PATIENT Dilemma Demanding/Disrespectful Family Member
Josephine Peters, 62 years old
Primary Concept
Coping
Interrelated Concepts (In order
... [Show More] of
emphasis)
● Pain
● Stress
● Clinical Judgment
● Collaboration
NCLEX Client Need Categories Percentage of Items from
Each Category/Subcategory Covered in Case Study
Safe and Effective Care Environment
● Management of Care 17-23% ✔
● Safety and Infection Control 9-15%
Health Promotion and Maintenance 6-12%
Psychosocial Integrity 6-12% ✔
Physiological Integrity
● Basic Care and Comfort 6-12% ✔
● Pharmacological and Parenteral
Therapies 12-18%
● Reduction of Risk Potential 9-15% ✔
● Physiological Adaptation 11-17%
Clinical Dilemma Activity: STUDENT
I. Scenario
History of Present Problem:
Josephine Peters is a 52-year-old female who is postoperative day one for anterior-lateral lumbar spinal fusion. Her pain has been controlled with oxycodone 5 to 10 mg PO every four hours. She has had no visitors today and has been resting comfortably between doses of pain medication. She had her chest tube pulled out three hours ago. Her last dose of oxycodone was 10 mg three hours ago. To support her back when she is out of bed, Josephine has a hard plastic back brace. She is currently sitting in a chair with the hardback brace in place.
Personal/Social History:
Josephine is divorced and has three children. She has chronic back pain and uses recreational marijuana (in a state where it is NOT legal) to manage this pain at home. She currently works as a nursing assistant in a skilled care facility. Her oldest son lives locally and has two teenage children.
What data from the histories is important & RELEVANT; therefore it has clinical significance to the nurse?
(Reduction of Risk Potential)
RELEVANT Data from Present
Problem: Clinical Significance:
1. Post Op day one for anterior-lateral lumbar spinal fusion.
2. Has no visitors today
3. Chest tube pulled out three hours ago.
4. Hard plastic back brace
5. Patient is on oxycodone 1. Anxiety, fear, pain and feeling unwell is common after a surgery and the patient may need some emotional support.
2. Patient has no support group
3. Removal of the chest tube may increase the patient pain
4. A hard plastic brace might make the post-op recovery more difficult for the patient because she is uncomfortable.
5. This can cause respiratory depression and is a strong opioid
RELEVANT Data from Social
History: Clinical Significance:
1. Divorced
2. Has three grown children one living locally with teenage children
3. Chronic back pain
4. Uses recreational marijuana (Illegally) while at home
5. Works as nurse’s assistant 1. Does not have a significant other as a support person after surgery, can increase stress, anxiety and increase metabolism of pain meds
2. Children are busy with their own lives
3. Pain can also increase anxiety and stress, causing the patient to become more emotionally distressed and slowing the healing process.
4. Lack of using her personal remedy for pain relief might be causing her additional anxiety and stress.
5. Working as a nurses’ assistant can put more stress on the patients back causing pain levels to increase. Patient will also have a long period off work which can cause stress due to finances.
When the oldest son comes to visit at change of shift, the patient becomes visibly agitated and begins calling out loudly,
“Take this brace off me! “I have never had pain like this before!” The oldest son becomes angry and upset and approaches the nurse and states, “You need to go out and call the doctor right now, I cannot watch my mother be in pain. I don’t understand how you people can watch a patient suffer and do nothing about it!” When the oncoming nurse explains that she needs to complete report and briefly perform an assessment before she can call the primary care provider, he states angrily, “I can’t understand why you can’t just go out and call the doctor, you must not know what you are doing!”
The nurse has all family members leave the room to complete the initial nursing assessment. Josephine begins to apologize profusely for how she was treated by her son and appears embarrassed. Her vital signs are T: 98.4 F/36.9 C P: 72 R:18 BP: 128/68. Her pupils are 3 mm/equal and reactive. Her pain is currently higher than it has been earlier and rates as a 7/10. After this assessment is completed, the nurse communicates to both the family and the patient the plan of care and contacts the primary care provider to address the need for more pain control.
What data from the current concern is important & RELEVANT; therefore it has clinical significance to the nurse?
(Reduction of Risk Potential)
RELEVANT Data from Current
Concern: Clinical Significance:
1. Patient becomes agitated and wants the brace off when the son arrives.
2. Oldest son becomes agitated insists that the nurse is not providing adequate care.
3. Apologizing profusely and appears embarrassed
4. Pain 7/10
5. The nurse communicates with family and patient 1. Patient has had no visitors and may be attention seeking when son arrives.
2. The mother putting her feelings on the son rather than explaining it to the nurse may have caused the son to become frustrated and experience stress, causing him to displace these frustrations onto the nurse.
