NSG 420 Stratford University

The Sanchez Family

Mr. and Mrs. Sanchez, aged 77 and 68 respectively, have been raising their two grandchildren for the past five years. Maria (age 10) and Tony (13) were orphaned five years ago when their parents (the Sanchez’s daughter and her husband) were killed in an automobile accident. The children’s father was driving home with his wife home from a party where he had been drinking heavily. Neither of the Sanchez’s two other children were in a position to take on parenting responsibilities. Mr. Sanchez is retired from a position with the post office. Mrs. Sanchez supplemented their income by cleaning apartments.

Approximately two months ago, Mr. Sanchez suffered a stroke, which left him with considerable impairment. He has been admitted to a rehab facility, where he is progressing well, and the expectation is that he will be returning home. He currently has some speech impairment and is partially paralyzed on one side. It is not clear how fully he will recover, but the expectation is that there will be some residual impairment. It is also unclear how he will be able to manage as the home has two stories, and the only bathroom is on the second floor.

Prior to Mr. Sanchez’s stroke, Tony was beginning to get into trouble at school. This took the form of “sassing” his teachers and failing to do his homework assignments. Last week, Tony assaulted another student and was therefore temporarily suspended from school. Maria, always a quiet child, has presented no problems at school, although her teachers have noticed that she now spends more time by herself.

Mrs. Sanchez initially was able to handle things with the same determination and task-oriented focus that she used to deal with the loss of her daughter and transition to the “parent” role for her grandchildren. However, Tony’s suspension from school has taxed her beyond her ability to cope. Mrs. Sanchez has become weepy, unable to focus, and unable to make decisions. She has had difficulty explaining to Tony and Maria what is happening to their grandfather. She has not told Mr. Sanchez about Tony’s suspension.

Mrs. Sanchez is called to attend a meeting with the school principal and social worker. When the social worker asks Mrs. Sanchez if she could give them any insight into why Tony has become so aggressive, she bursts into tears.


1. Identify the presenting problem or problems for each person and as a family?

a. Mrs. Sanchez

b. Mr. Sanchez

c. The Sanchez family

d. Tony

e. Maria

2. Identify the client’s. What are you visualizing from the information in the scenario?

a. Mrs. Sanchez

b. Mr. Sanchez

c. The Sanchez family

d. Tony

e. Maria

3. Identify the Current Stressors for each person in this case?

a. Mrs. Sanchez

b. Mr. Sanchez

c. The Sanchez family

d. Tony

e. Maria

4. What Information do you want to know? Is there more information to gather, if so WHAT and your rationale for the WHAT?

-2 nursing diagnosis and 1 intervention

5. What resources would you implement for all parties in this case?

6. Identify attitudes and stereotypes toward aging and older adults?

NSG 420 Stratford University

A Downward Spiral: A Case Study in Homelessness

Terri LaCoursiere Zucchero, PhD, RN, FNP-BC, and Pooja Bhalla, MSN, RN

National Health Care for the Homeless Council

Learning Objectives: At the end of this activity, you will be able to:

  • Analyze at least three issues contributing to homelessness.
  • Describe barriers to health care for individuals who are homeless.
  • Identify key characteristics of quality health care for the homeless.

Description: Thirty-six-year-old John may not fit the stereotype of a homeless person. Not long ago, he was living what many would consider a healthy life with his family. But when he lost his job, he found himself in a downward spiral, and his situation dramatically changed.

John’s story is a fictional composite of real patients treated by Health Care for the Homeless. It illustrates the challenges homeless people face in accessing health care and the characteristics of high-quality care that can improve their lives.

Case: Married with two young children, John and his wife rented a two-bedroom apartment in a safe neighborhood with good schools. John liked his job as a delivery driver for a large food service distributor, where he had worked for more than four years. His goal was to become a supervisor in the next year. John’s wife was a stay-at-home mom.

John had always been healthy. Although he had health insurance through his job, he rarely needed to use it. He smoked half a pack of cigarettes each day and drank socially a couple times a month.

One afternoon, John’s company notified him that it was laying him off along with more than a hundred other employees. Though he was devastated about losing his job, John was grateful that he and his wife had some savings that they could use for rent and other bills, in addition to the unemployment checks he would receive for a few months.

John searched aggressively for jobs in the newspaper and online, but nothing worked out. He began to have feelings of anger and worry that led to panic. His self-esteem fell, and he became depressed. When John’s wife was hired to work part-time at the grocery store, the couple felt better about finances. But demoralized by the loss of his job, John started to drink more often.

Two beers a night steadily increased to a six-pack. John and his wife started to argue more often. Then, about six months after losing his job, John stopped receiving unemployment checks. That week, he went on a drinking binge that ended in an argument with his wife. In the heat of the fight, he shoved her. The next day, John’s wife took the children and moved in with her parents. No longer able to pay the rent, John was evicted from the apartment.

John tried to reconcile with his wife, but she said she’d had enough. Over the next few months, John “couch surfed” with various family members and friends. At one point, he developed a cold, and when it worsened over a few weeks, he sought care at the emergency department. Hospital staff told him that he would be billed because he didn’t have insurance. John agreed, and a doctor diagnosed him with a sinus infection and prescribed antibiotics. With no money to spare, John could not get the prescription filled.

