NS4340 Clinical Management
Question:
1. Describe the pathophysiology of the presenting complaint in the case study. (300-500 words)
2. Evaluation of the nurse’s role to deliver developmentally appropriate nursing care in relation to your chosen case study.
Address:
- growth and developmental theories,
- family centred care and
- the effects of hospitalisation of the child, on the child and family.
Case Study 1
Anne is a 10-year-old girl who has presented to the emergency department in the local hospital with right iliac fossa pain. On further assessment by the emergency registrar, appendicitis is suspected. The surgical team agree that the signs and symptoms are associated with appendicitis and take Anne to theatre for an appendectomy. The handover on return to the ward is that the surgical team found a gangrenous perforated appendix with peritonitis. Anne has returned to the ward with a nasogastric tube in situ on free drainage, morphine PCA, IV therapy and triple IV antibiotics. Due to the severity of the infection and the potential complications, Anne will need to remain in hospital for 10 days of IV antibiotics and pain management. Anne is the oldest of five children and her parents own and run an Indian restaurant in the city.
Answer:
Providing health care facilities to the patients with co-occurring disorders is dependent on a variety of external and internal factors associated with the disease condition of the patient and the developmental pathways (Podda et al., 2017). The pathophysiology of a disease provides a detailed account of how the disease has developed in the patient and the root causal abnormalities that are needed to be addressed for the patient. This essay will attempt to discover the pathophysiology of a particular disorder and evaluate the nurse’s role in delivering developmentally appropriate nursing care with respect to growth and developmental theories, effect of hospitalization on the patient and his family taking the assistance of a case study.
The patient in the case study is a 10 year old girl named Anne who had been admitted to the emergency department with right iliac fossa pain due to the appendicitis that the patient had developed. The further assessment of the patient revealed that Anne had gangrenous perforated appendix with peritonitis. Now it has to be mentioned that peritonitis is a more or less common health disorder which is generally originated by either a ruptured appendix or perforation which leads to leakage of the fluid accumulated inside an inflamed and possibly infected appendix and leads to infection the abdominal area. Exploring the pathophysiology of the disease further, it has to be mentioned that gangrenous appendicitis is a condition where the appendiceal lumen of the appendix is blocked that restricts the blood flow in the surrounding region completely (Alvarado, 2018). As mentioned by Bhangu et al. (2015), the blockage can be caused due to a variety of different reasons ranging from. Followed by the obstruction of the appendiceal lumen, the bacterial overgrowth takes place in the blocked region of the lumen which leads to distension of the lumen and as a result there is a massive increase in the intraluminal pressure. This series of events then lead to lymphatic and venous obstruction leading to oedema, which then leads to acute inflammatory response and facilitates necrosis of the appendiceal wall with the bacterial mass translocating to the wall giving rise to gangrenous appendicitis (Snow et al., 2016). In case of Anne, there had not been any medical attention given to her when she acquired the gangrenous appendicitis, the lack of any intervention to reduce the infection or the inflammation the appendiceal wall perforated and led to the spillage of the appendiceal fluid into peritoneal cavity, which eventually led to the infection of the peritoneal cavity. As discussed by the authors, the infectious fluid being spilled in the peritoneal cavity leads to infection and resultant inflammation of serosal membrane present lining the abdominal cavity which also extends to the internal organs causing peritonitis. As mentioned by Matsushima, Inaba and Demetriades (2016), peritonitis is a severe infection and can easily lead to intra-abdominal sepsis in the patient; hence, Anne will require immediate medical attention and intervention to be able to avoid the risk of sepsis.
