicas parents. Adapting Jessicas on-going post-hospitalization care program to her familys ethnic origin may seem an unusual and even irrelevant task, it might also have an impact on the treatment outcomes, as it is explained later in the text. All Jessicas relatives have typical Australian names, but it does not mean that the family is native to Australia. In the case study, there is only an oblique reference to the girls familial background. In the girls personal details, it is stated that her given name is Jessica Ainija. Employing the method of deduction, one may uncover the approximate lineage of the girls parents. In such a manner, a quick scan of the Internet shows that Ainija is a rare, albeit existing, Indian female name. It is unlikely that the girls parents gave her an exotic Indian name just out of curiosity. According to Partridge (2000), the rates of asthma among South Asians living in the United Kingdom are somewhat higher than among the other residents of the country. However, he immediately adds a disclaimer:

Hospital admission rates may be higher than in the rest of the population but this is unlikely to reflect severity and, indeed, it is unlikely that there are any specific differences in the clinical pattern of the disease in Asians than in other groups of the population (Partridge 2000, p. 176).

While having limited the relevance to Jessicas development of asthma, her putative Indian extraction is certainly important in planning the post-hospitalization care for the girl. As Marsolini (2006) states in his book Raising Children in Blended Families, childrens health needs are often blithely ignored by at least one of the parents in the problematic families with the mixed ethnic background. Partridge (2000) further contends that the South Asians in the UK and, perhaps, other parts of the world tend to disregard the self-management plans more often than the white Europeans do. Whereas the detrimental home environment reflects some social barrier to the provision of care to the asthmatic patients, the unwillingness to adhere to the self-care plans reflects cultural barrier to the provision of care.

Another factor that needs to be considered in designing Jessicas post-hospitalization care is that her family has recently moved to the northern suburbs of Adelaide to live with Jessicas maternal grandmother, who is 75 years old. Because of the relatively mild climate, Adelaide is an ideal place for a variety of deciduous and evergreen trees and shrubs, as well as perennial and seasonal flowers. Many people believe that the fruit trees with rich blossom are more likely to trigger the asthma symptoms while, in fact, the opposite is true. The thing is that the pollen from blossoming trees is heavy and sticky and does not spread with the wind as readily as that from the other trees (Baillie-Hamilton 2005). Therefore, among the trees that are inimical to asthmatic people, there are ash, aspen, birch, cedar, elder, elm, hickory, oak, and willow. Most of these trees are tolerant of Adelaide conditions. Moreover, it is a matter of conventional wisdom that the suburbs are always densely planted with trees and flowers. Projecting these findings onto the case of Jessica, it appears that the familys decision to move to the suburbs may only complicate Jessicas condition and/or impede her recovery. Again, there is a dearth of information about the plants growing in Jessicas new neighbourhood, which might pose challenges to the nurse in charge of designing an effective post-hospitalization care programme for the girl.

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Apparently, the allergic reaction to pollens is not always an asthma trigger, but the possibility that this reaction may develop in the future should be ruled out. Jessicas situation may be also compounded by the fact that she was hospitalized with asthma in late February. Different trees release pollen at different times, but most do so in the early spring. Because pollen counts in the air are high in the spring, the season is a difficult period for asthmatic people with the outdoor allergies. However, it is true that even those asthmatics who do not have outdoor allergies may suffer in the springtime to a greater or lesser extent (Baillie-Hamilton 2005).

Because of living in the densely-planted and windswept area of the city, Jessica may have a hard time coping with her illness. Therefore, an effectively planned post-hospitalization care programme for Jessica should be tailored to her whereabouts, as well. The first thing the nurse should do is determine which plants, if any, trigger allergies in the patient. Once this is done, it will be easier to ascertain how the patient could avoid this pollen. Some recommendations, however, are similar to all the asthmatic people with the outdoor allergies. For example, the patient should be encouraged to stay inside when the pollen counts in the air are high, and wear a mask when he or she needs to go out. Usually, the pollen load is higher on dry and windy days and lower during cold and overcast spring days (Hannaway 2004). On any occasion, the pollen levels are lower in the evening, which is an ideal time for asthmatic people to perform the outside activities. In order to overcome the hazards of the dry indoor air, which facilitates the transmission of respiratory infections between household members and complicates the life of an asthmatic person, humidifiers should be installed in the building to add water vapour to the air (Hannaway 2004, p. 167). This recommendation is especially apt in Jessicas case if one considers the fact that recently, her grandmother was also hospitalized with asthma.

