Running head: PEDIATRIC CTP
Pediatric Critical Thinking Paper
Jennifer Fisher
Grand Canyon University
NUR 314
April 4, 2011
Critical Thinking Paper
The following critical thinking paper is based on a 15 – year – old male that was admitted to Cardon Children’s Medical Center. ST was admitted on February 25, 2011 for recurrent abdominal pain and irritability, as stated by his parents. This admission occurred approximately 24 hours after being released from Cardon’s on the 24th of February for abdominal pain as well. S.T. was diagnosed with cerebral palsy at a very young age, therefore symptomatology is rather difficult with him. Upon being admitted to the hospital S.T. has been diagnosed with small bowel obstruction. This paper will provide a complete evaluation of the assessment, care plan, and outcomes chosen for S.T. and his family.
Assumptions
In planning care for this family and patient it was difficult not to make any assumptions about the family or the level of care that the patient was going to need for the day. The first assumption that was made was due to S.T.’s necessity for round the clock care that his parents would be completely burnt out after providing daily care for S.T. for the past fifteen years, knowing that this will continue through his entire lifetime. Another assumption that was made was from a financial aspect. The assumption is thus that the parents must be struggling greatly in this economy, especially since having to provide both financially and caring for S.T. and his siblings. A third assumption would be that one parent over the other would be more involved in caring for the patient. When planning to work with S.T. it was taken for granted how some communities come together to help families who have mentally handicapped children. Another item that was taken for granted when planning care for S.T. was that he was still a normal adolescent who wanted to be active and not attached to IV tubing.
Functional Health Pattern
Health Perception and Management
Age Calculation:
Year Month Day
Date of Test: (2011-1)= 2010 (3+12)= 15 (21+30)= 51
Date of Birth: -1995 -8 -31
Age of child: 15 7 20
The calculated age for S.T. is 15 years 7 months and 20 days old. He was admitted on February 25, 2011, his current weight is 32.6 kilograms and 150.5 centimeters for his height. Currently his weight and height place him under the 5th percentile. Please see Appendix A and B for growth charts. Upon assessing S.T. his temperature was 36.9 degrees Celsius via axillary measurement, apical heart rate of 106 beats per minute, a blood pressure of 97/54, and respirations were 23 with regular rate and rhythm. When assessing his pain level the FLACC scale was used. This measures the facial expression, legs, activity, crying, and consolability of the patient. Using this scale it was determined that the patient had a 3 out of 10. His actions were not that of complete pain, however he was not completely comfortable either. Upon assessing his ileostomy, it was pink and moist. No evidence of infection or irritation to the site is present.
The reasoning for this admission to the hospital was for recurrent abdominal pain and irritability. His parents described S.T. to be crying, moaning, and experiencing episodes of vomiting. His emergency room laboratory workup showed 17400 WBCs, CO2 of 20, and potassium of 3.4. Upon looking at his abdominal x-ray it was found that there was a gross amount of dilation of the apparent colon. During this admission he has had a bowel resection, ileostomy placement, and the potential for a cholecystectomy (due to appendicitis). This admission occurred after being released from the hospital less than 24 hours prior for the same signs and symptoms. He was released on February 24, 2011 due to tolerating his gastrostomy tube feedings. The only treatments that the patient was receiving prior to this hospitalization was gastrostomy tube feedings, Topamax, and Tegretol for seizure prevention. Based on his developmental level S.T. is more than likely aware that he is in a hospital, however unsure of why he is there.
S.T. was born vaginally at full term with no complications noted. At three months of age he was diagnosed with microcephaly and demyelinization of his nerves. At sixteen months a gastrostomy was placed in S.T. at Phoenix Children’s Hospital due to an inability to feed. Following at four years of age S.T. was diagnosed with epilepsy and began treatment with Topamax and Tegretol. Cerebral Palsy was diagnosed during early childhood, unknown to exact date.
In regards to the family health practices the dentist is seen regularly for both S.T. and his family. Medical visits occur every six months for S.T. or sooner if there are complications noted. Annual visits to a primary care provider occur for the rest of the family. The family receives health and dental benefits through the father, who is in hotel sales management.
There is no significant health history noted for S.T.’s immediate family members. He has two older sisters, one older brother, and a younger brother. All of whom are blood related. S.T.’s father has been diagnosed with hypertension and his mother has been diagnosed with hypercholesterolemia. His siblings have no health histories noted.
GenogramKey:
= Female Deceased
= Female Living
= Male Deceased
= Male Living
S.T. has not had any exposure recently to communicable diseases. He has had all immunizations that are appropriate for his age. It has been recommended that he receive the HPV vaccine and the tetanus.
He has no known food, medication, or latex allergies. When S.T. is home he receives Topamax and Tegretol in order to prevent seizures caused by his epilepsy. Currently in the hospital he for scheduled medications he is receiving: Keppra 360 milligrams by mouth twice a day in the liquid form, pantaprazole 40 milligrams intravenous push daily (infuse over two minutes), and phenytoin 90 milligrams by mouth twice daily in the liquid form. For PRN medications he has acetaminophen 480 milligrams available for pain or temperature by mouth every four hours, Dilaudid for pain 0.5 milligrams intravenous push every four hours, and lorazepam for agitation two milligrams intravenous every eight hours. S.T.’s parents are both extremely knowleadagble about the medications S.T. is receiving in the hospital and at home. They know which side effects to watch for, what each medication is used to treat or prevent, and how to administer the medication. When S.T. is at home his mother and father trade off on who administers the medications to S.T. His medications at the hospital are given either via his PICC line (located in his right arm in the antecubital area) or his G-tube (Mickey). When he is home his medications are given via his G-tube. No alternative or complimentary medicine practices are currently being used or considered. For safety practices: at the hospital he has all four bed rails are up, unless being placed in his chair for transferring. When S.T. is being transported at home he is restrained in a specialized chair. Also, sharp objects or small objects that are choking hazards for children are removed from S.T.’s reach.
