Rationalise and justify an Intervention using evidence and developmental theories to support nursing practice

This assignment will examine the management of one acute problem of illness for an adolescent I have helped to nurse whilst on clinical placement. I will present the rationale behind the nursing intervention, show adequate grounds for the decisions taken and answer objections likely to be made against the interventions. I shall refer to our patient as Jyoti, a pseudonym to protect confidentiality (Nursing and Midwifery Council, 2004). Jyoti is 12 years old diagnosed with osteopetrosis (marble bone disease).

This condition may be inherited in either an autosomal dominant or autosomal recessive manner; “the recessive type is severe and the dominant type is mild” (Jenson, 2000, p. 518). In addition, another recessive form associated with renal tubular acidosis is due to carbonic anhydrase II deficiency. In severe form, bone density is increased throughout the skeleton but bones tend to fracture easily. Jyoti had had her one cycle of multi agent Chemotherapy and had been discharged home with out any complaints, Jyoti presented in Accident and Emergency with pyrexia due to infection.

Acute nursing care was provided to Jyoti to identify and manage underline infection. Whilst Jyoti presented in Accident and Emergency with pyrexia, I intend to focus on infection, solely on the first 4hours of Jyoti’s care. Most fever caused by infection is acute, appearing suddenly and then dissipating as the immune system defeats the infectious agent an infectious fever may also rise and fall through out the day or stays febrile whole day indicates high risk of infection or may present with septicaemia, or this character can be seen in oncology patient.

Families are taught to observe for signs of a raised temperature and the patient will be accepted in Accident and Emergency if he/she has regular pyrexia of 38 degrees centigrade on two subsequent occasions or of 38. 5 degrees centigrade on one occasion. ’(Selwood, 2000, p. 35) Pyrexia, in patients such as Jyoti, who do not produce an adequate inflammatory response, is often the only sign of infection. (Wujcik, 1993) ‘Infection is a serious complication and is the most common cause of death and more susceptible children are those who are on regular chemotherapy treatment. (Brandt, 1990, p. 82).

The importance of detecting infection in Jyoti is paramount and the development of pyrexia is a condition requiring immediate treatment. Life threatening septicaemia or sepses may progress extremely rapidly if not treated early. ’ (Pinkerton et al, 1994, p. 82). Fluid resuscitation is the mandatory first step in the treatment of septic shock (Steven et al 2006). Jyoti and her family arrived in the paediatric accident and emergency department (A&E). The triage nurse assessment is detailed in appendix one, where Jyoti presented with fever of 40. centigrade.

Observations were documented and bloods were taken from both of Jyoti’s lumen, a urine specimen was produced and other routine tests by RMO who were alerted to Jyoti’s arrival. This would establish base line value prior to commencement of treatment, enabling early detection of deviation from normal limits or any deterioration in Jyoti’s condition. (Barber, 2001). This all was done to complete a full infection screen. Jyoti exhibited no pulmonary symptoms so a chest X-ray was not ordered (Barber, 2001).

Jyoti was admitted in to cubicle for intravenous (IV) antibiotic. The reason for treating Jyoti in the cubicle is because all patient like her who receive cytotoxic chemotherapy are liable to neutropenia (neutrophil count less than 0. 5 x 10 /litre) at times and are then at risk of infection. The first dose of was given in A&E. This is accordance with local policy. ‘Broad spectrum antibiotics must be commenced immediately, as waiting for culture results in rapid deterioration in the patient. (Pinkerton et al, 1994)

Broad spectrum antibiotics covered both Gram-negative and Gram-positive infection until an identifying organism was found in Jyoti. (Schimpff, 1992) The antibiotics were delivered through the central line. Selwood (2000) describes set standards of care another NHS trust where antibiotic administration occurs with in 30 minutes of a pyrexia patient being seen by the doctor. It advised that there will be a chance to reduce any inconsistencies in care at the hospital Jyoti attended by the introduction of the time stipulations.

Selwood found, however, in audit, that ‘the average wait for administration was 63 minutes, with only 24% [of patient] receiving antibiotics within 30 and patients presenting out of normal hours were not always seen within half an hour due to medical staff being busy elsewhere or there may have been limited nurses on duty competent in administering antibiotics. In contrast, the management of Jyoti’s symptoms was expedited by effective communication and cooperation between the A&E department and oncology ward team.

