APPALACHIAN CASE STUDY #1
William Kapp, aged 55 years, and his wife, Gloria, aged 37, have recently moved from an
isolated rural area of northern Appalachia to Denver, Colorado, because of Gloria’s
failing health. Mrs. Kapp has had pulmonary tuberculosis for several years. They decided
to move to New Mexico because they heard that the climate was better for Mrs. Kapp’s
pulmonary condition. For an unknown reason, they stayed in Denver, where William
obtained employment making machine parts.
The Kapp’s oldest daughter, Ruth, aged 20, Ruth’s husband, Roy, aged 24, and
their daughter, Rebecca, aged 17 months, moved with them so Ruth could help care for
her ailing mother. After 2 months, Roy returned to northern Appalachia because he was
unable to find work in Denver. Ruth is 3 months’ pregnant.
Because Mrs. Kapp has been feeling “more poorly” in the last few days, she has
come to the clinic and is accompanied by her husband, William, her daughter Ruth, and
her granddaughter, Rebecca. On admission, Gloria is expectorating greenish sputum,
which her husband estimates to be about a teacupful each day. Gloria is 5 ft 5 in. tall and
weighs 92 pounds. Her temperature is 101.4°F, her pulse is regular at 96 beats per
minute, and her respirations are 30 per minute and labored. Her skin is dry and scaly with
poor turgor.
While the physician is examining Mrs. Kapp, the nurse is taking additional
historical and demographic data from Mr. Kapp and Ruth. The nurse finds that Ruth has
had no prenatal care and that her first child, Rebecca, was delivered at home with the
assistance of a neighbor. Rebecca is pale and suffers from frequent bouts of diarrhea and

colicky symptoms. Mr. Kapp declines to offer information regarding his health status and
states that he takes care of himself.
This is the first time Mrs. Kapp has seen a health-care provider since their
relocation. Mr. Kapp has been treating his wife with a blood tonic he makes from soaking
nails in water; a poultice he makes from turpentine and lard, which he applies to her chest
each morning; and a cough medicine he makes from rock candy, whiskey, and honey,
which he has her take a tablespoon of four times a day. He feels this has been more
beneficial than the prescription medication given to them before they relocated.
The child, Rebecca, has been taking a cup of ginseng tea for her colicky
symptoms each night and a cup of red bark tea each morning for her diarrhea.
Ruth’s only complaint is the “sick headache” she gets three to four times a week.
She takes ginseng tea and Epsom salts for the headache.
Mrs. Kapp is discharged with prescriptions for isoniazid, rifampin, and an
antibiotic and with instructions to return in 1 week for follow-up based on the results of
blood tests, chest radiograph, and sputum cultures. She is also told to return to the clinic
or emergency department if her symptoms worsen before then. The nurse gives Ruth
directions for making appointments with the prenatal clinic for herself and the pediatric
well-child clinic for Rebecca.

Study Questions
1. Describe the migration patterns of Appalachians over the last 50 years.
2. Discuss issues related to autonomy in the workforce for Appalachians.

3. Identify high-risk behaviors common in the Appalachian region.
4. Describe barriers to health care for people living in Appalachia.
5. What might the nurse or physician do to encourage Mrs. Kapp to comply
with her prescription regimen?
6. What would your advice be regarding each of the home remedies that Mrs.
Kapp is taking? Would you encourage or discourage her from continuing
them?
7. What might the nurse have done to help ensure that Ruth would make the
appointments for herself and her daughter?
8. What advice would you give Ruth regarding the home remedies that she
and her daughter are currently taking? Would you encourage or discourage
their use?
9. Do you think Mrs. Kapp will return for her appointment next week? Why?
What would you do if she did not return for her appointment?
10. Do you think that Ruth will make and keep appointments for herself and
her daughter?
11. What would you do to encourage Mr. Kapp to consent to a health
assessment?
12. What additional services could you suggest to assist the Kapp family at
this time?
13. What additional follow-up do you consider essential for the Kapp family?
14. What advice would you give Ruth regarding her daughter’s frequent bouts
of diarrhea?