Teaching and Anticipatory Care:
For S.T. his parents were educated about further support groups who are specialized for children diagnosed with epilepsy. Anticipatory guidance was given to the parents concerning S.T.’s gastrostomy tube for feedings to further advance nutrition status and healing processes.
Referrals:
The parents were given a referral to Phoenix Children’s hospital, whom have a specialized parent group that meet to give and gain support about their child with epilepsy. The number for them to verify the meeting time and place is 602-406-3581. Also
http://www.raisingspecialkids.org/resources/support-groups.aspx is a site that has further group support options for S.T.’s parents to look at if necessary. By having this specialized group available to S.T.’s parents they have a resource outside of their immediate family and friends for further support.
Nutritional/Metabolic
When S.T. was 16 months old he had a gastrostomy placed due to his inability to feed. Since this placement S.T. has been receiving tube feedings. Prior to his admission to the hospital his appetite was much greater according his mother. The recommended caloric intake for S.T. according to the Dietary Recommended Intake is about 1500 calories. His current tube feeding in the hospital uses Tolerex, a low fat feeding. This tube feeding has an added 500 milliliters of water added to the Tolerex solution in order to assist his body in tolerating the feeds, as well as, retaining the nutrients. This feeding is set at a rate of 80 milliliters over an hour and is on a continuous infusion. With S.T.’s feeding he is receiving approximately 2000 calories each day, along with 80 to 90 grams of protein. These feedings contain calories, protein, as well as, vitamins and minerals that are essential to maintaining S.T.’s body requirements. S.T. has no real likes or dislikes with the food, especially since he has not known anything other than tube feedings.
During the physical assessment S.T.’s current weight was 32.6 kilograms and 150.5 centimeters for his height, both of these fall beneath the 5th percentile for S.T. His head, ears, eyes, nose, and throat were: normocephalic and atraumatic. His pupils were equal and reactive to light, although unable to completely focus on what was in front of him. Ears were symmetrical and nontender, no palpable lymphadenopathy. No muchal rigidity was found. His teeth were present and clean. His lips were located cimetrically with his facial features. No tenting of the skin was present. S.T.’s extremities showed no clubbing, cyanosis, or edema. A + 4 was given to his muscle strength and tone. The surgical site, where the bowel resection had been performed, was completely scar tissue when assessed. No signs of infection or skin irritation were present. S.T. also had PICC line placement located in his just above the right antecube. The site was clean and intact. There were no signs of infiltration or infection. S.T. every once in a while would look at the PICC line and inspect it, then leave it alone again.
When assessing S.T.’s family, his mother said that they generally purchase health foods such as: apples, pears, chicken, and lots of vegetables. She did not go into a great amount of detail or explanations. They go out for meals every once in a while, depending on finances and time available. Mealtimes the family tries to prepare together when possible. They also enjoy eating their meals together as a family.
Teaching and Anticipatory:
Anticipatory guidance was given informing S.T.’s parents that pertaining to his surgeries he may need more calories and nutrients in order to prevent infections from occurring. Also guidance was given that when he is healthier he may not need as much of the feedings as he is taking in currently. Teaching his parents how to monitor his gastrostomy site and monitor for further bowel obstruction signs was completed.
Referral:
A referral to MyPyramid was given to his parents. By having this website available it will help not only monitor foods and nutrients that S.T. should be consuming but also each individual of the family. The website referred to is:
http://www.mypyramid.gov/guidelines/.
Elimination
When at home S.T.’s stool pattern is consistent with well formed stools after defication. There have been no abnormal smells noted when at home according to his parents. At the hospital he has an ileostomy in place pertaining to a bowel resection and bowel perforation that had occurred; the wafer was replaced on March 21, 2011 around 0700. The fluid found in the ileostomy was a green liquid with a very strong fecal smell to it. There was some minimal skin irritation prior to the cracker being changed, however once that was changed the skin returned to its normal state. Upon auscultation of the abdomen it was found that there were normoactive bowel sounds occurring. The abdomen was rounded, no evidence of distention present, and was nontender upon palpation. Prior to this hospitalization S.T.’s abdomen was hard and distended, directly after being admitted it was found that he had suffered an intestinal obstruction for about one week around the gastrostomy tube with fecal dilatation and perforation noted. Upon assessing the suprapubic area there was no irritation found and the area was pink. His testes were descended bilaterally and the anus was found to be parent. His skin was pink with a scar located to the right of his belly button from where the surgeons went in for the bowel resection. His capillary refill was less than three seconds long. His total output for a 24 hour period was 227 millimeters. Below is the calculation showing his hourly output.
Urinary output for past 24 hours:
227ml = 6.96ml/kg 6.96ml/kg = 0.29ml/kg/hr
32.6kg 24 hr
Waste and garbage at home is disposed of every two or three days, sooner if necessary. They have no dogs, in order to minimize the amount of flies in the back yard and too much to care for on top of caring for S.T. according to S.T.’s parents. There have been no issues with pests or rodents as noted by the parents, they have pest control on a regular basis to prevent problems.
