CNA342 | Family Health Care | Strategies for Therapeutic Engagement

Scenario One: Jamir (8 years) – Care provided by a school nurse in a primary care setting

You are a school health nurse working in a rural suburban neighbourhood. One day, when you are at one of the schools in your catchment area, a teacher shares her concern for Jamir, an eight year-old boy in her class.

Jamir was diagnosed with asthma 12 months ago. He has had three asthma attacks at school in the last 2 months, all of which occurred during a Physical Education (PE) session. Over the last few weeks, Jamir has participated less in the PE classes, preferring to watch the other children. The PE teacher has tried to encourage him, but is worried about his asthma. At school Jamir uses a Salbutamol puffer when needed to relieve his asthma symptoms. Jamir has also been absent from school a number of times this year and is falling behind in his studies.

Jamir lives at home with his three younger sisters and parents. His family immigrated to Australia from Afghanistan two years ago and his mother has since developed depression. His father works long hours in the family business. The teacher has talked to Jamir’s mother about his asthma, but nothing seems to change for Jamir. The teacher has asked for your help. What would you do in this situation?

Scenario Two: Emily (17 years) – Care provided by a RN in an outpatient care setting

You are a nurse working in the outpatient diabetic clinic at the local Children’s Hospital. You have just started in this role, taking over for a colleague’s maternity leave. At the clinic one morning, you meet Emily and her mother.

Emily was diagnosed with Type 1 diabetes 6 years ago. Emily’s mother, Karen, is her primary carer and is extremely knowledgeable about diabetes. Karen’s management of Emily’s diabetes has enabled Emily to successfully participate in school and club sports and have a varied diet. Emily has only had two presentations to hospital with unstable diabetes in the last 6 years, both associated with an acute infection.

Emily is being prepared for transfer to adult services. She has been taking over the management of her diabetes, assuming responsibility for her own insulin regime and diet. During the appointment, Emily goes to the toilet and Karen tells you she is concerned that Emily is not properly managing her condition because she has been having high blood sugar readings. She has stopped playing sport and Karen suspects Emily has been drinking alcohol at parties and might be dieting. Karen is upset about being excluded, particularly as she is a single parent and has therefore been solely responsible for Emily’s care. Karen asks for your help. What would you do in this situation?

Scenario Three: Sarah (11 months) – Care provided by a RN in an acute care setting

You are a new graduate nurse working a late shift on the paediatric unit at the local metropolitan hospital in a large regional city. You have been allocated a new admission from the Emergency Department – an 11 month old girl being admitted into an isolation room with acute exacerbation of eczema.

Sarah is being admitted for antibiotics and daily dressings to her eczema. She has a red and very angry looking rash covering most of her legs and one arm. Sarah appears small for her age – her weight and length put her on the 25^th percentile on the World Health Organisation growth charts.

Sarah is accompanied by her mother, Deborah who appears very tired and a bit

dishevelled. Deborah’s husband is in the army and has been stationed interstate for the last 6 weeks. He regularly calls and face times with Deborah and Sarah. Sarah has been needing daily dressings for her eczema and is very unsettled overnight, scratching and restless. When at home, Deborah’s husband usually does Sarah’s dressings because she does not get as upset when her father does them. When you ask Deborah about Sarah’s diet she becomes very defensive, stating that she is sick of people asking her about what Sarah eats. She knows Sarah is small, but says Sarah eats well, although her diet is restricted because so many things make her eczema worse. Deborah then bursts into tears. What would you do in this situation?

1. Describes the physical, social, cultural needs of the infant, child or youth and family. Identifies three priorities for nursing care relevant to the clinical scenario.
2. Develops strategies to engage with the infant, child or youth and family that are feasible and supported by relevant theoretical perspectives.
3. Synthesises and applies the best available literature to develop a plan of care tailored to ONE specific need of the infant, child or youth and family. Describes clear, practical and evidence-based interventions and evaluation.
4. Demonstrates and applies expected academic writing skills including accurately adhering to the Harvard referring style.

