Nursing
Analysis of Jane’s Condition
Jane Vuong, a Vietnamese undergraduate student was admitted into the hospital Emergency Department presenting with anxiety, difficulty in speaking and breathing and dusky lips following severe chest tightness during an exercise session at the local martial arts school. On examination she had a wheezing sound when breathing. She has no history of asthma but says she has some allergies which she treats with herbs. Her colleague also claims that Jane has recently had difficulties while going up the stairs and she no longer rides her bicycle like she used to before.
Jane is in her second year at the local University where she is studying cellular biology. Jane is a bright student who studies a lot and also works part time in the Universities’ research centre which gives her extra cash. She admits that she has been having a dry cough for some months which she associated with allergies. She also relates her inability to ride her bike to her allergies. Jane smokes at least one packet of cigarettes on a daily basis, and appears not to be ready to stop the habit. Jane had six months earlier tested positive for hepatitis B. This surprised her a lot because she was asymptomatic. Though she denies drug use, she admits to having multiple sexual partners. She does not want to be in a long-term relationship because she claims it could complicate her life. She also admits to not using protection on a regular basis.
Erikson (1993) described eight stages through which an individual passes through to adulthood. Every phase is established on successful completion of earlier phases of development. If the challenge is not completed it is expected to re appear in future as a new problem. Based on Erik Erikson’s stages, it is apparent that Jane did not successfully negotiate the identity versus role confusion as she seems to be having problems finding her own identity. She says that she is not likely to stop smoking because her roommate also smokes, an indication that she is trying to fit in by also smoking. According to Erik-Erikson’s inability to resolve a conflict at one stage could lead to inability to resolve conflicts in other subsequent stages. This is true for Jane because being at the young adulthood stage (where the conflict that needs resolution is intimacy and solidarity versus isolation); Jane is unable to maintain intimate relationships. She is eager to have many sexual partners in her life and her fear of a long-term relationship is evident from her statement that they can be complicated. At this stage, young adults try to seek out life partners and to find relationships that are mutually satisfying through marriage and friendships.
Freud’s theory based on shifting of sexual energy (libido) holds that sexually energy shifts over time from the oral, to the anal, to the phallic, to latency and finally to the genital stage at which sexual instincts mature. If an individual’s needs are left unfulfilled or overestimated, they may cause dramatic effects later in a person’s life. Jane appears to be fixated at the phallic stage evidenced by her overly promiscuous nature which has contributed to her contracting Hepatitis B. Often, fixation at this stage is an indicator of low self-esteem.
In his hierarchy of needs theory, Maslow (1943) explains that all human beings requires a sense of belonging, and being accepted among their social groupings including religious groups, clubs, co-workers, professional organizations, sports teams and other companies. This may explain why Jane associates herself regularly with the local religion, where she prays each morning, attends the local bar to meet with friends and partners and works part-time at the college laboratory to acquire extra cash. Maslow also adds that, all human being need to be loved both sexually and non-sexually by other people. This provides a sense of security and also a sense of belonging. Jane is trying to achieve this by involving herself with multiple partners and smoking to fulfill her sexual desires as well as security needs. Since peer pressure also influences an individual’s behavior according to Maslow, some of Jane’s behavior such as smoking has been influenced by her peers, for example her roommate who also smokes.
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Nursing Diagnosis # 2
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| Subjective data:
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Objective data:
1 .Jane smokes at least one packet of cigarettes on a daily basis.
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P=Problem |
E=Etiology
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S=Signs & Symptoms |
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| Nursing diagnosis: Ineffective Denial
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related to: lack of self esteem due to past experiences | as manifested by:
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| Measurable Outcomes/Goals
“The patient will…”
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Nursing Interventions that support corresponding goal.
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Rationale for each intervention | ||
| Short term: describe knowledge and perception of health problem |
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| Short term: describe her life pattern and report any changes that may occur
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| Long term: Jane will indicate both verbally and through her behavior an increased awareness of reality |
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Involvement in the decision-making and planning of care will encourage greater participation and more compliance with the treatment plan | ||
| Have patient perform their own self-care activities as she is able to tolerate | e:Performing own self-care activities enhances self-esteem and patient is able to regain independence | |||
WGU Prelicensure Nursing Program
Nursing Care Plan Template
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Nursing Diagnosis # 2
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| Insert à relevant, subjective and objective data from scenario to support nursing diagnosis. | Subjective data: Insert à
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P=Problem |
E=Etiology
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S=Signs & Symptoms |
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| Nursing diagnosis: Activity Intolerance
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related to: related to decline in body mass and insufficient physiological energy to complete desired daily activities abnormal heart rate response to activity, due to exertional dyspnea, ( Ackley, & Ladwig, 2008)
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as manifested by:
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| Measurable Outcomes/Goals
“The patient will…”
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Nursing Interventions that support corresponding goal.