Teaching and Anticipatory:
The teaching that was completed during care for S.T. included changing the wafer, and general care of the ileostomy site. Anticipatory guidance and teaching was given to the family regarding documentation and calculations for input and output in order to assess the client’s hydration and renal status.
Referral:
It was considered giving S.T.’s parents a referral to
http://www.psahealthcare.com/, a site that gives his parents access to home health care agencies. A home health care agency is being considered for this family, however finances are may make unlikely to obtain and keep a regular visiting home nurse.
Activity/Exercise
S.T. and his family have no know history of musculoskeletal injuries. Due to his diagnosis of cerebral palsy and severe developmental delay S.T. is unable to perform self – care activities on his own. For bathing, he likes taking showers, mother or father take turns washing him. Typically he is bathed either once a day or every other day, depending on the circumstances. His parents perform all the dressing and hygiene activities that are needed for S.T. to be ready for a typical day. S.T. is able to have input on what kinds of clothing he wants to wear for the day, however his mother or father have to help him get dressed.
Playing is one of S.T.’s favorite activities. He loves colors, sounds, and touching objects. He cannot always play like typical children his age, however he loves to dance. At Cardon’s Hospital there was an afternoon where the life specialists had a Pajama Party for the children with a D.J. and lots of games. When S.T. got off the elevator, hearing the music playing in the room his whole entire demeanor changed. He was thrilled to be helped out of his chair to go dance. His mother had stated that when S.T. goes to his school dances, his teachers take turns on who dances with him because he dances from the time they get there to the time they leave. When he was dancing at the hospital his activity level was decreased as compared to being home. His mother believed that it was do to being uncomfortable from the surgeries that S.T. had been through recently.
For his physical assessment, S.T.’s heart was a regular rate and rhythm, no murmurs, rubs, or gallops were found. Upon auscultation of the lungs they were clear bilaterally with no signs of labored breathing and 97 percent for S.T.’s oxygen saturation on room air. Extremities showed no clubbing, cyanosis, or edema being present. S.T. has full range of motion with a +4 in his muscle strength. It was fun watching and interacting with him, when up in his room after the pajama party, when his mother was talking with him about how he got to dance with all the pretty nurses he was lifting his legs over his head out of excitement from the event. His fine motor skills are delayed, especially in the hands. S.T. and his family like going to parks for exercising and outside activities. While he is confined to a wheel chair S.T.’s family loves being able to take him out and introduce him nature. The family does not have a specified exercise routine, however they try to go on evening walks when possible.
Teaching and Anticipatory:
Teaching has been completed showing the family the importance of having a regular activity and exercise regimen. Anticipatory guidance has been given to S.T.’s parents reminding them that since S.T. is in school he constantly sees other children running and walking around, S.T. may get extremely frustrated that his walking is not as smooth as that of children his age. Parents encouraged to show and verbalize support to S.T. through his accomplishments.
Referral:
Referral was completed in the hospital for a physical therapist to come to S.T.’s home and work with him and his family.
Sleep and Rest
S.T.’s parents state that no sleep aids are used for S.T. or the immediate family. S.T. sleeps in his own room down the hall from his parents. S.T.’s parents sleep in the same room and their youngest son, who lives at home sleeps in his own room. The two older sisters and older brother all have moved out and live on their own or with their significant others. When at home S.T. does not take naps because he is at school typically; he is in the eighth grade. His mother stated that the more activities that occur during the day, the better S.T. sleeps at night. During his stay at the hospital his sleeping times are much more frequent. At home he gets about eight to nine hours of consistent sleep being in the hospital it is a little more sporadic, however his sleeping times are more frequent.
There are no family or child issues with sleeping. Since they have been at the hospital S.T.’s parents trade on who stays the night with S.T. His parents do not like to leave him alone on his own in the hospital, especially since he is unable to comprehend that they will be back later. Due to this one or both parents are with S.T. at all times.
Teaching and Anticipatory:
Anticipatory guidance was given to S.T.’s parents noting that due to S.T.’s age he may start sleeping more than he has in the past due to his body needing energy to grow. Teaching was completed regarding the benefits of having a sleep schedule for S.T. (Hockenberry & Wilson, 2007).
Referrals:
Referral to the National Sleep Foundation (
http://www.sleepeducation.com/) was given to the parents for further education for sleep education and benefits for S.T.’s parents. The site listed gives his parents access to many different articles and educational pieces.
Sexuality and Reproductive
S.T. is a male and comprehends that much. However, due to his developmental age it is apparent that he does not know more about his sexual function than a typical two year old. Based off of the Tanner Stages for sexual development it was determine that S.T. is a stage two or three. This was due to the fact that his scrotum and testes were enlarging and pubic hair growth was well defined on S.T. His mother understands the importance of testicular exam for S.T. The testicular exam is completed by S.T.’s primary care physician, when his physical exams are being done. His mother at first did not seem to have any concerns about sexuality or reproduction. Later on in the day his mother voiced concern about the possibility that S.T.’s siblings might be carries and pass along genetic disorders that could be passed to their children. After their last son S.T.’s mother stated that they will not be having any more children.
Teaching and Anticipatory:
Teaching was completed to further emphasize the necessity for regular testicular exams for S.T. Teaching was also completed in further educating the mother about genetic disorders, further educating her to comprehend that S.T.’s cerebral palsy is not a genetic disorder.
