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Discussion

Judy is a 7-year old child who had been previously diagnosed with common cold and low grade persistent fever which was finally diagnosed as leukaemia. The child’s presenting symptoms included listlessness, irritability, pale skin, fever and the child looked anorexic. Other manifestations included weight loss, petechiae over the whole body, bruising without cause, complaints of joint and bone pain.  The child lives with her parents.

The client’s problem is that she is diagnosed with common cold which had been later changed to leukaemia. However, some of the manifestations of leukaemia had been concerning for Judy’s parents. They believed that the gradually developing symptoms were signs of an underlying fatal disease. Her parents assume that Judy’s death is impeding. Due to this assumption they are suffering from extreme apprehension, fear and depression. Therefore the two major issues for the family are the appropriate treatment for Judy and her parents’ fear and depression about Judy’s condition.

The family centered approach that will be used in the recovery of Judy will ensure to assess every immediate and special need of Judy and her parents. This approach will help foster communication between the professionals and the family members to render the family members an integral part of the care team. The collaborative intervention plan will be developed in order to address all the major needs of the client and her family members. The care plan will be recovery-oriented, goal-directed and person-centered in nature.

The aim of the care plan will essentially be to address Judy’s multidimensional needs and reduce the anxiety, fear and depression experienced by the family members. The major areas which will be focused on in the care plan are Judy’s acute joint and bone pain, nutritional imbalance and her parents’ anxiety (Pitman et al., 2018). Therefore, this care plan essay will be focused on describing the family centred approach that will be integrated in the care plan for Judy, the potential areas that needs to be prioritized in the care plan, the subjective and objective data that supports the diagnosis and a SMSRT goal based care plan outlining three major needs of the family.

Family centered approach follows the same concept and core principles of the person-centred care approach. This approach aims to plan, deliver and evaluate health care using techniques which are grounded in mutually benefiting collaboration among healthcare professionals, patients and their family members (Kokorelias et al., 2019). The collaboration ensures that the health care professionals are responsive to the preferences, needs, health aspirations, cultural needs and priorities of the client and the family members (Rait, 2015). Therefore, this approach promotes the alliance between the professionals, patients and their family members while recognizing the roles they can play in the in optimizing the care quality and safety of the client. The four core principles of the family centered approach are dignity and respect, information sharing, participation and collaboration (Adib-Hajbaghery & Aghajani, 2015). 

In the above case scenario, dignity and respect will be ensured in the collaborative client and professional relationship by respecting the cultural perspective, health perspective and care perspective of the client and the client’s family members (Adib-Hajbagher & Aghajani, 2015). In this context, Judy’s perspective about recovery and health should be considered in the care plan. Alongside that, the perspectives of Judy’s parents on the best interest of Judy should be incorporated into the care plan. The promote respect, the parents’ values, health beliefs and knowledge will be considered during the decision making of the care plan. To ensure dignity and respect for the client party, the client’s personal information will be retained in a confidential manner and the final care decision will be taken by the family members (Lin et al., 2013). The professionals can advocate for the client party but the care decision will be mutually taken. The care plan will also include the care plan for the parents of Judy as they are experiencing signs of depression and fear (Archer et al., 2012). Pessimistic thoughts can interfere with the involvement of the parents in the care plan and hamper their care giving capacities. Alongside the care plan for Judy, the professional must ensure to refer the parents to psychological support if required as it is essential for Judy’s parents to remain optimistic about the care plan that is developed.

Nursing Diagnoses

Furthermore, the professionals must transparently share unbiased and complete information regarding the diagnosis and the alternative treatment strategies that is available for Judy. Judy’s parents will receive timely, accurate and progressive information about Judy so that they can take decisions accordingly. No paternalistic approach will be followed.

The participation of Judy’s parents will be encouraged in the decision making for Judy in all stages of the care. No paternalistic decision will be made by the professionals. This principle is connected to the principle of information sharing.

Collaboration will be ensured between the family members and the professionals in order to reach final decision. There should an understanding between the two parties should that no misunderstanding and conflicts that can impede communication. In this context, the professionals must encourage the client and the client’s parents to actively participate in the care plan as this will increase the self-determination, self-agency, responsibilities and accountability of the parents in the care for Judy (Choi et al., 2014).

