Pathophysiology
For a minor patient with adverse health complications, the care planning and implementation is required to be holistic, taking into consideration the emotional and psychological needs of the patient along with the growth and development oriented aspects, as the disease process can significantly affect the growth and developmental pace as well (Regan, Curtin & Vorderer, 2017). Furthermore, the impact of the disease and subsequent hospitalization is extreme on the psychological wellbeing status of the patient and their family members. Hence the care plan made for the patient should also incorporate family centred care principles to ensure adequate interventions provided. This nursing case study will attempt to discuss the case of Anne, who had been admitted to the emergency department (ED) of the facility with acute gangrenous appendicitis with peritonitis, the pathophysiology of the disease process, the growth and development oriented care planning and family centred interventions applicable to her case study.
Exploring the pathophysiology of the appendicitis (Alvarado, 2018). The most plausible etiological pathway leading to inflammation of the appendix is due to the luminal obstruction. Which leads to restricting the blood flow in the surrounding region completely, paving way for bacterial overgrowth in the blocked region which distends the lumen and enhances the intraluminal pressure causing lymphatic and venous obstruction and oedema and the resultant inflammatory response (Bhangu et al., 2015). These series of events leads to necrosis of the appendiceal wall and spills the bacterial mass into the peritoneal cavity giving rise to the gangrenous perforated appendix. The lack of adequate and immediate interventions led to infection of the peritoneal cavity and the serosal membrane became infected leading to peritonitis.
Cellular level
Approximately 95% of serotonin is found in the gastrointestinal tract, located primarily in neuroendocrine cells. A rapid increase in serotonin secretion in the appendix plays a significant function in the pathogenesis of inflammation. Once the blockage occurs, secretions released by the epithelial mucosa cause an elevated luminal pressure. Pressure receptors found in the enterochromafin cells upon detecting luminal pressure, they secrete 5-HT into the lamina propria. This release worsens smooth muscle contraction, vasoconstriction and venous engorgement. There is also an increase in vasoactive intestinal polypeptide and substance P in the appendix which is the leading cause of pain on the right iliac fossa (Escolino et al., 2018). During inflammation, white blood cell count rises rapidly with the advancement of appendicitis. The leucocyte migrate from the peripheral circulation to the appendix to fight infection.
Organ level
Rapid increase in size ensues because of its little lumen capacity. The intraluminal pressure can attain 50 to 65 mm Hg. The cecum enlarges due to this appendicle condition. The cecal collection is stored and is not carried on to the right colon. An increase in luminal pressure leads to increase in venous pressure resulting to mucosal ischemia. Venules that empty blood to the appendix undergo thrombosis leading to the damage of the lymphatic and venous drainage. Due to mucosal hypoxia, ulceration begins causing damage of the mucosal barrier. This leads to invasion intraluminal bacteria such as Escherichia coli in the appendiceal wall.
Growth and development theories
Systemic level
If the appendix is not removed immediately bacteria and inflammation in the appendix causes a rapid increase in size and perforation may occur. Immediately perforation occurs the contents are released in the abdominal cavity and peritonitis occurs. The inflammation broadens to parietal peritoneum, serosa and lastly the adjacent organs. This results to the stimulation T8-T10 nerve fibres that get in the spinal cord. This cause’s preumblical and epigastric pain. At this phase somatic pain replaces the early mentioned pain, and clients usually experience a changing on the area of greatest pain to the right lower quadrant. If this condition progresses the blood flow in the arteries is compromised and localized necrosis occurs leading to a gangrene and perforation (Yousef et al., 2018).
