Mr. Winter
Tara Attwater; Lori Boen; Dorie-Anna Dueck; and Getahun Lombamo
Background
Mr. Winter is a fictitious patient. Any resemblance to real patients/health care providers is accidental and unintentional. As a resident in a rural setting in Saskatchewan, much of his narrative is typical of a person living in this setting. In this case study, fourth year undergraduate students in nursing, dentistry, medicine, and nutrition will be involved in the care plan. It is important for participants to identify a potential medical and nursing diagnosis, the risks and benefits of treatments and interventions, identify available supports and serve as conduits to resources. Each professional role will have the opportunity to collaborate in the decision-making.
Problem-based learning is an interactive, learner-centered approach to learning in small group setting. Successful learning in PBL is dependent upon team interaction and collaboration. Although students are not expected to have prior knowledge of case, they should come prepared to participate in discussion and sharing of what they know; they should be willing to ask for clarification and conduct credible research to add to the shared knowledge for enhanced team learning.
Day 1
Case Info:
Mr. Winter is a 48-year-old male who lives independently outside of Saskatoon, a couple of miles past Vanscoy. He manages his farm and describes himself as active and healthy. He has been advised in the past to reduce his sodium intake although he does not feel there is a need for him to make these dietary changes. Today he has come to the community clinic as he has been feeling tired despite sleeping his normal 4-5 hours per night.
You are a member of an interprofessional healthcare team stationed at the community clinic where Mr. Winter has come to visit. Your team’s task is to come up with a care plan that will enable you to provide the best possible care for Mr. Winter. How would you approach the situation based on what you know at this stage?
Note: This is a fictional case intended to approximate an actual clinical interaction.
Tutor Probes
- Why is sodium consumption important to discuss with a patient?
- What aspects of his social situation would you want to know about?
- List five differential diagnosis for fatigue.
- What are 2 priority nursing diagnosis? Can you think of 3 interventions per each diagnosis?
- Do you consider that his sleep pattern of 4-5 hours per night supports a healthy lifestyle?
- What medical history would you like to ask him about?
- What are the most common health issues among the demographic group Mr. Winter represents?
- What are health service access related issues for people living outside of the city?
- What community resources are available in Vanscoy area that people like Mr. Winter could utilize?
- What defines an “active” lifestyle? Are there any criteria that define various activity levels?
- What defines healthy? Who does Mr. Winter define as part of his health care team? Are there any gaps?
- What type foods contribute to high levels of dietary sodium intake?
- Salt makes our food taste better. How do you advise patients to reduce sodium intake? Are there any practical tips you could provide to patients?
- What are the current recommendations around sodium intake for Canadian population?
- Does the new Canada Food Guide provide any information you can use to counsel patients around sodium intake? [Hint: Check out Health Canada’s web-based application]
Wrap-Up Questions
- As a collective group, what are your top 3-4 priorities?
- What information do you need to follow up on?
- How would you summarize Mr. Winters’ situation based on what you know so far?
- What other professions need to be at the table to provide care for Mr. Winter?
Day 2
Case Info:
Mr. Winter has a big harvest coming up. He is spending a lot of time worrying about his fields. The previous years have been difficult for him and he has struggled to pay bills. He is married with three adult children; two are in university. His wife has been able to work in the city but drives back and forth from the city to the farm.
Although he recalls the advice given to him by his family physician last year about reducing his sodium intake, he did not follow up with her. He very rarely sees his family physician for primary and secondary health care prevention. The only other care provider he sees is his dentist, which was just over 2 years ago to repair a broken tooth. As he does not have dental coverage, a complete examination and cleaning was not done.
He admits that he smokes cigarettes and drinks alcohol occasionally but only in social situations.
He is taking no medications. He is unaware of any significant health problems. He reports two episodes of pneumonia last year but did not require hospitalization.