Part I:

The case scenario selected for the assignment focuses on Jamir, an eight year old ethnically diverse patient living in the rural suburban neighbourhood of Australia. The case was reported by a teacher who came to the clinic to share her concerns about the deteriorating asthma that Jamir had been suffering from ever since his diagnosis of asthma 12 months ago. The teacher has mentioned that the patient has had three asthma attacks within the last two months and all of which had been occurring during the physical exercise education classes. The teacher has also mentioned that she had spoken to Jamir’s mother regarding the asthma complications that he experiencing, signs of his deteriorating condition and his absenteeism and affected educational progress due to the deterioration. The teacher mentioned that they immigrated to Australia from Afghanistan two years ago and ever since his mother has developed depression and it being a family of five with only his father being an earning member, his father has to work long hours to sustain the family. The teacher explained that even though Jamir’s mother has been notified about the deteriorating condition, nothing changed for Jamir.

As per the information provided by the case study, there are various care needs that are present for the patient. First and foremost, it has to be acknowledged that exercise induced bronchospasms are prevalent in the patient groups with lack of properly medically managed asthma. Hence,

Part II:

It has to be mentioned in this context that asthma is a chronic lung disorder which is associated with many health related restrictions and lifestyle modifications. The physical exercise is one of these restrictions that an asthma patient has to undergo in order to be able to avoid the risk of asthma attack or exacerbations. As discussed by Jayasinghe, Kopsaftis and Carson (2015), vigorous exercise or physical activity is associated with exercise induced bronchospasms in the asthma patients, and hence, students with asthma should not be allowed to take part in regular vigorous physical activity to avoid risk of exacerbations. The information provided on the patient includes Jamir using salbutamol in school only when he experiences asthma attacks and yet his health had been deteriorating and he had been absent from the school for increasing number of days on a stretch which indicates that his health had been deteriorating further and without adequate interventions taken to address the issues that the patient is experiencing, it might lead to considerable adverse events and his studies are also going to get affected further (Weiler et al., 2016). Along with that, living in the care of a depressed mother and a work absorbed father with three younger sibling has a significant impact on the psyche and sense for safety of a child. Hence, there is need for proper therapeutic engagement with patient and his family to address the overlapping care needs.

Strategies for therapeutic engagement:

Hence, the first strategy for the patient will be to address the communication issues in order to develop the therapeutic relationship. Exploring this issue further, Jamir belonged to the ethnic Islamic background which is associated with many restrictions and cultural constraints associated with communicating with parents. The relationship between the children and their parents in this culture is respectful yet very formal with the affection guarded by conventional and traditional strictness (Yeh et al., 2016). Hence, the children feel awkward and afraid to communicate their needs and problems, and for Jamir the depression of his mother and extreme occupational stress of his father, his communication skills become limited. The strategy will need to involve different communication theories namely relational communication theory and interpersonal communication theory where, his personal ties and relationship will be evaluated and encouraged with the parents so that he feels comfortable in sharing his woes and health issues (Kurtz, Draper and Silverman 2016). Along with that, the nurse will have to include strategies to enhance the interpersonal communication with the family and develop a therapeutic alliance with Jamir.

Family centred care can be defined as the care approach that allows the parents of the child be the centre of the decision making for care planning and implementation with collaboration of the health care staff (Mohanty et al., 2018). In this case, Jamir’s health issues are not limited to just his physical health needs but also the emotional and mental health ne4eds which is associated with the parents and family. Here the nurse will have to suggest family oriented psychotherapies to enhance familial bond and suggest psychotherapeutic interventions for both Jamir and his parents that will also help his father deal with work stress and his mother to overcome depression. Along with that, the nurse will also have to focus on involving both parents in care planning and implementation procedure, to help them feel useful, connected with their child and in control. These will help the parents and the family build trust and comfort with the child and his family and will allow the nurse to engage in a therapeutic relationship and help address the care needs of Jamir and help him overcome his health concerns effectively and holistically (Coyne, 2015).