Referral:
Referral to their family primary care provider for regular testicular and physical examinations was completed. Also Planned Parenthood would be an additional reference for the family if the time came to talk with S.T. about sex (Planned Parenthood, 2011).
Roles and Relationships
S.T. speaks and understands solely the English language. As a 15 year – old S.T. with his developmental delay is able to speak forty words of English. S.T. seems to be extremely close to his mother. However, when his father came to the hospital after his day at work S.T. was extremely excited to see him. The father and son continued to hang out talk and gabbing with each other after the mother left to clean up. S.T.’s siblings come regularly to the hospital to visit him and check in on him. Having this kind of support from his family is extremely beneficial for S.T. He currently he has no girlfriends, when asked about girls S.T. just giggled, having a meschivious look on his face. His mother was teasing him after the dance saying he was quite the player having all the pretty nurses dancing with him.
S.T.’s father is the head of the house; all major decisions are finalized through him. However, the parents work to together, compromising and deciding what is most beneficial for the family as a whole. During the time spent with S.T. and his family there were several family theories that were able to be used in assessing them. The first theory that was used to describe this family was the family system theory. This system describes how the family acts as one unit continually interacting and changing with one another. It is a highly adaptable system that is put to the test when a member of that family changes they all change to adapt. An example of this would be with S.T., all of his siblings were born healthy with no complications. When S.T. was born it was that he had microcephaly and demyelinization of his nerves. This change in the system affects the entire family. Another theory used for this family was the stress theory. The stress theory evaluates how S.T. and his family cope with the predictable and unpredictable stresses of life. This hospital admission was an extremely unpredictable event for S.T.’s family the added stress of the hospital in addition to S.T.’s chronic diagnosis seemed to be taking a stressful toll on their family. Some of the extra stressors that this family is coping with are: safety of S.T. and their other children and finances. Surprisingly community support is not a major stressor for this family, their church community and family friends are extremely supportive, looking for ways to help this family, whenever possible. The final theory system used was the developmental theory. This theory describes how a family changes, adapting over time to the changing roles and functions of that family. S.T. has been sick, in and out of hospitals since he was born. Through this whole time his family is still learning to adapt. This adaptation process will be a life long process, continually adapting to each change in the family structure and situation.
During S.T.’s hospital stay his mother and father took turns on which of the two stayed with him over night. During the day time they also split who stayed with him. If the father had to work the mother would stay until his father got off work and came over to the hospital. Once at the hospital the parents would stay for a little while, catching up on each others day then the mother would leave to clean up and take care of chores and the children at the house.
Teaching and Anticipatory:
Anticipatory guidance was given to S.T.’s parents about the likely hood that S.T. would need further hospitalizations based on his ileostomy, if the physicians decided to perform a reversal, cholesystectomy, and possible future complications that may warrant hospitalizations. Teaching was completed regarding the need for the family to set apart time to spend as a family and time to spend with friends.
Referral:
The following website (
http://events.azfamily.com/) is a website that provides events and locations for families, sports, and educational activities. This site would be a great way for S.T.’s family to interact with each other and get out of their home.
Coping and Stress
S.T. does not seem to exhibit many signs of fear or stressors. Based off of his developmental age and reports from his primary nurse, S.T. is highly fearful of any invasive procedures. So much so that S.T. is sedated prior to procedures that would appear to be invasive to him. His mother has expressed that she is stressed about his illness and the unknown of when S.T. will be discharged. It has been extremely interesting watching and interacting with this family while they have been in the hospital. S.T.’s response with being hospitalized has been one of refusing to do his physical therapy with the nurses or physical therapist. No anxiety or response has been noted from separation with his family because there has not been a time since his hospitalization that he has been left alone without someone from his immediate family being there. Regarding his pain response, it is that of a typical child in his toddler years. S.T. squirms and thrashes around, this was not seen but mentioned by his mother and primary care nurse.
S.T.’s family has been extremely supportive of him and one another since the hospitalization has occurred. They take turns staying with him so that no one person becomes overwhelmed with S.T.’s care. His mother stated that “each person in the family responds to pain differently”, she did not give specifics though.
When asked about coping mechanisms S.T.’s mother said there were only a few things that worked to help S.T. cope with pain and anxiety. She said that if he was becoming aggravated or stressed, placing him in a quiet area with calming music (e.g. Mozart or Beetoven) he was able to calm down. S.T.’s mother’s way of coping is to either read a book or go to church to pray and talk with God.
Teaching and Anticipatory:
Anticipatory guidance was given to the family as a whole on the importance of finding time to separate themselves from the stressful situations at home in order to find an activity that relieved stress for each individual. Teaching was completed with the family that though S.T. has a fifteen year – old body he developmentally thinks as a toddler and therefore cannot always adequately express his feelings. Knowing this, it was important to teach the family to sit and listen to S.T.
Referral:
A referral to Doctor Karen G. Canulla (can be reached at 602-354-5137) has been considered for the family in order to provide them a safe environment with an unbiased person available to listen to their frustrations, grief, and great days.
Cognitive and Perceptual
Although S.T. is fifteen years of age according to Piaget’s Cognitive Development he is in the preoperational thought. This is evident in his egocentric thoughts and actions. His object permanence is developed. The word count of a typical child in Piaget’s early childhood is approximately 400 S.T., however has a word count of about 40. S.T. tries to mimic and imitate the people around, although not always successfully. When watching him he sees the people that surround him, knowing that they are actively working or playing, however it appears that he does not fully comprehend that there is a world outside of his own. S.T. is an eighth grader who attends classes for special needs children his age. His mother said that he attends classes at the public school near their home. S.T. loves being in class and was ecstatic to see his teacher, who came to visit him at the hospital. S.T.’s father has a bachelor’s degree in business management and his mother has a teaching degree. Nothing was stated about the education level of S.T.’s siblings.