Development psychology deals with changes that occur as individual age increases in terms of behaviour and mental process. Developmental psychology theory that is going to be discussed is social-emotional development theory by Erik Ericson (Cherry, 2017). Social emotional development talks about our social interaction and how emotions grow and changes overtime. The two most fundamental topics are attachment and parenting style. Attachment is determined or actuated by emotions, the stronger the emotion the stronger the attachment. Different methods parenting or the way our parents treats us as we grow affects our personality. Parenting style are divided into three, permissive, authoritarian and lastly authoritative. The attachment status of the child and the parenting style that they are accustomed with can play a profound role in defining the care approach that will suit them the best. No child recovers quickly without an attachment pattern based on the relationship with the care giver and the nurse. Lack of proper attachment may lead to depression, anxiety or illness. The nurse can create a strong bond with the client by introducing yourself to the client. This shows the patient that you care about them, it also removes the tension and anxiety from the client. Strong bond can also be created by saying what you are going to in every procedure and the importance of it. This increase trust and reduces any fears during the procedures (Coyne, Hallström & Söderbäck, 2016).
According to the stages of social emotional development coined by Ericson, there are 8 total stages of development, and each developmental stage represents different developmental milestones for the child which is intricately linked with the psychological wellbeing (Cherry, 2017). Hence, when a nurse is expected to provide care interventions to a minor patient, the developmental milestones of the child also is needed to be considered in the care. Anne is a 10 year old girl born to Indian Parents and is the eldest of 5 children, according to the social emotional development theory, it can be considered that she has grown through first 4 stages of development, namely Hope, Will, purpose and competence. Across these developmental stages a child understand to differentiate between trust and mistrust, autonomy and shame, initiative and guilt, and industry and inferiority. The nature of treatment provided can be easily recognized by a child that is past the first stage helps the child make a decision between trust and mistrust; hence, the impact of treatment provided and the communication approach taken by the nurse will help gain her trust and it will facilitate the establishment of a sound therapeutic relationship (Knight, 2017).
The second milestone is associated with autonomy and independence, where the child learns to exert independence and self-possession. Hence, in this case, the nurse providing care to Anne, the nurse will have to ensure providing independence and empowerment to her while respecting her autonomy to ensure optimal psycho-social wellbeing. The third milestone helps the child to assert a sense of purpose and feel useful by taking different initiatives. For Anne as well the ability to her own decisions and certain initiatives in her acre planning will be extremely helpful. Hence the nurse will have to ensure letting Anne take initiatives in her own care like feeding and self-care activities to help her feel purposeful and empowered. The fourth stage or milestone crossed by Anne as per her age is associated with competence as per Ericson’s stages, and this is the most important milestone that is needed to be considered while planning her care (Cherry, 2017). As Anne is a school age girl, the need for feeling competent will be most pertinent in her nature and hence it will influence her thought process, behaviour and character. In this case, the nursing care provider will need to consider encouraging her to employ competence such as encouraging her to feed on her own, engage in self-care ADLs and taking her medication under supervision of the nurse. Lastly, the growth appropriate care delivery is incomplete without adequate information sharing; as per Anne’s age, she might be curious and inquisitive, hence, the nurse will have to consider responding to her questions patiently and carefully regarding medical information sharing so as to not scare or alarm her as per the ethical guidelines (McAdams & Zapata-Gietl, 2015).
Family centred care can be defined as the care program that is designed and led by the patients with collaboration of the health care consulting, encouraging medical information sharing and effective communication to address each of the care need of the patient (Childrens.health.qld.gov.au, 2018). The nurse is needed to respect the individuality of the family, the culture and tradition and the wishes and demands of the family into planning and implementing care. For Anne, the traditional concepts of health and healing will need to be considered. In this case, the aid of a cultural diversity expert or language interpreter can be taken in case of any language barrier. The health information is needed to be shared with Anne’s family in a culturally appropriate manner. Information sharing and shared decision making are integral aspects of family centred care, nurse will have to provide medical information periodically and frequently, in a manner that is easily understood with medication safety education as well, preferably with pamphlets for future assistance (Coyne, 2015).