His vital signs when he presents to clinic reveals: Blood pressure is 157/85, heart rate is 95/minute and regular, SpO2 on room air is 94%, his weight is 104 kg and height is 72 inches; his waist circumference also measured 103 cm.
Note: This is a fictional case intended to approximate an actual clinical interaction.
Tutor Probes
- What are Health Canada’s recommendations for daily sodium limits?
- What is Mr. Winter’s BMI? What do the results mean? Do you think that a measure of BMI reflects a healthy height and weight? What limitations does the BMI have?
- What is waist circumference (WC) used for? What is normal WC? What does a WC of 103 cm mean? What are the potential health consequences of an elevated WC?
- How would you ask Mr. Winter to quantify his smoking and alcohol consumption in a non-judgmental manner?
- What are the nutrition implications of smoking and alcohol consumption to individuals like Mr. Winter?
- Are there specific nutrient deficiency risks associated to alcohol consumption and smoking? What are the current nutrient/dietary recommendations to people who consume alcohol?
- What are the impacts of smoking and alcohol on health?
- How do you make the diagnosis of hypertension? How is blood pressure accurately measured in clinic?
- Is Mr. Winter stressed? If so, what impact does stress have on blood pressure? On hypertension?
- What recommendations would you give Mr. Winter to reduce or cope with stress? What resources would be available to respond these recommendations?
- What access to healthy foods does Mr. Winter have in this rural setting? Would this have an impact on adherence?
- What is your role in linking Mr. Winter to resources?
- What is the relationship between periodontal disease and hypertension?
- What types of dental coverage are available to Saskatchewan residents (private or public programs)?
- As a group, what questions would you ask about his dental coverage option? Are there community resources that you could think of to help him?
Wrap-Up Questions
- List 5 potential diagnosis on your differential diagnosis.
- How would you prioritize his medical issues?
- What other risk factors for cardiac disease would you like to screen for. Can you identify why?
- How do we distinguish between primary and secondary prevention?
- What nursing interventions would be priority given the facts above?
Day 3
Case Info:
After three weeks have passed, Mr. Winter has returned to the community clinic for a follow up visit. You have explained to Mr. Winter that he has hypertension. After discussing the impact of stress and healthy eating with Mr. Winter, he has voiced a commitment to follow-up with the community health nurse and dietician that come to the community clinic in Vanscoy once per month.
However, he tells you that his smoking is not a problem. He needs this for stress relief. “I’m really busy with the harvest this month. Could I wait to discuss this in the spring?” He states that he only smokes outside to reduce second-hand exposure for his wife. Mr. Winter expresses that he is willing to explore further strategies for stress reduction when he meets with the community team.
How you modify Mr. Winter’s care plan at this stage? What would be your top priorities in terms of treatment plan and other recommendations?
Note: This is a fictional case intended to approximate an actual clinical interaction.
Tutor probes
- How common is hypertension in Saskatchewan? Where does SK stand on prevalence of hypertension compared to other provinces?
- Are there different severity levels to hypertension (low, moderate, severe etc.) and specific treatment approaches to each? What are the end organ consequences of poorly controlled hypertension?
- Are there specific dietary recommendations for patients with hypertension?
- How would you approach his question about smoking from a FIFE (Feelings, Ideas, Functioning, Expectations) framework?
- Are you aware of accessible community resources to support a smoking cessation approach that you could offer him? Are there any resources online?
- Can you think of 10 consequences of smoking? And consequences of second-hand smoking exposure?
- How can you address, using a strength-based approach, Mr. Winter’s decision to continue smoking as a coping strategy? Will confirming his receptiveness to accessing resources provide a foundation for further interventions? Do the community health nursing standards of practice require a strength-based approach?
- What is a strength-based approach?
- What are some nutritional aspects?
- How are smoking and appetite connected? Which nutrients are smoking people at greater risk of deficiency? Why?
Wrap-Up Questions
- How would you modify you care plan based on what you know about Mr. Winter?
- What would be a priority issue your team sees needing immediate attention?