No vision or hearing aides are used for S.T. His mother wears glasses, while the rest of the family has no need for vision or hearing aides. S.T. has gross growth abnormalities. Such as: abnormal gait when walking, dysphagia, unclear speech, and unable to focus during eye assessment.
Teaching and Anticipatory:
Teaching completed giving the parents further education on how to handle the fact that their son will not likely be developing further cognitively pertaining to his diagnosis of cerebral palsy. S.T. may develop cognitively further, however based on where he is currently it is unlikely. S.T.’s mother was given anticipatory guidance as to what to expect if S.T. were to develop further.
Referral:
Referral for a speech therapist was given to the family for S.T. The pediatric speech and language specialists can be reached at 480-991-6560 and located in Scottsdale, Arizona. They also have an office located in Chandler if the parents would rather drive there.
Self Perception and Self Concept
Using the Erikson’s Psychosocial Development it was determined that S.T. is in the toddler stage (autonomy versus shame and doubt). This was seen with S.T. learning to walk, when at home he was walking with support consistently. Since being in the hospital and laying bed for extended periods of time, his muscle tone has decreased and is having to practice walking with support again. He is learning through trial and error, as well as, imitating those who surround him.
Looking at S.T.’s moral development it appears that he is in stage one (preconventional) of Kohlberg’s Stage. This stage is where the rules that have been set in place are followed in order to avoid punishment from those in authority, not because he understands the reasons for the rules being in place. When his mother or the nurse tells him to let them look at his PICC line or his G-tube S.T. cooperates allowing them too, solely because he understands that what his mother asks him to do he does.
Based off of the child’s developmental age and inability to communicate the child’s perception of himself or the family was unable to be determined. His mother describes S.T. as being a fun loving child. S.T. loves playing and interacting with other children and adults. He also highly loves to dance and make his mother smile.
S.T. seems to comprehend that he is in the hospital, or at least not at home. He does not seem to fully understand his illness or the effects that it can have on him or his family. S.T. seems more saddened that he is not at school with his friends. His family on the other hand completely understands the concept of S.T. being ill.
Teaching and Anticipatory:
Teaching to the family regarding S.T.’s moral development and Erikson’s stage levels were completed. Anticipatory guidance was performed helping S.T.’s parents to further understand that even though S.T. is fifteen, developmentally his decisions are based off of that of a toddler.
Referrals:
S.T’s family was given a referral to a non – bullying website that will give his parents signs to watch for if S.T. is being bullied, as well as, how to prevent bullying. The website that was given to them as a referral is
http://www.stopbullying.gov/.
Value and Belief Pattern
S.T.’s family is highly involved in their church body, volunteering to teach Bible studies, and help where the church needs help. The perceived meaning for their purpose in the world for this family is to cause no harm to others. Their meaning in life is to treat others with respect and be good to all. The family as a whole believes that there is a higher being who watches and loves his people. Prior to S.T. their family had had no issues with illness or hospital visits, other than visiting an occasional friend in the hospital. Once S.T. was born and placed in the hospital the family dove farther into their faith in God. For S.T. having known nothing outside of being ill and considering his developmental age there has been no impact on his faith. When attempting to assess S.T.’s spiritual beliefs and his stage placement in Fowler’s Faith Stage Theory, it was determined that S.T. does not match any of the levels of Fowler’s Faith Stage Theory. Due to his developmental age S.T. is unable to comprehend and vocalize his or his family’s beliefs.
S.T.’s family has a support system available to them through the church, their immediate family, and friends and neighbors. It was wonderful to see how even S.T.’s middle school teacher came to visit him and see if his family needed anything. There were no pertinent cultural practices that his family participated in according to his mother.
Teaching and Anticipatory:
Anticipatory guidance that occurred provided the family with the knowledge that developmentally S.T. currently cannot make his own decisions about his faith. However, that as he grows developmentally he may explore faiths, wanting to make up his own mind about what he believes (Hockenberry & Wilson, 2007). This is currently unlikely based on his age and developmental growth. Teaching completed taught the family about the Fowler stages of faith.
Referral:
Referral to Vacation Bible School at Living Streams Church was completed. By having this outlet for S.T. his parents are able to have some free time of their own while leaving S.T. in a safe and healthy church environment.
Validation
When reviewing the assumptions that had been made prior to caring for S.T. and his family it was found that a great majority of the assumptions made had been invalid. The first assumption made, that both of the parents would be burnt out because of the level of care that was necessary for S.T. was incorrect. Actually his parents made sure that both of them cared for him equally, so that neither one would become overly spent. If they both felt that they were starting to wear thin they have a system in place to have a friend or family member come over to relieve the both of them. Another assumption that was partially invalid was that finances were a great burden for this family. In actuality while finances are important to this family, it was not a priority, whatever S.T. or one of their children needed the parents found a way to make it happen. Finally, the third assumption that one parent was more involved than the other was completely invalid. It was wonderful to see how involved both of his parents were not only in his care but also his school and life. There was not one thing that either parent did not know about S.T. They either found out directly from being with him or from the other parent.