The four possible nursing diagnoses for Judy are acute pain, anxiety, imbalanced nutrition and fatigue. The objective experience of acute pain can be assessed by using a pain scale. Judy had complaints of joint and bone pain. The complaints of symptoms like weight loss, fatigue, and listlessness is indicative of nutritional imbalance. Assessment of nutritional content in body through a blood test can indicate the measure of nutritional content in Judy’s body. Anxiety is manifested through the symptoms of restlessness, listlessness and irritability. Objective assessment of anxiety can be done by administering Anxiety scales for children. Petechiae can be caused due to a viral and bacterial infection or can be the manifestations of serious underlying health conditions like leukaemia. The objective symptoms of Petechiae include bruising without cause and small red spots on whole body. This is the manifestation of the leukaemia.

The nursing diagnoses that have been considered in the previous section are acute pain, petechiae, anxiety and imbalanced nutrition. These diagnoses have been prioritised as these diagnoses are interfering with the normal functioning of Judy. Acute pain of the joint and bone can cause issues in mobility, depression and irritability. The acute pain should be immediately intervened as it can cause irritation, depression and anxiety in Judy. Imbalanced nutrition or nutritional deficiencies can exacerbate fatigue, weight loss and risks of further infection. It is essential to prioritize the nutritional imbalance to reduce the chances of infection and fatigue. If the nutritional deficiency is sustained, the body might lose the capacity to repair the loss of deficiency. If the minimum nutritional deficiency of the body is satisfied, chances of infection can be considerably reduced.

As mental and physical health is associated, the experience of anxiety and fear can further hamper the health of Judy as it will make the body susceptible to infection. Consistent stress, fear and anxiety can reduce the ability of the body’s immune system to fight any infection that the body might have been exposed to. The fear and anxiety can also interfere with Judy’s ability to remain resilient and positive in the face of his condition. Children who suffer from leukaemia often suffer from the depression and fear of never recovering. A child as young as Judy might possess the ability to understand the concept of death. However, in this context, the nurses should ensure that her parents never discuss about the negative consequences of the diagnosis in front of Judy. This might increase her fear and anxiety related to the diagnosis. Hope and optimism in the face of unpredictability and fear can lead to positive health outcomes which can hasten recovery.

Fatigue is an essential diagnosis for Judy as fatigue can be indicative of an underlying nutritional deficiency, infection or weakening immune system (Davis, Viera & Mead, 2014).Unless fatigue is highlighted through the diagnosis it might not be intervened adequately leading to deterioration in her condition. Fatigue can interfere with daily functioning leading to reduced productivity, loss of mobility, inability to focus, dizziness, headache and sleepiness.

The first nursing diagnosis is acute pain that is related to reflex muscle spasms and tissue trauma that is secondary to cancer which can be supported by Judy’s complaint of joint pain in the limb and bone pain. In order to overcome the pain, the goal that needs to be set for her is to improve the pain to a tolerable and manageable level. The SMART goal is to state 2 non-pharmacological methods in order to reduce pain within 2 weeks. The intervention involves teaching the child and parent distraction measures such as rocking or holding, hugs and kisses from parents, engaging in simple games, using hand puppets, blowing bubbles, shaking rattles and watching television or listening to music with parents (Scates et al. 2020). This will help in increasing Judy’s concentration on non-pain stimuli and decrease her awareness and experience related to pain. Another intervention in relation to pain management is teaching the application of hot and cold to the parents. Malanga, Yan and Stark (2015) opined that heat helps in reducing pain by improving the blood flow to the area and reducing the pain reflexes. Cold compression helps in reducing pain, muscle spasticity and inflammation by reducing the release of pain-inducing chemicals and slowing down the conduction of pain impulses (Heinonen and Laukkanen 2018).

The second goal for Judy is to decrease the pain score below 4 as per the wong baker faces pain rating scale in 2 weeks. The goal can be achieved by adopting effective interventions. The first intervention is to teach Judy and her parent the use of the rating scale in order to rate the intensity of either past or present pain. This involves asking Judy to set a goal by selecting of a pain level that would allow her to perform effectively and with ease. In case the pain level is higher for a long period, she needs to take action to decrease it or notify her parents or health care team so that effective pain management interventions can be implemented (Lawson et al. 2021. The use of this goal forms a basis of a direction and modification if any required in the treatment plan. Another intervention that can be aligned with the goal is to explore the pain experience by Judy and her family and its impact on culture. Matsuoka (2021) opined that this helps in the determination of how to help the person with the nurse by understanding and implementing in a culture-friendly manner.