While providing care to the paediatric patients is complex with the interlinked emotional and developmental stress of the illness or disease on the psyche and growth progress of the child. In order to ensure optimally positive outcomes for the child it is crucial for the nurses to focus on the developmental and growth related markers of health or wellbeing while planning care interventions along with the medical care needs of the patient (Alvarado, 2018). In this case, Anne is a 10 year old girl who is in the concrete stage of growth or development as per the theory of cognitive development by Piaget. This theory postulates children to move through 4 stages of development while growing up (Demetriou, Shayer & Efklides, 2016). The growth and development of a child is dependent on the biological, psychological and emotional changes, each of which can be equally affected by the illness that Anne is suffering from. According to this theory, in the concrete operation stage, the children develop the ability to think logically about the concrete events, develop ability to understand the conception of conservation, develop organized logic to create concrete perception, and lastly attain inductive logic and reasoning. Hence, Anne will get a clear understanding of her disease and the severity, and the nurse will require to calm her and engage in therapeutic communication with her where she will needed to be given a brief idea of her illness and recovery so that she has enough information to calm her (Lind, 2017).
As per the emotional development pace, Anne is at an age where she might be very curious and inquisitive, the nurse will need to be very patient and address each of her question to respect her demands and answer to her very carefully with medical information so as to not alarm her. It has to be mentioned that being a 10 year old, Anne has not yet attained the age of understanding complex medical terms to be involved in medical information, yet she has rights to information related to her condition. The nurse providing acre to her will therefore needs to abide by the ethical requirements of sharing information but will have to filter the amount of details that can be shared to a minor patient. Lastly, along with safe-guarding the patient rights and sanity, the developmentally appropriate care will also need to include nutritional requirements as well, the impact of her operation and perioperative care might affect her nutritional status as well (Demetriou, Shayer & Efklides, 2016). Hence, the nurse will also have to consider providing a developmentally appropriate diet including high protein and antioxidants to conclude developmentally appropriate care.
Family has a profound association with the health and wellbeing of a child, and the involvement of the family members in the care planning has a fundamental importance in facilitating recovery in the child. Coyne (2015), have defined family centred care to be a care program that is led or designed by the parents with the health care professionals acting as the consultants providing encouraging communication and medical information to the family helping them choose the best options for the child. There are nine inter-related elements to the family centred care, recognizing family to be constant in the life of the child, facilitating parent professional collaboration, honouring the diversity of the child, recognizing individuality and family strengths, sharing unbiased and sufficient information, family support network, child and developmental needs, adopting family oriented policies, and designing health care that is flexible (Coyne, Hallström & Söderbäck, 2016).
In this case, the family will needed to be included optimally in the care planning for Anne for the 10 days that she will remain the hospital. First and foremost, the nurse will need to acknowledge and respect the culture and traditional health concepts. The nurse will have to communicate the health information to her family in a culturally appropriate manner, preferably taking the assistance of a language interpreter. Researchers are of the opinion that the lack of accurate and timely information provided to the family is often the cause of panic and restlessness in the family members of patients which is easily transferred to the patient as well, especially for the paediatric patients (Childrens.health.qld.gov.au., 2018). Providing accurate, evidence based and timely information in an easy to understand manner will help the family remain calm and participate more in the care planning for Anne. Another very important aspect for the family centred care is providing patient education regarding medication safety and general precautions that Anne will need to incorporate in her life in the future. In this case, the nurse will have to provide education that is tailored to meet the needs of the family in an easy to understand simple English with additional pamphlets and brochures to help them adhere to the instructions adequately. The siblings of Anne are also very young and can also be affected by the illness, their care should also be taken into consideration by nurse recommending child support or counselling care (Childrens.health.qld.gov.au., 2018).
Lastly, the impact of the hospitalization is also a very important aspect associated with a paediatric patient and her family. As mentioned by Hockenberry, Wilson and Rodgers (2016), illness and hospitalization has a profoundly stressful impact on the paediatric patient and their families. It is very important to be able to understand the impact of the detachment from the family and especially the parents cannot just make the paediatric patient anxious and distressed, it also be adequately reflected on the behaviour and responsiveness of the child. Along with that, researchers are of the opinion that fear and anxiety is also stemmed from the detachment from the family and living in an unknown and sterile environment of the hospital in a paediatric patient suffering from a severe illness. Hence, the nurse will need to be very compassionate and empathetic to the child and provide nurturing support and care so that the child is not afraid or anxious. It is also possible for the children to become irritable and uncooperative while being away from family, in this case the nurses will have to focus on resilience and person centred care to provide comfort.
