Caring for patients with physical challenges (Case study)

Harriet Brown is a 56 year old woman who called the outpatient clinic requesting an urgent appointment due to a low-grade fever, dry cough, and shortness of breath.

She was diagnosed with type 2 diabetes 10 years ago, and has had ongoing difficulty taking her medications consistently.

As a result, she developed a foot wound that became infected and progressed to osteomyelitis, ultimately leading to a right below knee amputation 18 months ago.

Miss Brown arrives at the clinic in a transportation van. With the driver's help, she carefully lowers herself down the steps, taking them one at a time until she reaches the pavement.

Using her walker, she makes her way to the clinic door, only to realize there's no automatic button to open it. As she struggles to pull the door open, Nick, the physician assistant, arrives for work, and steps in to help.

Once inside, Mercedes, the receptionist, gives Miss Brown a tablet to fill out her registration information, but she hasn't used one before, and the words on the screen look blurry.

She eases herself into a chair in the waiting room, breathing heavily from the effort it took to get inside the clinic, and takes a moment to catch her breath before trying to focus on the screen.

Lynette, the nurse, calls for Miss Brown to walk with her toward the scale to obtain her weight. Miss Brown is unable to step up or stand on the scale without holding on to the walker.

She tells the nurse her prosthesis weighs 8 lbs. Miss Brown's current weight is deferred, and she's escorted to the examination room, where she's asked to sit on the exam table.

However, Miss Brown isn't able to lift her right leg onto the step. Lynette calls for help, and together, Nick and Lynette assist Miss Brown onto the table.

To help patients of all abilities safely enter and navigate public buildings like clinics, healthcare spaces should follow accessibility requirements and use universal design principles.

That means building environments that are easier, safer, and more intuitive for everyone to use, not just for people with disabilities.

In addition, the Americans with Disabilities Act, or ADA and the European Accessibility Act or EAA outline specific standards to ensure access for people with physical or mental impairments.

The clinic that Miss Brown is visiting can improve accessibility by installing a blue button, or push plate, on the front door that automatically swings the door open when activated.

They can also help patients who are unfamiliar with using a tablet to input patient information, by asking patients if they need assistance, or ensuring tablets with a voice-activated button are available to assist patients with inputting information.

The clinic would also need a height-adjustable scale for patients who are unable to step up and balance on the scale, and a height-adjustable examination table with grab bars to help patients with mobility issues.

Ms. Brown's current respiratory condition has developed because of several interconnected factors.

To start, she has had difficulty consistently taking her prescribed medications for type 2 diabetes, which led to persistently high blood glucose levels.

Over time, this caused a number of complications, including peripheral neuropathy, or nerve damage that reduced sensation in her feet, peripheral artery disease, which limited blood flow to her lower extremities, and a weakened immune system, which increased her risk for infection.

Together, these issues set the stage for a foot ulcer that eventually became infected. When the infection spread to the bone, it led to osteomyelitis, and ultimately required a below knee amputation.

The amputation restricted Miss Brown's mobility and had some significant detrimental effects. Reduced mobility impaired her lung expansion and weakened her respiratory muscles, making it difficult for her to clear respiratory secretions through deep breathing and coughing.

As a result, secretions began to pool in her lungs, creating an environment where bacteria could grow and increasing her risk for pneumonia.

On top of that, her already weakened immune system made it even harder for her body to fight off infection. Lynette measures Miss Brown's vital signs, which are temperature 100.7 °F, or 38.2 °C, P 92 BPM, respiratory rate, 22 breaths per minute, and BP 142/88 millimeters of mercury.

Her oxygen saturation is 95% on room air, and she reports mild pain, rating it a 2 out of 10 on a 10-point scale. Lynette then asks how she's been feeling and managing at home.

Miss Brown explains that even routine activities take a lot of energy, leaving her tired most of the time. She also has trouble putting on a prosthetic limb, and often relies on a wheelchair instead, but this makes it difficult to get around the house and use the bathroom.

She adds that she does receive some help from a caregiver for a few hours in the late morning, 5 days a week, which has been very helpful.

Miss Brown also tells Lynette that she has a transfer board to help her move from the bed to her wheelchair when she's not wearing her prosthesis.

However, she says she doesn't always use it, and the wheelchair slipped a couple of times, although she hasn't had any falls.

Lynette reminds her to always lock the wheelchair wheels before getting in or out to help prevent accidents. Next, Lynette helps Miss Brown remove the prosthetic limb and liner.

The skin is dry and intact, and she reminds Miss Brown to continue daily hygiene and inspection of the lower limb. She assists Miss Brown in a comfortable position, and lets her know Doctor Lee will be in shortly.

Doctor Lee enters the room, introduces himself, and begins examining Miss Brown. As he listens to her lungs, he notes diminished breath sounds in both lower lobes.

He orders a chest X-ray and prescribes a broad-spectrum antibiotic. Next, Doctor Lee examines Miss Brown's residual limb.

Miss Brown tells him she doesn't always wear her prosthesis, even though not using it makes it harder for her to leave the house for groceries and other errands.

She explains that she doesn't want to rely on the walker, so sometimes she tries to take a few steps at home without it, even though she's also afraid of falling.

Doctor Lee recommends that she use her prosthesis, along with a walker for safety. He reassures her that walking will become easier with time, but only if she uses the prosthesis consistently.

After the exam, Lynette returns to the room to help Miss Brown apply the liner and prosthesis, and asks if she needs any help with getting her medications.

Miss Brown says she has limited finances and tries to space out the diabetes medication, usually taking it when she eats more carbohydrates than she should.

Lynette gives Ms. Brown coupons for the diabetes medication, diabetic supplies, and some information on planning a healthy diabetic diet using low-cost foods.

When asked about transportation, Ms. Brown says she uses the transportation van to go to the pharmacy and to buy her groceries.

Finally, Lynette reassures Miss Brown that the clinic setup will be easier for her to navigate when she comes back for a follow-up in 2 weeks.

They're purchasing a new scale with handrails, a ramp, and a platform large enough to fit a wheelchair. And several examination tables with adjustable height and support rails.

They'll also be installing a lighter door at the front entrance, with an automatic door opener. Miss Brown thanks Lynette as she walks her to the entrance, holds the door open for her, and assists her in the transportation van.

All right, it's a quick recap. Miss Brown experienced challenges with accessibility during her visit to the clinic.

To address issues like this, public facilities, such as this clinic, must ensure their environments and equipment meet ADA and EAA standards, so they can support patients of all abilities.

Making these changes helps improve access to equitable care, enhances patient safety, and ultimately leads to better patient outcomes.