The second diagnosis is a nutritional imbalance that is linked with an increase in calories requirement and challenge in ingesting a sufficient amount of calories due to cancer thus, initiating weight loss. The goal that would be set to overcome nutritional imbalance is to offer adequate nourishment to Judy. The first SMART goal is to increase Judy’s appetite by 2 methods within 3 weeks. The first strategy is to teach her parent the strategy of frequent and small meals. The even distribution of daily caloric intakes would be helpful in the prevention of gastric distention would help in increasing appetite and allow better tolerance. The second intervention is to teach Judy and her family healthy maintenance of good oral hygiene after meals. The maintenance of oral hygiene help in increasing appetite as the aspect of oral mucosa is important to the ability to eat (Rocha et al. 2018). The oral mucosa is moist in nature that produces adequate saliva that helps in the digestion of food. The second goal is to identify the nutritional requirement of Judy in two weeks. The first intervention involves suggesting the use of a zinc supplement. As per the opinion of Amin et al. (2020), supplementary zinc will have a positive impact on nutritional status and increase weight. This will reduce the number of infections and will help in preventing any adverse effects related to chemotherapy thus, eventually improving quality of life. The second intervention is the introduction of vitamin C into her daily routine. Mastrangelo et al. (2018) opined that leukaemia is a condition that occurs due to vitamin C deficiency and is thus, linked with biochemical scurvy. Thus, leukemic patients need nutrients in the treatment process.

The third diagnosis is the anxiety associated with leukaemia as it was found that Judy was upset and worried. The goal, in this case, is to reduce the stress on Judy and her parent in a week’s time. McFarland et al. (2019) opined that it is not easy to deal with cancer at any later, especially the age of the patient is 7 years. However, it is important to deal with it. The first intervention that can be suggested to both of them is counselling. Van Schoors et al. (2019) opined that counselling has been found to show a positive impact on cancer patients. It includes relaxation training, mental imagery exercise, support from family and friends and positive thoughts about coping. It is important for Judy’s parents to have a positive outlook if they are sad and depressed, it will make her more anxious. Thus, counselling can be considered to be an effective treatment that will allow for the uplifting of psychological and emotional aspects of the patient that will allow her to be happy and bear positive thoughts and outlook toward life. The second intervention, in this case, is to be active and conduct an exercise that may improve the quality of life to a large extent. McTiernan et al. (2019) opined that physical exercise is linked with improvement in mental health issues such as depression and anxiety. This is because physical exercise help in improving their energy level of Judy which will in turn allow them to be active and positive. This will allow for improving the quality of life of acutely ill patients. Aerobic exercise is also known as cardio is a type of exercise that increases the heart rate, strengthen the heart and lung and do not allow for feelings of depression. This is helpful because it is flexible in nature and can be performed anywhere and anytime without any restrictions. Therefore, Judy needs to do physical activity especially exercise at the given time with the aid of her parent in order to manage her chronic illness and pain in an appropriate manner.

The fourth diagnosis is fatigue associated with leukaemia as it was found that Judy was tired and do not feel to do any activity. The goal is to reduce fatigue within a period of a week. The first intervention is to include energy-rich food such as fruits, whole grains, beans, milk, yogurt, and starchy vegetables (potatoes, corn, and peas). The family need to be aware of her need and diet so that they are able to provide the foods that would help her in fighting fatigue. The second intervention involves taking an adequate amount of rest that will help in conserving energy. This will allow her to gain energy and feel fit most of the time.

Conclusion

In conclusion, Judy has been diagnosed with Leukaemia with diverse needs and her parents are experiencing symptoms of depression and anxiety. The plan of care was devised in a manner which will be aimed at incorporating subjective and objective data on the symptoms of Judy. The assessment report of Judy will be reviewed and a collaborative approach will be undertaken to ensure that the perspective and preferences of Judy and her family members is taken into consideration. The use of SMART framework has been made to develop three care plans for Judy which will be reviewed and modified if needed.

 References

Adib-Hajbaghery, M., & Aghajani, M. (2015). Patients dignity in nursing. Nurs Midwifery Stud, 4(1), e22809. Adib-Hajbaghery, M., & Aghajani, M. (2015). Patients dignity in nursing. Nurs Midwifery Stud, 4(1), e22809.

