Patient Profile M.S. is an 81-yr-old woman who came to the United States from India 4 years ago with her son and daughter-in-law and their 4 children. She has several health problems, including coronary artery disease, hypertension, osteoarthritis in her right hip, and diabetes. Her daughter-in-law is the primary caregiver and often brings her to the urban community health clinic for a variety of health-related problems. Recently, M.S. has been having memory problems. The entire family comes to the health clinic with M.S. Because English is a second language (Hindustani is their first language) for all the adult family members, the staff relies on the oldest granddaughter to interpret. At this clinic visit, M.S. is presenting with shortness of breath. Through her granddaughters interpretation, she tells the nurse that she is having trouble walking up the stairs in the apartment building. The nurse does the history and assessment, checks her blood glucose (which is within normal limits), and tells her that she should get more exercise. Given M.S.s memory problems and limited English, the nurse does not complete a 24-hour dietary recall or teach her or the family about diabetes management. M.S. is scheduled for an appointment with the cardiologist for an evaluation of her hypertension and heart disease. Two weeks later, when she sees the cardiologist, her shortness of breath is much worse, and she is having chest pain. She is hospitalized immediately. Meanwhile, the clinic supervisor is completing a chart audit for the clinics quality review program. She is reviewing M.S.s chart and notices that, although she has been a patient in the clinic for 3 years, she has never received instructions on blood glucose monitoring or general diabetes management. The clinic has a nurse diabetes educator who teaches individual patients and groups of patients with diabetes. The clinic manager reviews these findings with the nurse and asks why she has not recommended that M.S. see the diabetes educator. The nurse states that with M.S.s memory problems and the language barrier, she assumed that M.S. and her family would not benefit from the consultation. 
Discussion Questions 
1. What type of health disparity has M.S. experienced?
2. What factors led to her not receiving the standard of care?
3. What other assessment should have been done at the initial visit?
4. Patient-Centered Care: What strategies may have worked to enhance patient education? 
5. Patient-Centered Care: How would you assess M.S.s religious and spiritual needs? 
6. Quality Improvement: If you were the clinic manager, how would you recommend that the nurse improve her practice?