3. Was attention seeking from the son, probably due to her own anxiety and stress, later feels guilty.
4. Increased pain may have caused her agitation to the son which ultimately caused the son to become frustrated with the nurse.
5. This communication will help relieve the stress and anger being experienced by the patient and family members.
III. Resolving the Dilemma
1. Interpreting RELEVANT clinical data, what is the essence of this clinical dilemma? (Management of Care)
The main essence of this clinical dilemma is that the patient is in pain, and the family member feels like they are not being cared for properly. The family member is frustrated because their mother is in pain; the stress of being unable to help results in a disrespectful and demanding tone while communicating with the nurse.
2. What additional information is needed by the nurse to clarify the dilemma? (Management of Care) Some additional information, which may be needed by the nurse to clarify the situation, would be to understand the total experiences of the family in the hospital. They may be experiencing outside pressures, separate from the situation of their mother being in pain, which is leading to enhanced frustration. Perhaps they have some trauma from a previous hospital experience. Maybe the son feels guilty about not visiting his mother sooner. Sometimes the frustration and disrespect does not necessarily have to do with the specific situation at hand. Understanding the whole picture can allow the nurse to have empathy and patience with family members, and professionally execute care, without taking things personally.
3. What additional members of the healthcare team could be used in this situation? Why?
The social worker and possibly the pastoral can meet with the family and present options; so that
the family feels like their mother's care is moving in a positive direction.
4. What is the nursing PRIORITY? (Management of Care)
Ineffective family coping related to situational stressors as evidenced by the inappropriate use of defense mechanisms by family member becoming angry and upset, stating, “You need to go out and call the doctor right now, I cannot watch my mother be in pain”. and “I don’t understand how you people can watch a patient suffer and do nothing about it!”, as well as, “I can’t understand why you can’t just go out and call the doctor, you must not know what you are doing!”.
5. What are the PRIORITY nursing interventions? (Management of Care)
PRIORITY Nursing
Interventions: Rationale: Expected Outcome:
1. The Nurse will Provide chances to express concerns, fears, feeling, and expectations throughout the shift.
2. Use empathetic communication during all interactions with the patient and family member.
3. Encourage patient and family member to make choices and participate in planning of care and scheduled activities as necessary. 1. Verbalization of actual or perceived threats can help reduce anxiety and open doors for ongoing communication.
2. Acknowledging and empathizing creates a supportive environment that enhances coping.
3. Participation gives a feeling of control and increases self-esteem. 1. The patient and family member will communicate effectively.
2. The patient and family member will feel calmer and more confident in the nurse’s ability to care for the patient.
3. The family member and patient will feel like they are involved in the plan of care and that they are being heard.
6. What is the expected response of the patient and family that indicates nursing interventions were effective?
(Management of Care)
The patient and family member will communicate effectively with the nurse. They will feel calmer and more confident in the nurse’s ability to care for the patient. And they will feel like they are involved in the plan of care and that they are being heard.
7. What response by the patient would indicate that a change in the plan of care and nursing interventions are needed?
(Management of Care)
If the patient continued to be disrespectful then this could mean the plan of care and interventions need to be changed.
8. What principles of therapeutic communication can be utilized to develop trust and encourage dialogue between the nurse, patient, and family? (Psychosocial Integrity)
The nurse should ensure that he or she interacts with the patient at a suitable time where the patient is comfortable discussing with the nurse. If the patient had just undergone some treatment and feeling a bit tired, probably due to the impact of medication, then the nurse should not disturb the patient with discussion related to his or her health. However, this would be a good time to discuss information with the son and let him know you will be back to further discuss this with the patient as long as the patient has stated this is ok. One of the most important aspects of therapeutic communication on behalf of the nurse is to be non-judgmental and she should be an active listener in therapeutic communication.
9.
implement, and evaluate patient care?
It is important to include the family in all decisions and give choices when available.
10. What is the patient and family likely experiencing/feeling right now in this situation?
(Psychosocial Integrity/Basic Care and Comfort)
The patient and the family member are likely undergoing stress and fear r/t the surgery and hospital stay. They may have frustrations because they have had an experience where their family member maybe wasn’t taken care of well in the hospital also.
11. What can I do to engage myself with this patient’s experience, and show that he/she matters to me as a person? (Psychosocial Integrity/Basic Care and Comfort)
I think involving the patient and family member is the most important thing in showing that they matter as a person. Also, ensuring when every you’re in the room that you ask if they need anything, if they are feeling alright, and giving them choices in decisions when appropriate. Encouraging and supporting the family unit in decisions is important as well as active listening.
12. What was learned from this case study that you will incorporate into your practice?
(Management of Care)
I think that effective and therapeutic communication is so important. Collaborating and keep the family unit involved is just as important. These would be thing that I will ensure I incorporate into my practice. [Show Less]