Amin, N., Clark, C. C., Taghizadeh, M., & Djafarnejad, S. (2020). Zinc supplements and bone health: The role of the RANKL-RANK axis as a therapeutic target. Journal of Trace Elements in Medicine and Biology, 57, 126417.

Archer, J., Bower, P., Gilbody, S., Lovell, K., Richards, D., Gask, L., ... & Coventry, P. (2012). Collaborative care for depression and anxiety problems. Cochrane Database of Systematic Reviews, (10). https://www.nationalelfservice.net/cms/wp-content/uploads/2012/10/CD006525.pdf

Choi, J., Tate, J. A., Hoffman, L. A., Schulz, R., Ren, D., Donahoe, M. P., ... & Sherwood, P. R. (2014). Fatigue in family caregivers of adult intensive care unit survivors. Journal of pain and symptom management, 48(3), 353-363. https://doi.org/10.1016/j.jpainsymman.2013.09.018

Davis, A., Viera, A. J., & Mead, M. D. (2014). Leukemia: an overview for primary care. American family physician, 89(9), 731-738. https://www.aafp.org/afp/2014/0501/p731.html

Heinonen, I., & Laukkanen, J. A. (2018). Effects of heat and cold on health, with special reference to Finnish sauna bathing. American Journal of Physiology-Regulatory, Integrative and Comparative Physiology.

Kokorelias, K. M., Gignac, M. A., Naglie, G., & Cameron, J. I. (2019). Towards a universal model of family centered care: a scoping review. BMC health services research, 19(1), 1-11. https://link.springer.com/article/10.1186/s12913-019-4394-5

Lawson, S. L., Hogg, M. M., Moore, C. G., Anderson, W. E., Osipoff, P. S., Runyon, M. S., & Reynolds, S. L. (2021). Pediatric Pain Assessment in the Emergency Department: Patient and Caregiver Agreement Using the Wong-Baker FACES and the Faces Pain Scale–Revised. Pediatric emergency care, 37(12), e950-e954.

Lin, Y. P., Watson, R., & Tsai, Y. F. (2013). Dignity in care in the clinical setting: a narrative review. Nursing ethics, 20(2), 168-177. DOI: 10.1177/0969733012458609

Malanga, G. A., Yan, N., & Stark, J. (2015). Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury. Postgraduate medicine, 127(1), 57-65.

Mastrangelo, D., Massai, L., Fioritoni, G., Coco, F. L., Noguera, N., & Testa, U. (2018). High doses of vitamin C and leukemia: In vitro update. Myeloid Leukemia.

Matsuoka, S. (2021). Recovery?oriented nursing care based on cultural sensitivity in community psychiatric nursing. International Journal of Mental Health Nursing, 30(2), 563-573.

McFarland, D. C., Walsh, L., Napolitano, S., Morita, J., & Jaiswal, R. (2019). Suicide in patients with cancer: identifying the risk factors. Oncology (08909091), 33(6).

McTiernan, A. N. N. E., Friedenreich, C. M., Katzmarzyk, P. T., Powell, K. E., Macko, R., Buchner, D., ... & Piercy, K. L. (2019). Physical activity in cancer prevention and survival: a systematic review. Medicine and science in sports and exercise, 51(6), 1252.

Pitman, A., Suleman, S., Hyde, N., & Hodgkiss, A. (2018). Depression and anxiety in patients with cancer. Bmj, 361 doi: https://doi.org/10.1136/bmj.k1415 

Rait, D. S. (2015). A family-centered approach to the patient with cancer. https://psycnet.apa.org/record/2014-48591-074

Rocha, J. S., Arima, L. Y., Werneck, R. I., Moyses, S. J., & Baldani, M. H. (2018). Determinants of dental care attendance during pregnancy: a systematic review. Caries research, 52(1-2), 139-152.

Scates, D., Dickinson, J. I., Sullivan, K., Cline, H., & Balaraman, R. (2020). Using nature-inspired virtual reality as a distraction to reduce stress and pain among cancer patients. Environment and Behavior, 52(8), 895-918.

Van Schoors, M., De Paepe, A. L., Norga, K., Cosyns, V., Morren, H., Vercruysse, T., ... & Verhofstadt, L. L. (2019). Family members dealing with childhood cancer: a study on the role of family functioning and cancer appraisal. Frontiers in psychology, 10, 1405.

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