Strengths and Weaknesses
There are many strengths that are possessed by both S.T. and his family. Other than the abnormal assessments that were found pertaining to his diagnosis of small bowel obstructions, S.T. is physically normal compared to his baseline. S.T. has cerebral palsy and thus the physical implications that also occur with that disease. However, for his normal baseline at home S.T. is within his normal individual limits from home. Other strengths that occur are that his family is extremely supportive and caring. They also have a great support system from the church, other family members, and close friends. If S.T. or anyone in their family were in need there would be a long list of people who would jump to their aid.
S.T.’s weaknesses include his diagnosis of small bowel obstruction, as well as, the complications and side effects that can occur. All irregularities have been highlighted in yellow in the above writings. Other weaknesses that occur to the family and S.T. are the lack of consistent and continuous exercise regiment. Also there is a great need to be more conscientious about the nutrients being consumed by the family.
Cluster Clues/Inferences and Nursing Diagnoses
In the following paragraphs will be listed clusters of clues that help to identify the physical problems or health patterns that may be problematic in the future to both the patient and his family. In identifying these problem areas the nursing staff who cares for S.T. have a better idea of how to care for this patient.
Child:
For the first cluster abnormal findings that may cause future complications include: a decreased amount of urine output, an ileostomy placement, PICC line, small bowel obstruction and perforation, possible appendicitis, and a decrease in the patient’s appetite.
Cluster #1
- Decreased urine output
- Ileostomy
- PICC line
- Small bowel obstruction and perforation
- Possible appendicitis
- Decreased appetite in patient
Out of all the clusters this is the most important, due to the fact that because of the PICC line and ileostomy, along with the bowel obstruction, and a decrease in the patient appetite infection is a great risk. The PICC line and ileostomy open S.T.’s body up to more areas of entrance for bacteria and infection causing germs. The low urine output and decreased appetite place S.T. high risk for infection pertaining to the body not having enough energy or being hydrated enough to fight the bacteria that is entering.
Nursing Diagnosis #1:
Risk for infection related to compromised host defenses secondary to prolonged immobility and stress as is evidenced by bowel obstruction, ileostomy, PICC line, decreased urine output, and decreased appetite of the patient (Carpenito-Moyet, 2010).
Cluster #2:
- Patient seated in the less than 5th percentile nationally for body growth
- Gastrostomy
- Ileostomy
This cluster and diagnosis are the third most important of the nursing diagnoses for S.T. The cluster here represents that the patient potentially could not be obtaining all the nutrients that are necessary for his growth and complete health. All three of the clues above have a great impact on his nutrients being stored and are also affected by the amount of nutrients he receives.
Nursing Diagnosis #2:
Imbalanced nutrition: less than body requirements related to decreased desire to eat secondary to stress and illness as is evidenced by gastrostomy, ileostomy, and patient being less than the 5th percentile on the body growth charts (Carpenito-Moyet, 2010).
Cluster #3:
- Decreased urine output
- Wheelchair bound
- Gastrostomy
- Ileostomy
This third set of clusters is second most important of the nursing diagnoses for S.T. This cluster shows a great risk for the patient to have impaired tissue perfusion and integrity. By being bound to a wheelchair and unable to constantly walk S.T.’s blood circulation does not flow as easily. Also by having the ileostomy the acids that come from the intestines have more of a chance to cause skin break down on the patient’s abdomen.
Nursing Diagnosis #3:
Impaired tissue integrity related to decreased blood and nutrients to the tissues secondary to bowel obstruction and cerebral palsy as is evidenced by ileostomy, wheelchair bound patient, and gastrostomy (Carpenito-Moyet, 2010).
Family:
Viewing the family dynamics as a whole there are relations between S.T.’s diagnosis (both chronic and acute), existent stressor in all of their lives, as well as, lifestyles that warrant interventions.
Cluster #1:
- Chronic illness of S.T. (cerebral palsy)
- Acute illness of S.T. and hospitalization (small bowel obstruction and perforation)
- Potential for numerous surgeries
- Financial worries and constraints
With this groups of clustering it is evident that the family is under an increased amount of stress. This increased stress has the potential to be of great risk to the family’s health and well-being. This cluster is chosen as the primary nursing diagnosis for the family, especially since it shows that there may be a potential for improper coping mechanisms for the family. By not having established and strong coping mechanisms the family itself is at risk for being weekend from a strong working unit.
Nursing Diagnosis #1:
Stress overload related to acute and chronic illness of a family member as is evidenced by financial worries and constraints, the acute and chronic illness of the family member, and potential for further surgeries for that same member (Carpenito-Moyet, 2010).
Cluster #2:
- Lack in set regimen for exercising
- Unstable nutrient intake as is evidenced by mother’s comments
- Hypertension and hypercholesterolemia in family history
This is second priority in the groupings; this second cluster shows a family history that if not monitored with exercise and good nutrition could be dangerous for the family as a whole. The combination of lacking in a consistent and precise exercise regiment, unstable nutrient intake, and the family history puts the family entirely at risk for further complications.
Nursing Diagnosis #2: Ineffective health maintenance pertaining to deficient knowledge and family history as is evidenced by the lack in exercise regiments, unstable nutrient intake, and family history.
Cluster #3:
- S.T.’s parents mainly caring for him
- Most of parent’s time when not working is spent with patient or running errands
- Chronic and acute illness of the patient (24 hour care)
Lastly is the third cluster while S.T.’s parents love him endlessly it is still a burden to be a full time parent and caregiver for a child who is developmentally delayed, especially with S.T.’s condition.
