Case Study 1: The Nurse and Cost Containment: Duty to Society
Case Study Assignments
Ramon Ortega, a 42-year old farm laborer with a history of hypertension, had been experiencing
headaches on an almost daily basis for 2 to 3 weeks. Disturbed by the persistent and severe nature of
the headaches, he visited the state-supported health clinic serving his rural community. Ms. Tracey
Anderson, the family nurse practitioner and sole staff member of the clinic, listened as Mr. Ortega
describe his headaches. She then performed an initial examination, which revealed good general health
with the exception of an elevated blood pressure of 190/108. Since Mr. Ortega had described some
dizziness and visual disturbances during his headaches, Ms. Anderson also completed a neurological
assessment. Everything seemed within normal limits except for Mr. Ortega’s peripheral vision. Ms.
Anderson’s assessment demonstrated that he had some difficulty seeing objects in the visual field on his
left side. Ms. Anderson realized this disturbance was probably a manifestation of his present headache
in combination with his known visual deficit. Since no other abnormalities were identified, the
possibility of a more serious problem seemed remote, according to Ms. Anderson’s judgment. Yet Mr.
Ortega was very distressed by his headaches. He asked the nurse practitioner what he could do to
prevent the headaches or, at least, what could be done to lessen the pain he was experiencing. Could
she be sure no other problem was causing the headaches?
A few months ago, Ms. Anderson would not have hesitated to refer Mr. Ortega to University Medical
Center, 100 miles away, for an exam by a physician and a neurologic evaluation of his headaches. She
would have done this for no other reason than to relieve the patient of his worry and to confirm the
absence of a more serious problem. She believes that, a referral would be of some help. In recent
weeks however, the state agency that provides funding to the rural health clinics had urged all health
clinic personnel to be careful in referring patients for costly lab or evaluative testing and in incurring the
added expense of clinic-sponsored transportation. There are decreased monies to support the
personnel and services in rural health clinics because the agency had adopted a strict cost-containment
program. In fact, the continued operation of the rural health clinics depended on how well the
individual clinics contained costs, even though they provided greatly needed services to populations like
the low-income farm community in which Mr. Ortega lives.
Ms. Anderson had been cutting the operating costs of her clinic in every way she could, particularly in
her judicious referral of patients to the University Medical Center. But she could not overlook the fact
that Mr. Ortega was distressed by his headaches, and there was always the possibility, albeit remote,
that he was presenting early signs of impending cerebrovascular disease, the effects of which could
seriously affect him and his family. She was uncertain about what choice to make.
1. If Mr. Ortega was your patient, which action (s) would you take?
2. What factors would be important to you in making decisions about Mr. Ortega’s care?
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