The impact of hospitalization is generally acute on a minor patient, the detachment from parents and siblings, the sterile ambience of the hospital, and the exhaustion of the treatment procedure has been reported to enhance fear and anxiety among children affectively (Franck et al., 2015). The impact of living in the impersonal ambience of the hospital can affect the psychological wellbeing of the child and can affect the family as well. The fear of the prognosis, the safety of the child in the hospital and the detachment of the child instils fear, irritability and anxiety in the patients which further depresses them and leads to hyper-reactive response. As Anne is eldest to 4 other siblings they will also be affected by watching her in pain and detached from them, they will be anxious, distressed and confused. These psychological impact will also lead to physical issues such as exhaustion due to excessive crying, fatigue from not eating well and sleeplessness as well. The nurse will have to address the impact of hospitalization on Anne, her parents and the siblings. For Anne, the nursing care will need to focus on compassion, empathy and resilience providing nurturing support and comfort to her. For the parents, the nurse will require to repeatedly reassure them and involve them in the care planning and decision making along with sharing timely information regarding Anne’s recovery progress (McAdams & Zapata-Gietl, 2015). The nurse will also need to instruct the parents to consider child support for caring for the siblings and also orchestrate opportunities for the entire family to visit Anne all the while following the safety guidelines which will help calm and assure them and will also help Anne recover faster.
Conclusion:
A chronic acute illness is often associated with various complications and the nursing care plan for the patients suffering from the chronic complicated illness or adverse conditions needs to be individualized and optimally patient centred. Especially for the patients that are paediatric and minor, the care planning that the nursing professional that is addressing the patient, needs to focus on various factors other than just addressing the physical health issues for the patient. This case study illustrated developmentally appropriate care for Anne, a 10 year old patient suffering from gangrenous perforated appendicitis with peritonitis along with family centred care with emphasis on impact of hospitalization on the paediatric patient and their families.
References:
Alvarado, A. (2018). Clinical Approach in the Diagnosis of Acute Appendicitis.
Bhangu, A., Søreide, K., Di Saverio, S., Assarsson, J. H., & Drake, F. T. (2015). Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. The Lancet, 386(10000), 1278-1287.
Childrens.health.qld.gov.au. (2018). Family Centred Care in Queensland. [online] Available at: https://www.childrens.health.qld.gov.au/wp-content/uploads/PDF/qcycn/qcycn-fcc-sd.pdf [Accessed 26 Aug. 2018].
Coyne, I. (2015). Families and health?care professionals’ perspectives and expectations of family?centred care: hidden expectations and unclear roles. Health expectations, 18(5), 796-808.
Coyne, I., Hallström, I., & Söderbäck, M. (2016). Reframing the focus from a family-centred to a child-centred care approach for children’s healthcare. Journal of Child Health Care, 20(4), 494-502.
Regan, K. M., Curtin, C., & Vorderer, L. (2017). Paradigm shifts in inpatient psychiatric care of children: approaching child?and family?centered care. Journal of Child and Adolescent Psychiatric Nursing, 30(4), 186-194.
Escolino, M., Becmeur, F., Saxena, A., Till, H., Masieri, L., Cortese, G., … & Esposito, C. (2018). Infectious Complications After Laparoscopic Appendectomy in Pediatric Patients with Perforated Appendicitis: Is There a Difference in the Outcome Using Irrigation and Suction Versus Suction Only? Results of a Multicentric International Retrospective Study. Journal of Laparoendoscopic & Advanced Surgical Techniques.
Yousef, Y., Youssef, F., Dinh, T., Pandya, K., Stagg, H., Homsy, M., … & Shaw, K. (2018). Risk stratification in pediatric perforated appendicitis: Prospective correlation with outcomes and resource utilization. Journal of pediatric surgery, 53(2), 250-255.
Cherry, K. (2017). Erik Erikson’s Stages of Psychosocial Development. Psychology. Psychosocial Theories. Päivitetty, 14, 2017.
Knight, Z. G. (2017). A proposed model of psychodynamic psychotherapy linked to Erik Erikson’s eight stages of psychosocial development. Clinical psychology & psychotherapy, 24(5), 1047-1058.
McAdams, D. P., & Zapata-Gietl, C. (2015). Three strands of identity development across the human life course: Reading Erik Erikson in full. The Oxford handbook of identity development, 81-94.
Franck, L. S., Wray, J., Gay, C., Dearmun, A. K., Lee, K., & Cooper, B. A. (2015). Predictors of parent post-traumatic stress symptoms after child hospitalization on general pediatric wards: A prospective cohort study. International journal of nursing studies, 52(1), 10-21.
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