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Rationale for each intervention | ||
| Short term: Patient will achieve adequate oxygenation of body tissues |
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| Short term: Patient verbalizes and uses techniques to conserve energy (EHS, 2011)
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| Long term: Jane will maintain activity level within capabilities and demonstrate increased tolerance to activity beyond discharge (EHS, 2011) |
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Meeting nutritional needs will help to supply the necessary energy to carry out activities of daily living (EHS, 2011) | ||
| Provide encouragement and emotional support client to incrementally carry out self-care activities for herself
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Fear of pain or breathlessness can lead to decreased desire to carry out one’s own self-care activities. | |||
Relevance of Theories
Erik Erikson’s theory of development is relevant to Jane’s care because it helps to form the basis for assessment, analysis and response to the client’s care. Nurses being familiar with Erikson’s Development Theory can help in analysis of the symptomatic behavior a patient has in the context of their struggles with current developmental tasks (Current Nursing, 2011). Using the theory it is possible to identify Jane’s faulty behavior based on what is expected at her developmental stage. This will also be beneficial in determining which intervention will be necessary for Jane because then the care given to her will be directed at the appropriate developmental stage. Further, interventions will be provided with the goal of helping her resolve the conflict that she needs to resolve in order to move on to the subsequent developmental stage. For instance, Jane has had problems resolving the role confusion versus identity stage which is causing her to participate in certain activities merely to fit in, thus to help her be her at her appropriate developmental stage she may need counseling to help her understand why she believes she cannot stop smoking. Once the challenge of the adolescent developmental stage has been resolved, Jane will be in a position to begin managing the challenge of her appropriate development stage which is intimacy versus isolation.
Using Freud’s psychosexual theory is also relevant to Jane’s care as it helps the nurse to be more sensitive to the client, Jane whose promiscuous behavior may have contributed to her infection with Hepatitis B. Rather than being judgmental about Jane’s behavior, using Freud’s theory it is possible to understand Jane’s situation and her fear of ‘complications’ in a long-term relationship. According to Freud fixation at the phallic stage is manifested by sexual promiscuity in adults and is often an indicator of low self-esteem. This knowledge is applicable to Jane’s care because by addressing the factors that may cause her to have low self-esteem, Jane will be in a position to be more careful about how many sexual partners she has and the use of protection during sexual encounters. This will in effect protect her from STIs and possible reinfection with Hepatitis B. Understanding Freud’s developmental stages is thus important because it can help the nurse assist Jane to make more health-conscious decisions about her life and promote preventive care so that Jane can take responsibility for her personal well-being.
Maslow’s hierarchy of needs is relevant to Jane’s nursing care as it can be used to prioritize her care. It can also form the basis for providing holistic care to the client because according to Maslow’s hierarchy for one to achieve self-actualization all aspects of one’s life need to be considered that is the physical, sociocultural, intellectual, psychological and spiritual (White, 2011). Based on the hierarchy of needs, Jane has met some of her needs and others have not yet been met. For instance, in prioritizing Jane’s care, her physiological needs first have to be met to be able to maintain life. This is what was first addressed on arrival at the ER, that is, she was put on oxygen to help her breathe better and to meet her nutritional needs she was put on a balanced diet. Once these have been met then other needs that are focused on quality of life but which also affect her health can be met. These include safety, security, love and belonging, self-esteem and self-actualization. To motivate Jane’s behavior towards better health choices such as stopping smoking and safe sex, she first needs to have the physiological needs met then her other needs related to quality of life can be addressed.
Adaptations to meet Jane’s Cultural Needs
Some of the adaptations to meet Jane’s cultural needs include advocacy for the client’s needs. To advocate for Jane involves having a framework that respects her wishes, needs and priorities. In practicing cultural safety, the nurse ensures the patient’s autonomy by making it possible for the client to access and use quality healthcare in a way that accommodates their cultural belief, values and behavior (La Borde, 2012). In Jane’s case some adaptations that can be made to accommodate her cultural beliefs include an assessment of her cultural values so that the nurse knows how they can help the client in the proper way. First and foremost, it is important to show respect for Jane’s health practices and beliefs. It is common for Vietnamese patients to use both Asian and Western medicine concurrently (La Borde, 2012). In this case, Jane uses both, that is, herbs to treat her allergies and she has also gone to the ER to get Western medicine. Having a negative reaction to the use of herbs may cause Jane to feel judged by the nurse and due to this the patient-provider communication could be impaired leading to poor compliance with treatment.
Jane’s belief about her cough being caused by allergy is an indication of Vietnamese culture to attribute illness to physical problems, hence her decision to use herbs for treatment and her decision to seek out a Vietnamese medicine man for treatment. The medicine man gives her herbs to steam after coining and cupping her back and chest to ‘remove bad air’. The nurse needs to adapt to this perception of etiology of disease without judgment. Instead of having a negative reaction to Jane’s beliefs, the nurse can adapt to this by listening to Jane with an open mind and using the opportunity when Jane talks about her understanding of illness to explain to Jane her current condition and the expected treatment process.