John continued to live with family and friends, but his heavy drinking and anger only got worse, and his hosts always asked him to leave. He went from place to place. Finally, when John ran out of people to call, he found himself without a place to stay for the night and started sleeping at the park.

One night when John was drunk, he fell and got a cut on his shin. The injury became red and filled with pus. John was embarrassed about his poor hygiene and didn’t want a health care provider to see him. But when he developed a fever and pain, he decided to walk to the nearest emergency department. He saw a provider who diagnosed him with cellulitis, a common but potentially serious bacterial skin infection, and gave him a copy of the patient instructions that read “discharge to home” and a prescription for antibiotics. John could not afford the entire prescription when he went to pick up the antibiotics, but he was able to purchase half the tablets.

Winter arrived, and it was too cold for John to sleep outside, so he began staying at a shelter run by the church. Each morning, he had to leave the shelter by 6 AM. He walked the streets all day and panhandled for money to buy alcohol.

One evening, some teenage boys jumped John in park, stealing his backpack and kicking him repeatedly. An onlooker called 911, and John was taken to the emergency department. Later that evening, the hospital discharged John. He returned many times to the emergency department for his health care, seeking treatment for frequent colds, skin infections, and injuries. Providers never screen him for homelessness and always discharge him back to “home.”

One day at the park, an outreach team from the local Health Care for the Homeless (HCH), one of about 250 such non-profit organizations in the United States, approached John. The team, including a doctor, nurse, and case worker, introduced themselves and asked John, “Are you OK?” John didn’t engage. They offered him a sandwich and a warm blanket. John took the food without making eye contact. The team visited John for the next several days. John started making eye contact and telling the team about his shortness of breath and the cut on his arm. The team began seeing John frequently, and he began to trust them.

A couple weeks later, John agreed to go the HCH clinic. It was the first time in years that John went to a health clinic. Upon his arrival, the staff at the clinic registered him and signed him up for health insurance through Medicaid and food benefits. John felt comfortable in clinic, and he saw some of the people who also stayed at the shelter and spent their days in the park. They were happy to see him and told John about how the clinic staff care and would be able to help.

John began going to the HCH clinic on a regular basis. He saw a primary care provider, Maggie, a nurse practitioner. In John’s words, she treated him like a real person. In addition to primary care, the clinic offered behavioral health services. Both scheduled appointments and walk-in care was available. John connected with a therapist and began working on his depression and substance abuse.

A year later, John’s health has improved. He rarely needs to go to the emergency room. He is sober and working with a case manager on finding housing.

Terri Zucchero is the Family Team Director at Boston Health Care for the Homeless Program and an Assistant Professor at the Graduate School of Nursing, University of Massachusetts Worcester. Pooja Bhalla is the Chief Operating Officer at Boston Health Care for the Homeless Program. For more information on health care for the homeless, please visit the National Health Care for the Homeless Council and Boston Health Care for the Homeless Program.


  1. What were some of the barriers John faced in accessing health care?
  2. Why do you think the emergency department was the first place John thought to go for care? How might the emergency department improve care for patients like John?
  3. Why do you think John wouldn’t make eye contact with the HCH team at first? How would you build a trusting relationship with a person like John?
  4. What aspects of the HCH care do you think represent high-quality care for the homeless? How do you think Maggie made John feel like he was a “real person?”
  5. In your own experience, have you encountered a homeless individual? What was that like? Do you recall what you were thinking?

Remember some of these questions are Two questions in One. Ensure you answer all completely (detailed) but does not need to be a novel. (300+ words)

NSG 420 Stratford University

Sarah is 34 years old and married. She does not work on Mondays and when she is alone she spends her time at home. One Monday in the summertime she was at home relaxing and listening to music, naked in the living room. It was quite loud and her neighbor from the apartment opposite hers came in (without knocking first), in order to ask her to turn it down. When he found Sarah undressed, he took it as an invitation and despite her resistance, he raped her.

Victim’s response and symptoms

Sarah feels ashamed and guilty about the attack. She wishes that she had not had the volume up so loud and that she had locked the door. She wonders whether she should have resisted more when her neighbor started to make advances, when he had found her naked. She is also ashamed to have to explain to people that she was at home naked in the middle of the day. She thinks the whole thing is her fault.

She can no longer face her own reflection and feels dirty. She also feels stupid and is gradually withdrawing from others, even her husband and children who are desperate to help her.

Sarah is constantly thinking back to the scene of the rape and imagines various scenarios. She is unable to resume her normal life, because everything reminds her of the rape.

She cannot bear her husband touching her and refuses any kind of sexual contact since the rape. She is sure that she will never be the same again, that she is destroyed and will never be able to make love again. She has gained quite a bit of weight and no longer wears a dress or make-up, worried about arousing men.

Even though the neighbor has been arrested, Sarah wants to move. She no longer feels safe in her home and finds it unbearable to be home alone on Mondays. Sarah has lost all motivation, talks little, and has suicidal thoughts.


You are the Community Nurse, discuss this case. (what are your thoughts, synopsis)

What are you going to do?

Remember you need to think out of the box, as a nurse, but not just a unit nurse. Be detailed as this is your client and their life. (300 words +)

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