The impact of hospitalization of a child will also impact the Anne’s family including her parents and siblings. The parents are generally depressed, anxious and hyper-reactive during the hospitalization of a child. The fear of the prognosis, the safety of the child in the hospital and the detachment of the child instils fear, irritability and anxiety in the patients. In this case, the role of the nurse will be to involve the parents in the care planning and decision making which will provide a sense of empowerment and control calming them (Hockenberry, Wilson & Rodgers, 2016). The nurse will also have to provide adequate and timely information about the progress Anne is making and will instil hope and positivity in the family. The parents should also be allowed to visit Anne from time to time to help both the patient and their family cope with the stress better. The siblings of Anne will also be negatively impacted by Anne’s hospitalization where they will be afraid, anxious and sad to see her in pain and hospitalized without properly understanding her condition or progress. In this case, the nurse will have to educate and encourage the parents to take the aid of therapy and counselling to cope with the distress (Regan, Curtin & Vorderer, 2017).
On a concluding note, the impact of disease always has a deleterious impact on the psycho-social health and wellbeing of the patient, and for the paediatric patients, the impact is multiplied multiple-folds due to their higher biological vulnerability to stress. This essay successfully explore the care aspects of a child suffering with a severe illness, how to provide care taking into consideration the growth and development of the child and incorporate family into the care planning as well. Lastly, the essay evaluated the impact of hospitalization not only on the child but on her family as well so that the care provided is safe, effective and patient or family centred.
References:
Alvarado, A. (2018). Clinical Approach in the Diagnosis of Acute Appendicitis.
Bhangu, A., Søreide, K., Di Saverio, S., Assarsson, J. H., & Drake, F. T. (2015). Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. The Lancet, 386(10000), 1278-1287.
Childrens.health.qld.gov.au. (2018). Family Centred Care in Queensland. [online] Available at: https://www.childrens.health.qld.gov.au/wp-content/uploads/PDF/qcycn/qcycn-fcc-sd.pdf [Accessed 26 Aug. 2018].
Coyne, I. (2015). Families and health?care professionals’ perspectives and expectations of family?centred care: hidden expectations and unclear roles. Health expectations, 18(5), 796-808.
Coyne, I., Hallström, I., & Söderbäck, M. (2016). Reframing the focus from a family-centred to a child-centred care approach for children’s healthcare. Journal of Child Health Care, 20(4), 494-502.
Demetriou, A., Shayer, M., & Efklides, A. (2016). Neo-Piagetian theories of cognitive development: Implications and applications for education. Routledge.
Hockenberry, M. J., Wilson, D., & Rodgers, C. C. (2016). Wong’s Essentials of Pediatric Nursing-E-Book. Elsevier Health Sciences.
Lind, G. (2017). The Theory of Moral-Cognitive Development A Socio-Psychological Assessment. In Moral Judgments and Social Education (pp. 25-48). Routledge.
Matsushima, K., Inaba, K., & Demetriades, D. (2016). Management of Complicated Appendicitis: Percutaneous Drainage and Interval Appendectomy or Immediate Surgery? Open or Laparoscopic Surgery?. In Acute Care Surgery Handbook (pp. 377-387). Springer, Cham.
Podda, M., Cillara, N., Di Saverio, S., Lai, A., Feroci, F., Luridiana, G., … & Vettoretto, N. (2017). Antibiotics-first strategy for uncomplicated acute appendicitis in adults is associated with increased rates of peritonitis at surgery. A systematic review with meta-analysis of randomized controlled trials comparing appendectomy and non-operative management with antibiotics. the surgeon, 15(5), 303-314.
Regan, K. M., Curtin, C., & Vorderer, L. (2017). Paradigm shifts in inpatient psychiatric care of children: approaching child?and family?centered care. Journal of Child and Adolescent Psychiatric Nursing, 30(4), 186-194.
Snow, A. F., Vannahme, M., Kettley, L., & Pullyblank, A. (2016). Ruptured hepatic artery aneurysm precipitated by gangrenous perforated appendicitis: a case report. Journal of surgical case reports, 2016(5), rjw083.
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