Jane also explains that she only likes to eat Vietnamese food. Out of respect for her culture and also as an adaptation to the culture, the nurse can encourage Jane to eat larger portions of the Vietnamese meals she prefers. She needs to eat bigger portions to help her maintain an optimum weight as she currently is on the verge of being underweight. Also, even though it may not be easy to get only Vietnamese diet in the hospital, where possible Jane can be allowed to select her meals as long as they are a balanced diet along her preferences.
Since Jane believes that meditation and communion with her dead ancestors helps her to succeed and stay healthy, an adaptation such as allowing her time to meditate in her room while she is admitted may be beneficial to her as it will help her to remain spiritually healthy. Recognizing the importance of religion is necessary to enable provision of holistic care.
Nursing Process
The nursing process has several components: assessment, diagnosis, planning, implementation and evaluation. Use of the nursing process helps to promote critical thinking, decision-making and problem-solving (Keenan et al, 2008). This is important for prioritizing care. In Jane’s case during assessment the primary nursing diagnosis will form the basis of care for the first 24 hours and as she continues to improve other nursing diagnoses will be established until she is ready for discharge. During admission, the objective signs of difficulty in breathing, difficulty in speaking and dusky lips helped to reach the primary nursing diagnosis of ‘impaired gas exchange’. Based on this, interventions such as putting her on supplemental oxygen and taking her blood samples for further investigations as well as doing a chest X-ray are implemented. The impact of some of the interventions has an almost immediate outcome, for example putting her on oxygen immediately improves her oxygen supply and she is able to communicate better allow for easier history taking and assessment. In this case, the nursing process has helped to prioritize care in such a way that the client’s physiological need of lack of adequate oxygen is met first and then once this need has been met, then other health needs can follow in order of priority until favorable outcomes have been achieved and the patient is ready for discharge. Following the nursing process systematically ensures that information is overlooked or skipped. This is evident from the nurse’s assessment of the client, Jane which revealed the markings on Jane’s chest and back. Had the assessment not been systematic perhaps this would have been missed leaving out the important information of her health seeking behavior and cultural beliefs as well.
The nursing process helps to focus care on an individual patient making care individualized. During assessment objective and subjective signs are assessed to determine the nursing diagnosis of the client. These nursing diagnoses are unique to the patient based on how the patient presents. Further interventions will be designed to meet the needs identified. In Jane’s care due to the influence of her culture, individualized care is necessary to help in effective communication. The risk for ineffective communication is high due to cultural barriers, having a nursing care plan based on the nursing process is beneficial as it provides the nurse receiving the patient and other nurses in Jane’s care with a summary of the client’s needs.
The patient’s participation is also promoted by use of the nursing process. By encouraging self-care activities and independence, the client is likely to have a greater sense of control an important factor in a positive health outcome for clients. Jane’s Vietnamese culture has a lot of respect for authority and this includes healthcare professionals. Often many Vietnamese will not ask questions regarding their care to avoid looking disrespectful or stupid in the eyes of a person with a higher status. The nursing process by outlining self-care activities helps the nurse not to overlook providing information to the client on their care as well as encouraging them to participate in their own care. In Jane’s case doing so is beneficial to her as it will help to achieve faster recovery and also increase her self-esteem.
References
Current Nursing, (2011), Theory of Pyschosocial Theory, available at http://currentnursing.com/nursing_theory/theory_of_pyschosocial_development.html
Erikson, E.H. (1993). “Childhood and Society”. New York, NY: W. W. Norton &
Company. p. 242. ISBN 978-0-393-31068-9.
Freud, S. (1940). “An Outline of Psychoanalysis” Standard Edition 23, pp. 189–192.
Elsevier Health Sciences, 2011, Activity Intolerance, Weakness; decondition, sedentary, available at http://www1.us.elsevierhealth.com/MERLIN/Gulanick/archive/Constructor/gulanick01.ht ml
Keenan GM, Yakel E, Tschanen D and Mandeville M, (2008) Documentation and the Nurse Care Planning Process, Patient Safety and Quality: An Evidence-Based Handbook for Nurses, Agency for Healthcare Research and Quality
LaBorde P, (2012), Vietnamese Cultural Profile, Ethnomed, available at http://ethnomed.org/culture/vietnamese/vietnamese-cultural-profile
Maslow, A.H. (1943). A theory of human motivation. Psychological Review, 50(4), 370–96. Available at
http://psychclassics.yorku.ca/Maslow/motivation.html
Telford AK (2006) Acceptance and Denial: Implications for people adapting to chronic illness: Literature Review, Journal of Advance Nursing, 55(4); 457-464
White L, (2011), Foundations of Nursing: Caring for the Whole Person, Cengage Learning, Albany, NY