The ward was able to provide an experienced oncology nurse, who was familiar to Jyoti and supportive of the senior house officer. The nurse had prepared Jyoti’s antibiotics as prescribed and therefore effected timely administration. Therefore, each trust’s policies ‘will be unique as they will reflect details of care which will vary between hospitals’. (Selwood, 2000). On admission to the A&E ward a’ management plan for the infection in oncology child’ was written for Jyoti. Appendix 2) this care plan details specific nursing interventions that would move Jyoti towards a desired outcome (well child and discharge) within a defined period. Keeping Jyoti under observation would allow the nurse to do ongoing assessment and recognition of any variance. (Selwood, 2000)

This care pathway was adhered to for the duration Jyoti’s of acute symptoms to utilize multidisclinary guidelines. It also maintained Jyoti’s quality of care as it reflects current local best practice and evidence-based medicine. (Cramer and Tucker, 1995) Kitchiner and Blundered, 1996) Any deviation, for example, a chest X-ray was not requested for Jyoti, required documentation and a rationale for the action taken. (Selwood, 2000) Management of Jyoti’s problem continued through the day. Nursing care comprised ensuring there was reliable venous access; observing Jyoti’s general condition carefully; prompt administration of medication and supportive therapy; monitoring urine output; support of Jyoti and her family and; monitoring her temperature and pulse (Selwood et al , 1999).

Hourly observation of temperature and pulse(appendix 1) and blood pressure measurement when Jyoti’s temperature was found to exceed 39 degree centigrade were documented . In support of this action , raised pulse, as evidenced by Jyoti, and a falling blood pressure are clinical feature of septic shock (Selwood et al ,1999) and such symptoms should be reported to the medical team. Supportive care for Jyoti involved antipyretics and fan therapy by stripping off her clothes leaving just her vest on to control the temperature. (Wesley and Coran, 1996).

The body maintains the stability with in this range by balancing the heat produced by metabolism with heat lost to the environment. The “thermostat” that control this process is located in hypothalamus (A small structure located in the brain). The nervous system constantly relays information about the body temperature to the thermostat. In turn the thermostat activates different physical responses designed to cool or warm, the increase and decrease blood flow of body’s core, where it is warmed, to the surface, where it is cooled (McFerran, 1988, p. 386).

This is often reported feature of the acute care of adolescent patients like Jyoti. For nursing team this highlights the importance of considering the role of the parents and developmental aspects of child life. Jyoti’s parents especially mother was very upset for her been at hospital on her birthday. Casey (2004) agrees creating a supportive environment may be action to assist the parents psychologically; the nurse plays an important role to furnish the parent with appropriate knowledge, skills and altitudes which provides them to participate in Childs care.

In Jyoti’s case a lot of psychological support provided to parents by reassurance and keep them informing about the treatment as was going along. Glasper (1995) identified about most effective concept in supporting family is actual nursing care and environment help to promote the strength and individuality of the family in order to enable them greater scope for caring for their sick Child. This framework for delivery of nursing care refers to maximize the effectiveness of the family as a Child fundamental source of support.

The teenager needs to regain the control and this is expressed in part through Jyoti’s understanding about need of antibiotic at that point The study by Kyngas and Rissanen (2001) found that the most powerful predictor of compliance amongst adolescents was support from nurses. It is therefore fundamental to the care of teenagers that their independence is respected and that they are able to make choices. Further, it is vital that nurses’ interacting with teenagers is able to gain their trust and protect their important relationship with Jyoti and her peer.

Evans, 1996) Four hours after the hospitalization, the care pathway was discussed with Jyoti and her mother, in order to promote understanding, individualised interventions and to allow them to feel part of the system by negotiating care. (Giuliano and Poirer, 1991) This two-way communication between the nurse, patient and family, is a key argument in response to those healthcare professionals wary of care plans, who describe rigid adherence as detrimental to patient care. (Giuliano and Poirer, 1991)

In conclusion, this acute problem was resolved through an awareness of our professional responsibilities as nurse and knowledge of jyoti’s psychological and developmental needs. Good communication and interpersonal skills applied to practice. The accurate assessment of Jyoti’s need; identification and prioritising of her symptoms: and the planning, evaluation and documentation of her care, in relation to the holistic individuality of Jyoti and her family, a successful outcome to her hospitalisation.

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