Scholarly Term Paper: Importance of Family-Centered Care
In this paper, I describe a patient from my clinical placement that was significant to me and devise a detailed plan of care. I reflect on how this patient scenario expanded my learning of family-centered care and how I will use it in my future nursing practice going forward.
Description of the Patient
Patient X is a 3-year-old male that came into Alberta Children's Hospital (ACH) emergency room late at night presenting with a barking cough, inspiratory stridor, restlessness, and increased work of breathing. Patient X's mother informed the triage nurse he had rhinorrhea and a low-grade fever for the past two days. Patient X was diagnosed with severe laryngotracheobronchitis (LTB), also known as croup. Croup is an acute inflammation of the upper and lower respiratory tracts and is commonly caused by parainfluenza virus type 1. In the emergency room, he was treated with racemic epinephrine and systemic corticosteroids and then was admitted to Unit 4 for observations. Patient X has had no other hospital visits or major health concerns prior to this incident and is otherwise a healthy child (see Appendix A and Appendix B for genogram and ecomap).
Assessment of the Patient
I first encountered Patient X the morning after his admission. Upon assessment, I noticed inspiratory stridor and a barking cough. His lung sounds were diminished to the bases, his respirations were 52 breaths per minute, and his oxygen saturation was 96 percent on two liters. He was afebrile at this time, however, he had been receiving ibuprofen and acetaminophen overnight. I noticed Patient X became fatigued quite easily with any physical activity or exertion. His fatigue had an effect on his ability to eat and drink at meal times as he would quickly become short of breath.
Protective factors for patient X include full-term birth, history of breastfeeding, and current vaccinations. Risk factors and health concerns I identified included a family history of obesity and the mother's smoking habit. In terms of socioeconomic determinants of health (PHAC, 2001), obesity and smoking are indicative of poor personal health practices and coping skills. I often observed the family bringing in fast food to eat, and the older brother would snack on chips and cookies. Second-hand smoke greatly affects the physical environment and can lead to many health concerns later in life, however, I noticed the mother made many attempts to limit the exposure to her children by doing things like changing her sweater and washing her hands when she came back into the room. The major strength I observed was the strong bonds between Patient X’s family. Patient X had a very positive social environment and many support networks available including family and close family friends.
Applying Developmental Stages
At 3 years old, Patient X is at the end of autonomy vs shame and doubt phase in Erikson's Theory of Psychosocial Development (Perry, Hockenberry, Lowdermilk & Wilson, 2013). He has developed autonomy by his acquired motor skills and ability to control his own body. He has demonstrated this by walking and climbing up onto his mother's lap. He is able to manipulate objects with his hands as shown by playing with toys in his crib. He has shown his ability for selecting and decision making by choosing which arm or leg he wants the blood pressure cuff attached. Negative feelings of shame and doubt may arise due to being dependent on others while being in the hospital and feeling small and self-conscious with all the attention from doctors and nurses assessing him.
Patient X is at the beginning of the preoperational phase (2-7 years) of Piaget's Theory of Cognitive Development (Perry et al, 2013). The main focus of development is egocentrism. Patient X only sees objects and people in relation to him, rather than from their perspective. His thoughts are about what he can hear, see, or experience. He is able to use language to represent objects in his environment such as asking for his book on the bedside table to be read to him. He also uses transductive reasoning. For example, when he sees the nurses holding a syringe he thinks he is getting a needle and associates it with pain and starts crying, even though it may be for flushing his IV or oral medication.
Patient X is in the preconventional level of Kohlberg's Theory of Moral Development (Perry et al, 2013). During this phase, he determines whether something is good or bad based on the consequences. He does things to avoid punishment, and he obeys the people who enforce the rules in his life such as his mother and maternal grandparents. In the later stages of the preconventional level, Patient X will believe the right behavior is doing things that satisfy his own needs.
Meleis’ Transition Theory
The patient is going through a single health and illness transition for his diagnosis of croup (Meleis, Sawyer, Im, Messias, & Schumacher, 2000). This transition has a huge effect on the child’s ability to play, eat, and drink. His daily structure and routine have been altered by staying in the hospital. At 3 years old he is aware he is sick but doesn’t understand why he is sick and what that really means. He does not quite understand the interventions that are meant to help get better and breathe easier, therefore he had little engagement in the process of his transition. The timespan of his hospitalization was 2 days, however, croup symptoms can last for up to two weeks. The most critical points in his transition were the day his symptoms first began, being admitted to hospital and his discharge home.
Facilitators to this transition include strong community conditions in relation to his supportive family (Meleis et al, 2000). The mother spends the night with the patient and the maternal grandparents visited once a day. An inhibitor to this transition is his personal conditions in regards to the lack of anticipatory preparation and knowledge due to the patient's age (Meleis et al, 2000).
Process indicators of a healthy transition are the child continuing to have healthy interactions with his mother, brother, and the nursing staff (Meleis et al, 2000). He felt the need to stay connected to his mother as evidenced by him reaching for her and settling easily in her arms. Outcome indicators showing a healthy completion of transition are that by the end of the patient's hospital stay he became less wary of the nursing staff and was more accepting of the nursing staff performing assessments (Meleis et al, 2000). The mother showed knowledge of learning upon discharge teaching regarding croup and was prepared to continue to care for him from home.