The third strategy will undoubtedly have to focus on the need for cultural safety for the therapeutic engagement and subsequent care planning. It has to be mentioned in this context that Jamir belongs to an ethnic Islamic background which is associated with many traditional healing concepts and ideologies which is needed to be acknowledged in the care planning. And developing a therapeutic alliance with a patient belonging to CALD background, the need for a culturally safe and appropriate approach will be essential (Cené et al., 2016). Language and non-verbal communication is a very important aspect of the therapeutic engagement with Jamir and his parents, hence there will be need to incorporate a language interpreter for Jamir and his family to understand and participate optimally in the process. Lastly, respecting the cultural identity and the honouring the choices and preferences are a very important aspect of caring for as culturally diverse child, hence the nurse will also require to respect his and his family’s cultural identity and ethnicity along with taking the assistance of cultural liaison officer and CALD expert to put across my thoughts and concerns better to the family and help them understand me more effectively and help in strengthening the therapeutic engagement (Arnold and Boggs, 2015).

Care plan:

The most important care need for Jamir is better management of his asthma exacerbations and frequent bronchospasm attacks that were mostly exercise induced which indicated at the fact that his asthma not being properly medically managed.

References:

Arnold, E.C. and Boggs, K.U., 2015. Interpersonal Relationships-E-Book: Professional Communication Skills for Nurses. Elsevier Health Sciences.

Cené, C.W., Johnson, B.H., Wells, N., Baker, B., Davis, R. and Turchi, R., 2016. A Narrative Review of Patient and Family Engagement: The “Foundation” of the Medical Home. Medical care, 54(7), p.697.

Coyne, I., 2015. Families and health?care professionals' perspectives and expectations of family?centred care: hidden expectations and unclear roles. Health expectations, 18(5), pp.796-808.

Jayasinghe, H., Kopsaftis, Z. and Carson, K., 2015. Asthma bronchiale and exercise-induced bronchoconstriction. Respiration, 89(6), pp.505-512.

Keeney, G.E., Gray, M.P., Morrison, A.K., Levas, M.N., Kessler, E.A., Hill, G.D., Gorelick, M.H. and Jackson, J.L., 2014. Dexamethasone for acute asthma exacerbations in children: a meta-analysis. Pediatrics, pp.peds-2013.

Kurtz, S., Draper, J. and Silverman, J., 2016. Skills for communicating with patients. CRC Press.

Mohanty, S., Wells, N., Antonelli, R. and Turchi, R.M., 2018. Incorporating Patient-and Family-Centered Care Into Practice: The PA Medical Home Initiative. Pediatrics, p.e20172453.

Murray, C.S., Foden, P., Sumner, H., Shepley, E., Custovic, A. and Simpson, A., 2017. Preventing severe asthma exacerbations in children. A randomized trial of mite-impermeable bedcovers. American journal of respiratory and critical care medicine, 196(2), pp.150-158.

Peter, D., Robinson, P., Jordan, M., Lawrence, S., Casey, K. and Salas-Lopez, D., 2015. Reducing readmissions using teach-back: enhancing patient and family education. Journal of Nursing Administration, 45(1), pp.35-42.

Puranik, S., Forno, E., Bush, A. and Celedón, J.C., 2017. Predicting severe asthma exacerbations in children. American journal of respiratory and critical care medicine, 195(7), pp.854-859.

Teach, S.J., Gill, M.A., Togias, A., Sorkness, C.A., Arbes Jr, S.J., Calatroni, A., Wildfire, J.J., Gergen, P.J., Cohen, R.T., Pongracic, J.A. and Kercsmar, C.M., 2015. Preseasonal treatment with either omalizumab or an inhaled corticosteroid boost to prevent fall asthma exacerbations. Journal of Allergy and Clinical Immunology, 136(6), pp.1476-1485.

Weiler, J.M., Brannan, J.D., Randolph, C.C., Hallstrand, T.S., Parsons, J., Silvers, W., Storms, W., Zeiger, J., Bernstein, D.I., Blessing-Moore, J. and Greenhawt, M., 2016. Exercise-induced bronchoconstriction update—2016. Journal of Allergy and Clinical Immunology, 138(5), pp.1292-1295.

Yeh, H.Y., Ma, W.F., Huang, J.L., Hsueh, K.C. and Chiang, L.C., 2016. Evaluating the effectiveness of a family empowerment program on family function and pulmonary function of children with asthma: a randomized control trial. International journal of nursing studies, 60, pp.133-144.