Diabetes Mellitus Type 1 NURS 480 CSUSM By: Crystal Fernandez
Introduction:
The Morres are a traditional American nuclear family made of a mother, father and two children, two girls. The mother (MM) is a 26 year old secretary and is the primary caregiver for the children. The father (BM) is 30 years old and is an engineer. They own home in San Jose, CA and have a 6 year old daughter (JM) and a 3 year old daughter (CM). They are family oriented, but due to his demanding job, BM works long hours and every other weekend as well. The family usually goes to Catholic mass then the movies and has family dinner with BM’s parents every Sunday.
The Diagnosis:
For about a week, JM has been complaining of belly pain, and mother MM has noted JM has been very hungry and thirsty lately. MM also notes that JM has been very tired lately and has not been her usually active self. MM’s teacher also sent a letter home stating that JM has been having lots of potty breaks and has been tired and trouble paying attention in class. MM takes JM to the clinic to get her further evaluated. At the clinic they do a CBC and UA. The CBC is normal except for glucose of 264. Her US results come back with +2 ketones and positive for glucose in the urine as well. She is diagnosed with hyperglycemia and admitted to the local hospital for management of glucose and further evaluation. She is diagnosed with diabetes mellitus. Her mother being the primary caregiver, takes time off of work to be with JM in the hospital, she also has to continue managing the household and manage care of CM. MM eventually learns the signs and symptoms of hyper/hypoglycemia, carb counting, and calculating and administering insulin. She is discharged after diabetic teaching is complete, and is closely followed by her physician, an endocrinologist and a dietician.
Family’s Roles/Structure/Function The Morres are a traditional American-Immigrant family. Both MM and BM have extended family that live by and BM’s parents live in the same city. They are close with BM’s parents and visit them on a weekly basis. The Morres are not necessarily active in the church but they do go to mass every Sunday, and help participate in big church events. MM and BM have a strong relationship, but because of BM’s long hours MM feels stressed with need to be the main caregiver in the family, and often feels frustrated on the lack of support from BM. MM and BM have brought up their children to be respectful and thoughtful with good manners. MM is more of an authority figure while MM acts more like a friend. Because of JM’s illness, BM suggests M leaves her job as he is able to financially support the family, but MM is hesitant on fear of money being tight and wants the independence of working supporting the family. Changes in the Family Due to JM’s diagnosis, MM continues her role as primary caregiver and has to balance the stress of her work and being the main caregiver for JM during her illness. MM is very paranoid regarding JM’s diet and insulin needs. Because their insurance does not cover the equipment preferred by the MD, the family has to pay out of pocket for JM’s glucometer and test strips. JM’s diet ability to eat what she wants is altered due to necessity of carb counting. JM is reserved and sad because she is “tired of being sick.” CM is frustrated hat her older sister is the center of attention. BM feels guilty that he cannot be as hands on with his daughters care as MM is. During JM’s hospitalization, they rely on BM’s parents to pick up and drop off CM from day care, and take care of her in the evenings until BM gets home. MM feels frustrated that BM is not very involved in JM’s care.
Developmental
CM is a 3 year old and is in the “Initiative vs. Guilt” stage.CM is a normally active 3 year old but follows directions and is respectful towards parents. Due to her older sister’s illness CM feels rejected and guilty because she thinks that she did something wrong for her parents to be “ignoring” her.
JM is a 6 year old and is in the “Industry vs. Inferiority” stage. She has always been a good child and is happy and proud of being a protective big sister. JM is starting to feel inferiority due to her illness and increased reliance on her mother to take care of her health needs. She does not show initiative as she feels as she lost her independence.
MM is a 26 year old and is in the “Intimacy vs. Isolation” phase. MM feels increasing isolated due to BM’s long hours at work and what she perceives as lack of support taking care of JM.
BM is a 30 year old and is in the “Intimacy vs. Isolation” phase. BM is very appreciative and admires all the hard work MM does, but does a bad job of acknowledging her hard work. He loves his wife, but feels she is pulling away from him emotionally.
Culture/Religion
The Morres have very strong ties to their Mexican culture and Catholic religion. A nurse would have to take in consideration of the families ties when providing care. The Morres are very close to their family, and believe all family members are responsible when taking care of an ill member of the family. Food is also a big part of their culture and the nurse will have to make sure to reiterate the need for a balanced diet with controlled sugars and carbohydrates and that not following diet and being non-compliant to care can lead to various health complications. While the family integrates religion into their care, religious items should be allowed to be hung in and around JM’s room, and time for prayer should be allowed and be interrupted.