Some measures may be necessary in order to reduce the amount of pollen near the house. Therefore, the lawns should always be neatly trimmed, as the mature grass generates more pollen (Hannaway 2004), and any ragweed that grows nearby cut down before it pollinates. More radical measures, for example, pruning back the branches of a tree or felling it altogether, may be needed in order to reduce the pollen load in the air. In the case the recommendations are not followed, and the patient feels sick, there should always be an over-the-counter asthma drug and prescription in the house to alleviate or eliminate the symptoms. Some other specific recommendations may be designed to fit the needs of the patient, depending on the severity of his or her asthmatic reactions to pollen.

One important reservation is that Jessicas diet should also be thoroughly monitored. Children of her age may not realize the importance of their parents words and are often blase about the dangers. Given that Jessica has eczema, such dangers are legion. Eczema is a disease that makes patches of human skin rough and broken; it is often caused by an external irritation. Most important, however, eczema is associated with the food allergies (Davey 2014). According to Davey (2014), The oral allergy syndrome is the association of inhalant allergy to birch pollen in association with lip and tongue swelling when eating soft fruits, such as peaches, nectarines, apples, almonds and other closely related fruits (p. 162). In fact, the list is much longer and includes both fruit and vegetables. It means that the patients with an evident allergy to birch pollen should avoid eating these products raw in order to prevent itchiness and swelling in the mouth. For the asthmatics, the benefits of eating fruit do not necessarily outweigh the associated risks.

Because Jessica has both eczema and asthma, the post-hospitalization care programme for the girl should include the recommendations about her diet. In the case study, there is a paucity of information about any foods that cause allergies in Jessica. Therefore, the allergy skin tests need to be conducted in order to identify her sensitivity to the asthmatic stimuli and allergens and, therefore, ascertain whether certain foods may worsen her asthma or not (Fanta, Cristiano, Haver & Waring 2003). Despite not being the most precise method, a hive reaction to a modicum of raspberry injected into the patients skin may give a glimpse whether eating raspberries will worsen the patients asthma or not. With a greater success, similar tests may be performed in order to determine the impact of the dust mite allergens on the patients asthma. Depending on the results of this test, the decision should be made whether or not to take any preventive measures associated with the dust mite allergy. Indeed, if the patient does not have the dust mite allergy, such measures will hardly help his or her asthma. Returning to Jessicas eczema and its potential influence on asthma, it is necessary to say that a carefully planned and implemented dietary manipulation can help the girl cope with the condition. Nevertheless, first, an elimination diet with sequential reintroduction of foods must be undertaken in order to identify which food cause the symptoms (Davey 2014). Likewise, a self-explanatory double-blind placebo-controlled challenge may be undertaken for the same purpose.

Among the other potential barriers to the effective planning of the care transition for Jessica is her familys love for pets. They have two long-haired dogs and one short-haired cat. In fact, it is not the length of the fur that matters because the animal dander and saliva rather than fur trigger and/or exacerbate asthma. It appears from the information contained in the case study that Jessica likes her pets, but it is not clear whether she is allergic to animals or not. Indeed, according to Tinkelman and Naspitz (1992), only 30% of asthmatic people are allergic to the animal dander. The tests need to be conducted in order to obtain the necessary information in Jessicas case. If she turns out to be allergic, it may be a gruesome experience for her to part with the animals. Finally, the fact that Jessicas maternal grandmother has returned from rehabilitation after a recent cough-variant asthma and needs care from her daughter also is to be considered when designing a post-hospitalization care programme for the girl. It may serve as a barrier to effective planning of the care transition for Jessica not so much because her grandmothers disease will somehow affect Jessicas condition, but rather because Jessicas mother, as the main provider of care in the family, will have to shunt between her daughter and own mother.

Overall, assessing the information provided in the case study, one may conclude that it is adequate for the hospital treatment of Jessica but is definitely insufficient for developing an effective post-hospitalization care programme for the girl. Particularly, it is necessary to find out whether Jessica is allergic to food and animals, whether the girls mother had been exposed to domestic violence before she gave birth to Jessica, and whether the family has firm Indian or any other non-Australian origin. Similarly, there is a paucity of information about the plants growing in the familys neighbourhood. The tests and observations need to be conducted in order to fill in the gaps and design a truly effective post-hospitalization care program for the girl. Likewise, it might be useful to ascertain whether the girls learning difficulties are related to her premature birth. Drawing on the case of Jessica White, the paper has shown that pathophysiological, cultural, and social factors have a significant impact on the provision of care for the asthmatic patients with the long-term care needs.

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