Application of the nursing process in clinical practice

¶ … Nursing Process

Description of the Patient

LD is a 12-year-old female born on February 10, 994. She has four brothers, one is residing with his own family, while the other three are living with her along with her father and a sister at Massillon, OH. Her mother died of cancer in the spring of 2006. The family maintains a health insurance through the Golden Rule Insurance Company.

LD has not started menstruating yet. She has no known allergies. She has past medical record related to surgery - she undergone hip surgery in 2004 because her growth plates were not fusing. She has no history of sleeping problems (used to sleep at 10:00 or 11:00 in the evening) and maintains a regular diet. She is being home schooled, usually 7:30-3:45 PM everyday. LD acts older than her stated age. She enjoys indoor activities like working on a puzzle, watching movies, playing piano and sleeping. She has pets (3 cats and a dog). She seems a bit shy because she is very distant when she listens to other people to talk.

LD had a motor vehicle accident on September 8, 2006. She was ejected from the jeep into a patch of poison ivy. She spent one whole week in the surgical intensive care unit and was eventually admitted to the pediatric unit. When admitted, her vital signs were:

Temperature: 97.3°F

BP: 99/62

Pulse ox: 97%

Respirations

Apical Pulse

After the accident, LD is suffering from poor appetite, blurry vision and headaches especially when reading (which was dwindling within the last few days), nausea (which was caused by the Morphine in the ICU) and ptosis of right eyelid (which is related to traumatic brain injury). Her capillary refill is less than 3 seconds.

LD receives CT scans between 1:00 AM to 2:00 AM while in the hospital. Her CT scan results include:

September 2006: CT of the brain without contrast - 2mm depressed fracture on right anterior and mid-temporal bone with right middle cranial fossasubdural hematome. There is an extension of extra-axial fluid collection moving upwards into the right lateral frontal region as well as the presumably hemorrhage contusion in the left anterior temporal lobe. The fluid filling the sphenoid and right maxillary sinus suggests occult fracture with hemorrhage.

September 2006: CT cervical spine without contrast - Reversal of the normal cervical lordosis, which can be linked to the positioning and/or spasming; no fractures identified

12 September 2006: Single view of the lateral C-spine - No acute process seen at the C1-C6

18 September 2006: CT scan of the brain. The components of the right frontal lobe is unchanged in size - 2.4 cm in thickness

Blood tests conducted for LD shows abnormal results:

September 2006: Potassium - 2.9 Eq

September 2006: Glucose - 133; BUN - 60 mg/dL

10 September 2006: Glucose - 112

13 September 2006: Potassium - 3.0 Eq

16 September 2006: Glucose - 118

LD's current prescribed medications include:

Hydrocortisone 1% cream; 8 hourly (applied to the legs)

PRN: Acetaminophen 32mg/mL; 4 hourly

Zofran 4 mg IV 4 hourly (for the nausea)

Developmental Assessment

On Medical Results

The normal Glucose level is: 70-110 mg/dL (tested after fasting) while the average Potassium level is 3.5-5.0 mEq/L (http://www.bloodbook.com/ranges.html,2006). Thus LD has too much glucose and a below minimum potassium level. Bu this all can be attributed to the fact that she has not been eating well after the accident. Her sleeps are also not normal because she has not had a very good sleep. What is good with her results is that the latest tests conducted revealed that her results is becoming very close to the normal levels.

On Behavior

LD has been showing signs that she is different as compared to other girls or children with the same age. It must be noted that with her age (12 years old), it is normal to have certain issues regarding competence or inferiority. Children who are under the age of 6-12 are learning to make things, use tools, and acquire the skills to be a worker and a potential provider. These, they all do while making the transition from the world of home into the world of peers (http://psychology.about.com/library/weekly/aa091500a.htm,2006). However LD has no significant peers of her age.

LD is just being home schooled. The only friends that she can talk about are her only sister and/or the family friends from the church. She has low interaction when it comes to children of her age. She is always at home, playing with her indoor games or with her pets. This also could be the reason why she seemed a bit distant when talking with other people. She seemed not used to be with other people and thus she show signs of low self-esteem.

Meanwhile, if seeing LD as an adolescent (which usually happens to the children under the age 12-18), LD is also different from the other adolescents under this stage. It must be noted that this phase of life (adolescence), issues regarding identity and role confusion usually arises. This is the time when the adolescent integrate the healthy resolution of all earlier conflicts. Adolescents who have successfully dealt with earlier conflicts are ready for the "Identity Crisis," which is considered as the single most significant conflict a person must face (http://psychology.about.com/library/weekly/aa091500a.htm,2006). However, guidance from the older person is very important for a kid to successfully overcome such confusion.

The best possible source of guidance is the parent, and since LD is a girl, a mother is the best possible source of guidance for her. Since LD's mother just died, she has no one to look up to when it comes to 'girl things'.

Hence, LD's peculiar behavior can all be attributed to her situation wherein she has not had any chance of interacting with other children her age and her lack of mother whom she can turn to.

Planning and Implementation

Goal

First of the goal is to achieve normal medical/laboratory test result for LD. She must have normal glucose, potassium other components of the blood tests on her next laboratory test. Second, LD blurry vision and frequent attacks of headaches should be minimize and eventually eliminated. Lastly, LD's confidence or self-esteem must be enhanced in a way that she would learn to talk freely with all other kids her age.

Nursing Intervention and Rationale pediatric nurses are providing outstanding child-focused, family-focused, sensitive, and technologically-proficient care (Selekman, 2000).

To achieve better medical laboratory test result for LD, her diet must be enhanced. She needs more amount of carbohydrate and fruits to increase both her glucose and potassium level. She should be fed with the combination of bread, wheat, milk, banana and other fruits on her meals. If LD continuously complain about lack of appetite, nurses then may intervene by putting extra efforts with the food. Such as giving her reward or incentive if she eats what is served to her (Selekman, 2000).

Rewards may include game activities, hearing nice stories or small items such as ribbons, clips or headbands for her hair.

Regarding LDs blurry visions and headache attacks, nurses could then advice LD to minimize her reading activities for the meantime. Her eyes are affected by the impact of the accident. She should not over use her eyes. Instead, she must have extra long hours of rest and sleep, which is also good for to ease her headaches.