Nursing Diagnosis #3:
Risk for caregiver role strain related to duration of care giving required as is evidenced by chronic and acute illness of the patient, parents caring for patient, and decreased amount of relief time before returning to caring for the child.
Outcomes and Nursing Interventions
Based on the priority family and child nursing diagnoses from above, family and child centered outcomes have been searched for. In the following paragraphs these outcomes and interventions will be reviewed, in the hope of providing specialized care that will increase the chance of the family and their child to reach the desired outcomes listed for them.
Child:
The priority nursing intervention for S.T. was Risk for infection related to compromised host defenses secondary to prolonged immobility and stress as is evidenced by bowel obstruction, ileostomy, PICC line, decreased urine output, and decreased appetite of the patient (Carpenito-Moyet, 2010). Listed below are the outcomes and interventions that were determined for this child.
Client – Centered Outcome 1: The client will remain free from symptoms of infection while staying in the hospital for miscellaneous treatments (Swearingen, 2008).
Nursing Intervention 1a: Assessment: The nurse will monitor the pediatric patient’s temperature, looking for an elevated temperature of greater than 100.0 degrees Celsius.
Rationale 1a: “Fever is often the first sign of an infection” (Ackley, & Ladwig, 2008).
Nursing Intervention 2a: Educational: The nurse will educate the family on using alcohol – based hand rubs and the importance of good hygiene.
Rationale 2a: “By introducing the use of hand rubbing with an alcoholic solution, there was significant improved hand – cleansing compliance” and reduced spread of infection in the hospital setting (Ackley, & Ladwig, 2008).
Nursing Intervention 3a: Therapeutic: The nurse will assist the patient with normal living activities (e.g. showering, walking, etc…).
Rationale 3a: Assisting the patient will help to increase blood flow for the patient and oxygen demand, thus helping the body to fight off infections (Ackley, & Ladwig, 2008).
Nursing Intervention 4a: Therapeutic: The nurse will encourage the intake and increase of fluids via IV.
Ratoinale 4a: “Fluid intake helps thin secretions and replace fluid lost during fever”, also helps to prevent fever (Ackley, & Ladwig, 2008).
Client – Centered Outcome 2: The family and patient will report risk factors associated with infection and precautions necessary to prevent by the time of patient discharge.
Nursing intervention 2a: Educational: The nurse will educate the patient and family on proper care for the ileostomy bag.
Rationale 2a: In doing this the family and patient are further educated on how to provide proper and adequate care for their son, preventing further risks for infection.
Nursing Intervention 2b: Therapeutic: The nurse will provide the family with temperature and intake and output logs.
Rationale 2b: By doing this the family is able to monitor the patient’s vital signs after discharge, thus helping to place them in control of preventing any infections.
Nursing Intervention 3b: Assessment: The nurse will monitor the PICC line placement, monitoring for infiltration and infection.
Rationale 3b: In doing this the nurse is able to monitor for sites that are highly vulnerable for infection.
Nursing Intervention 4b: Educational: The nurse will educate the family on signs to monitor for signs of infection (e.g. fever, decreased urine output, cool clammy skin, lethargy, etc…).
Rationale 4b: Through this the parents and family will be able to monitor their child when home.
Family:
The priority nursing diagnosis that was determined for this family was Stress overload related to acute and chronic illness of a family member as is evidenced by financial worries and constraints, the acute and chronic illness of the family member, and potential for further surgeries for that same member (Carpenito-Moyet, 2010). Listed below are the outcomes and interventions that were determined for this family.
Family – centered Outcome 1: The family will verbalize ways to decrease stress and feelings when being overwhelmed by the end of the shift (Carpenito-Moyet, 2010).
Nursing Intervention 1a: Educational: The nurse will help the clients to distinguish between short – term stressors and chronic stressors (Carpenito-Moyet, 2010).
Rationale 1a: In doing this the nurse will help the family to identify stressors that they can control and stressors that cannot be (Carpenito-Moyet, 2010).
Nursing Intervention 2a: Therapeutic: The nurse will provide information as needed to reduce stress responses to acute and chronic illnesses (Carpenito-Moyet, 2010).
Rationale 2a: Through this the nurse is able to monitor what stressors the family receives medically and helping to prevent them from being overwhelmed (Carpenito-Moyet, 2010).
Nursing Intervention 3a: Assessment: The nurse will help the family to work on reducing the stressors affecting the child and family as a whole (Carpenito-Moyet, 2010).
Rationale 3a: Through this the nurse is able to assist the family in deciding what stressors their family can handle, thus helping to prevent them from being overwhelmed (Carpenito-Moyet, 2010).
Nursing Intervention 4a: Therapeutic: The nurse will help to find a community resource to help ease the burden and stress level of having a mentally handicapped child (Carpenito-Moyet, 2010).
Rationale 4a: In doing this the nurse is reminding the parents that there are other people who can help and assist them in caring for their child, that they do not have to do this alone.
Family – centered Outcome 2: The family will verbalize intent to change at least two behaviors to decrease or manage the stress levels that come with their life by the end of the shift (Carpenito-Moyet, 2010).
Nursing Intervention 2a: Educational: The nurse will “assist them to recognize their thoughts, feelings, actions and physiologic responses” (Carpenito-Moyet, 2010, p. 649).
Rationale 2a: “Self-awareness can help the person reframe and reinterpret their experiences” (Carpenito-Moyet, 2010, p. 649).