Communication
The Morres are generally a very open and honest family, but due to BM’s work MM does not always get to express her needs as she understands the stress of her husband’s work. Due to the increased stress, MM feels isolated and alone and she does not communicate her need for support. Both BM and MM have their own way of communicating with their children and CM and JM can always communicate their needs without fear to their parents. Because of her illness, MM has taken over care of JM and will dictate care, rather than having JM have input in her meals and care. BM has also noticed now because of her illness JM does not make much eye contact and will shrink away and stiffen when it’s time for her blood sugar checks and insulin administration. The nurse needs to make sure to facilitate communicate between family member s and make sure MM allows JM to vocalize her needs and let JM participate in her own care.
Strengths They have extended family that is open and willing to help. Have a strong faith. MM is very hands on and very involved with care. Financially secure. JM is accepting of care. Good interpersonal care within the healthcare system. Challenges Lack of communication between parents and children. Parents bond is dwindling. Parents are not very open with affection, are isolating each other. Family members feel isolated in feelings. BM not very hands on in care. MM feels stressed because she is the primary caregiver. JM is not able to be hands on with her care. Insurance not covering all healthcare costs.
Family Systems Theory Issues
the Morres family must be able to resolve. Include the following. JM has increased dependence on her mother and feels like she unable to take care of herself and not be a regular child anymore due to her diagnosis. MM is having stress being the main caretaker for her family and managing JM’s illness. MM also feels that she is getting little to no support from BM, and while BM wants to be supportive of the family, he cannot communicate his appreciation or physically be there for his family as he has a highly demanding job. I believe that the Family Systems Theory will be highly beneficial to this family as it “allows nurses to understand and assess families as an organized whole and/ or individuals within family units who form an interactive and interdependent system” (Kaakinen, Coelho, Steele, Tabacco & Hanson, 2015, p. 76). Concept 1: All Parts of the System are Interconnected Because of JM’s illness all her family members have been affected. BM has to work more hours to financially support the family. CM feels that she cannot rely on her parents as she does not fully understand her sisters need for attention due to her illness. MM has to take become the main caregiver and manage JM’s illness, as well as handle all the household chores. JM feels less independent and relies on her mother for management of her care. Concept 2:The Whole is More Than the Sum of its Parts Because of BM’s increasing work hours and MM’s stress of managing a new routine for JM based on activity and diet there is a change in the family’s normal routine and rituals. The family previously was able to sit down for dinner but because BM works late now, he often comes too late for dinner. MM must also cook two separate meals or change recipes for JM’s diet, and must also closely calculate carbs for JM. Dinnertime was the one daily event the family shared but there is now a loss of routine and ritual which deeply affects the family’s tradition of sitting down and having a meal together. That meal represented unity and community, and now means a loss of tradition and identity. Concept 3:All Systems Have Some Form of Boundaries or Boarders Between the System and Its Environment Before JM’s diagnosis the family has their own fixed routine with some flexibility. Things are now more rigid and structured. MM believes continuity and a fixed routine would better benefit JM, especially when it comes to diet. MM needs to understand some flexibility is needed to allow JM freedom to explore, grown and gain independence and confidence. Concept 4: Systems Can Be Further Organized into Subsystems MM helps to manage the care of JM’s illness. MM makes meals, counts carbs, MM needs to allow JM some independence, even if it is something small like using the lancet to do glucose checks. Later JM should be given more responsibilities as her cognitive skills improve such as administering her own insulin and later drawing up and calculating totals needed. BM also needs to be more involved in his child’s illness and management of her disease. JM also needs to become a partner of her care. MM can return to work as school nurses provide care, which will allow BM to go back and possible cut back on his hours in order to go back to spending time with his family; this will allow MM to have some support from BM and well ask taking away some stress and be able to interact more with both daughters. BM’s parents can also become involved with care, learn about JM’s illness so they can have caretakers they feel condiment in when they have to have someone take care of the children, or when the grandparents want to give the parents a break.