Priority Nursing Diagnoses
Diagnosis 1
Ineffective breathing pattern related to edema and constriction of the airway as evidenced by persistent barking cough, inspiratory stridor, and tachypnea (Bulechek, Butcher, Dochterman, & Wagner, 2013, pp. 472).
Intervention 1. Reposition child in an upright position supported by pillows as necessary (Bulechek et al., 2013, pp. 76). Ensure optimal ventilation through maximum lung expansion. Upright positions lead to higher lung volumes, increasing elastic recoil of the lungs and chest wall, and lead to higher expiratory pressures due to the position of the expiratory muscles (Katz, Arish, Rokach, Zaltzman & Marcus, 2018).
Intervention 2. Administer corticosteroid, nebulized racemic epinephrine, and oxygen as indicated (Bulechek et al., 2013, pp. 76). Corticosteroids are used to help reduce airway inflammation and edema; epinephrine provides symptomatic relief temporarily by increasing vasoconstriction in the mucosa reducing airway edema and allowing time for the systemic corticosteroids to reach peak action (Petrocheilou et al., 2014).
Outcomes. After repositioning the child his lung expansion will have increased and work of breathing will have visibly decreased. Almost immediately after the administration of both medications and oxygen administration (as the onset of the therapeutic effects is fairly rapid), Patient X will have adequate ventilation as evidenced by respiratory rate within normal limits for age, oxygen saturation above 92%, clear breath sounds, and no use of accessory muscles.
Diagnosis 2
Fatigue related to dyspnea as evidenced by the inability to eat and emotional irritability (Bulechek et al., 2013, pp. 494).
Intervention 1. Explain the importance of conserving energy to avoid fatigue to the family and encourage activities that do not require exertion (Bulechek et al., 2013, pp. 175-176). This will promote understanding of Patient X's response to respiratory distress and the importance of rest and support to prevent fatigue. Quiet play prevents excessive activity, which requires more energy and increases respiration (Perry et al, 2013).
Intervention 2. Assist parents to develop a plan for bathing, feedings, and bathroom visits around rest periods (Bulechek et al., 2013, pp. 175-176). This will prevent interruption in rest or sleep (Perry et al, 2013).
Outcomes. After implementation of teaching and formulation of a scheduled plan, we will notice an improvement in Patient X’s sleeping patterns and an increase of oral fluids and food intake each day for the remainder of the hospital visit.
Diagnosis 3
At risk for childhood obesity related to an intake of nutrients that exceeds metabolic needs as evidenced by a family history of obesity and observed eating patterns (Bulechek et al., 2013, pp. 572).
Intervention 1. Determine family nutritional knowledge and provide parent/family teaching to fill in the gaps on appropriate nutrition and caloric intake for toddler and school-aged child (Bulechek et al., 2013, pp. 274-275). When conducting teaching, it is necessary to discover what the family/parent already knows to ensure they have the correct information and to know what additional information to provide (Bradshaw & Hultquist, 2017). Using different ways to implement teaching (books, websites, etc.) can further learning and improve outcomes (Bradshaw & Hultquist, 2017).
Intervention 2. Promote exercise and physical activity for the whole family (Bulechek et al., 2013, pp. 182). Supply ways to integrate exercise into family routines. Examples include family walks, going to the park, kicking the soccer ball outside, and enrolling children in community sports teams. Physical activity and age-appropriate free play are important for childhood development of essential motor skills (Joy & Lobelo, 2017). Providing education to parents and families about daily exercise requirements is an important step in promoting health and well-being (Joy & Lobelo, 2017).
Outcomes. By the end of the hospital visit, the mother will be able to differentiate healthy meal choices from poor meal choices, know the recommended caloric intake for each child’s age, and have a plan to implement daily exercise into the family routine. She will also be able to identify health risks associated with obesity.
Reflection
I chose to write about patient X because he was the first pediatric patient I took care of and my first real introduction to pediatric nursing. I have had limited experience in dealing with young children prior to my pediatric placement and I was absolutely terrified to care for them.
While caring for Patient X, I slowly learned more about his mother and the rest of his family. His father worked out of town and his mother was raising Patient X and his brother mainly on her own while working part-time. She raved about how helpful her parents have been over the past few years with babysitting and helping out at home, but I could tell she was having a tough time without her husband there for support, especially with patient X in hospital. This was the first time either of her children had been hospitalized and the fear of the unknown and unfamiliar was huge for her emotionally. In terms of Melies’ Theory, parents often experience their child’s transition alongside them (Meleis et al, 2000). I realized how important family-centered care is and what that means in the pediatric population.
According to Joy & Lobelo (2017), family-centered care focuses on enacting care that is considerate of each families’ needs and values. As a future registered nurse, part of my role is to address the needs of the family as well as the patient, and this experience with Patient X and his family really opened my eyes to its significance in the pediatric population. With collaboration, engagement, and empowerment we can better support parents in caring for their children (Smith, Swallow & Coyne, 2015).
Moving forward, I will use what I learned about the importance of family-centered care and apply to my future patients. Instead of only assessing and treating the patient, I will address the family and assess their needs as well. Whether they need help with coping, teaching/education, or just someone that will listen to their concerns and know that they were heard.