Nursing Intervention 2b: Therapeutic: The nurse will have the patient and family list one or two changes that can be made in their life styles to reduce the stress (Carpenito-Moyet, 2010).
Rationale 2a: “In a person who is already overwhelmed, small changes in lifestyle may have a higher chance for success and will increase confidence” (Carpenito-Moyet, 2010, p. 650).
Nursing Intervention 3b: Assessment: The nurse will ask the family and assess what is important in their life (Carpenito-Moyet, 2010).
Rationale 3b: “Values clarification assists the overwhelmed person to identify what is meaningful and valued and if it is present in their actual living habits” (Carpenito-Moyet, 2010, p. 650).
Nursing Intervention 4b: Therapeutic: The nurse will assist the family to set realistic goals (Carpenito-Moyet, 2010).
Rationale 4b: “Setting realistic goals with increase confidence and success” (Carpenito-Moyet, 2010, p. 650).
Evidence – Based Intervention
For S.T. infection is a high risk. The patient is bound to a wheel chair (with minimal times to walk with assistance), has an ileostomy, PICC line, gastrostomy, and has a low urine output. All of these factors greatly increase his risk of obtaining an infection brought in from bacteria on the nurses, family, or physician’s hands. The article being reviewed in the next paragraphs evaluates the use of PICC lines and how to best prevent the spread of infection to them.
The research article “An Evidence – Based Systematic Review of Literature for the Reduction of PICC Line Occlusions” evaluated the reasoning and prevention for PICC lines becoming occluded. By preventing occlusions from occurring in the patient’s PICC line nurses are able to help prevent infections happening in their patients. The author reviewed seven articles noting their results and research commenced on this topic, thus finding that there are indeed several interventions that nurses can take in preventing infections or occlusions in their patients PICC lines.
One intervention that was highly suggested was to have a dedicated PICC line team to place the PICC lines. In having this there would be a select group who understood the mechanics and lagistics of the PICC line (Bartock, 2010). By having a dedicated PICC team there was a significant reduction in PICC line occlusions (Bartock, 2010). Another way to prevent infections in the central lines through reducing the occlusions was to do saline or heparinized flushes in the PICC lines every 12 hours or so. In doing this the nurse is preventing clots from building around the catheter of the PICC, thus preventing an occlusion and further more infections (Bartock, 2010).. These strategies for nurses seem to be supported by N.I. Fong and authors of “Peripherally inserted central catheters: Outcome as a function of the operator” and also D. Funk and authors of “Concise communications. Two-year trends of peripherally inserted central catheter-line complications at a tertiary-care hospital: Role of nursing expertise” (Bartock, 2010).
The use of the saline or heparinized flushes for the PICC lines is mandatory at Cardon’s Hospital. All the nurses that have been using this technique agree with the studies that have been performed. Also, when speaking with the physicians about this article, the majority of them place it in their orders for the nurses to perform heparinize flushes on the patient’s PICC line.
Evaluation
After listing the care above for the patient and her family, now is the time to evaluate the care given to see if the outcomes were met. The first outcome: that the patient would show no signs of infection was met. Through monitoring the entire day S.T. never showed any signs of increased temperature, lethargy, or change in consciousness or personality, and was in no pain. His laboratory levels, other than lipase, were all normal. Throughout the day his skin was warm, pink, and he was as active as his physical body would allow. Further proving that there was no immediately direct evidence of an infection being present for S.T.
The second nursing outcome that was designed for the client was that the family would verbalize risk factors and signs and symptoms of infection that would be evident for this child. This task was completed by the end of the shift, throughout teaching the family that day. It was highly evident that this family comprehended what signs to look for and how to monitor. Mother showed and verbalized to the nurse throughout the day how to monitor her son. The father also came in and was vocal and verbalized his complete understand. When both were asked the signs and risk factors they both were able to list off several different indicators.
For the family outcomes the family outcomes there were also two listed: 1. for the family to verbalize the a reduction of stress and feelings of being overwhelmed and 2. to verbalize two changes that could be made in the family to reduce or manage the stress levels. All of these were completed successfully at the end of the shift. The mother and father both agreed to start walking for thirty minutes each day consistently and eating more fruits and vegetables. By doing this the family not only reduces their stress levels they also are becoming healthier individuals. The family also was able to verbalize a reduction of feeling stressed. They went for a walk during the shift and were much relieved.
Conclusion
S.T. throughout the day was a delight to work with; his parents were caring and loving people who needed just a little break here and there and a little light at the end of the tunnel for hope. All of the nursing steps, diagnoses, assessments, planning, and interventions were all put to use for the betterment of care for S.T. and his family. His current state will be an on going battle for him and his family. However, hopefully with the referrals, teaching, and support given to him be the nursing faculty and the students who aided them S.T. and his family will be better able to handle the stressful days to come. For this paper and more importantly the care of S.T. critical thinking was absolutely vital and well used.
References
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Fong, N. I., Holtzman, S. R., Bettmann, M. A., & Bettis, S. J. (2001). Peripherally inserted central catheters: Outcome as a function of the operator. Journal of Vascular and Interventional Radiology, 12(6), 723-729.
Funk, D., Gray, J., & Plourde, J. (2001). Concise communications. Two-year trends of peripherally inserted central catheter- line complications at a tertiary-care hospital: Role of nursing expertise. Infection Control & Hospital Epidemiology, 22(6), 377-379.
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