THE NURSING PROCESS
NANDA: Disabled Family Coping r/t family members with chronically unexpressed feelings (guilty, anxiety, fear), dissonant coping styles, ambivalent family relationships, shift in health status and ability AEB ineffective communication within the family in regards to JM’s illness and inability to express feelings within the family unit. Goals The family will be able to come to terms with JM’s illness, and have a realistic understanding of JM’s chronic illness. The family will be able to openly communicate with each other and express feelings and concerns within the family unit. BM and MM will be able to participate positively in the care of JM, and will allow JM to be a partner of her care. Treat JM as a normal child as appropriate in order to meet her physical, psychological, psychosocial and spiritual needs.
Interventions: Identify current behaviors of each family member, such as withdrawal, ignoring the patient, hostility, anger, expressions of guilt, and non verbal cues such as therapeutic touch (or lack of). Rationale: This will help indicate the extent of issues existing within the family unit. Relationships among the family will affect the ability of family members to deal with problems of caretaking and other issues related to the patient’s chronic illness (Moorhouse, Murr, & Doenges, 2013, p.221). Active-listen for concerns from various family members, both over concern and lack of concern. Rational: This will help the nurse evaluate the family’s understanding of the patient’s illness, course of illness and measure overall concern within the family unit which may interfere with ability to resolve situations (Moorhouse, Murr, & Doenges, 2013, p. 222). On average, a diabetic patient and/or family member drop 2.6 clues per clinic visit. Hints can be related to anything from frustration and loneliness to shortage of money. Although healthcare workers do not and cannot solve every problem, an empathic response to the patient's concerns can improve clinic dynamics and change outcome. Missed clues mean lost opportunities to improve the patient’s health (Alzaid, 2014). Assist the family to identify coping skills being used and assess and evaluate if these skills are useful or are hindering the family deal with the situation. Rationale: Can help family members enhance positive coping skills that are effective in promoting health family functioning. Will help identify negative coping skills that harm the family units Moorhouse, Murr, & Doenges, 2013, p. 222). Diabetic patients coping strategies which are typically influenced by their health values and consequently may affect their diet and exercise choices, frequency of blood glucose monitoring, and compliance with prescribed medication regimens (Collins, Bradley, O’Sullivan & Perry, 2009) Assist and refer the family to appropriate resources such as family therapy, spiritual advisors and support groups. Rationale: Will help family receive additional help to deal with the difficult situation they are currently having and have outlets and resources to help cope with emotions (Moorhouse, Murr, & Doenges, 2013, p. 222).
Outcomes:
1. Met. The nurse was able to evaluate the way the family behaves as a unit, and how they interact not only with JM regarding her illness, but how they function as a family unit. The nurse is able to assess various strengths and weaknesses within the family unit.
2. Met. The nurse is able to see the concern MM has for the lack of support within the family unit. The nurse is also able to assess BM’s lack of ability to support MM and JM due to the fact that he does not know how to care for JM and lack ability to vocalize concerns and wish to participate. The nurse also assess JM’s need to be a part of her care and to go “back to normal.” The nurse is also able to note CM’s resentment of the lack of attention and inability to comprehend why family dynamics have shifted.
3. Met. The family members are able to self-evaluate selves and come to terms with their positive and negative coping skills. The family learns new ways to positively cope with JM’s illness.
4. Met. The family has been going back to church to help meet their spiritual needs. The family also goes to a bimonthly support group with other families who have children with diabetes mellitus; this helps the family not feel so isolated and alone. The family has also been seeing a family therapist bimonthly to help support the family and foster open communication and feelings.
REFERNCES Alzaid, A.
(2014). There Is a Missing Ingredient in Diabetes Care Today. Diabetes Technology & Therapeutics, 16(8), 542544. doi:10.1089/dia.2014.0076 Collins, M. M., Bradley, C. P., O'sullivan, T., & Perry, I. J. (2009). Self-care coping strategies in people with diabetes: a qualitative exploratory study. BMC Endocrine Disorders, 9(1). doi:10.1186/1472-6823-9-6 Kaakinen, J. R., Coehlo, D. P., Steele, R., Tabacco, A., & Hanson, S. M. (2015). Family health care nursing: theory, practice, and research. Philadelphia, PA: F.A. Davis Company. Moorhouse, M. F., Murr, A. C., & Doenges, M. E. (2013). Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (4th ed.). Philadelphia, PA: FA Davis Company.