Motor Vehicle Accident MICHAEL MACAL NURSING 480 CALIFORNIA STATE UNIVERSITY SAN MARCOS
The Situation
Ngoc is an 18 year old male who was driving home at three o’clock in the morning on Saturday April 16th, 2015 from his part time job at a local Starbucks. While driving through an intersection, Ngoc was hit by a drunk driver who failed to yield at a stop sign. The police arrived on the scene followed by the paramedics, who found Ngoc unconscious in the driver’s seat. Once he was extracted from the vehicle, paramedics initiated cardiac pulmonary resuscitation and later intubated Ngoc while transporting him to the emergency department. Upon arrival to the ED Ngoc was placed on a ventilator and underwent several assessments and diagnostic tests including a computerized tomography (CT) scan of the head and neck followed by a magnetic resonance imaging (MRI) of the head (Ignatavicius & Workman, 2016). Ngoc was transferred to the critical care unit where he is currently in a coma. His family was contacted and informed of his current state. They arrived at the hospital and are waiting to speak with the neurologist. It was determined Ngoc had sustained several fractured ribs as well as a severe traumatic brain injury due to blunt force head trauma and sudden acceleration-deceleration. Ngoc was administered medication to decrease the intracranial pressure and edema of his brain; however, a cerebral angiogram with contrast and an electroencephalogram determined blood perfusion and electrical activity to the brain are inadequate resulting in cerebral hypoxia (Ignatavicius & Workman, 2016). It is recommended Ngoc be taken off life support due to brain death.
http://www.local2533.com/?zone=/unionactive/view_article.cfm&HomeID=487076
Traumatic Brain Injury o
Traumatic Brain Injuries, or TBI occur as a result of an external force to the brain not related to neurodegenerative or an inherited condition (Ignatavicius & Workman, 2016).
o
TBIs can be classified in several different ways including direct or indirect injury, primary or secondary injury, open vs. closed injury and by severity: mild, moderate, or severe (Ignatavicius & Workman, 2016).
o
TBIs account for 30% of injury and death in the United States (Centers for Disease Control, 2016).
o
Motor Vehicle Accident (MVA) for all age groups are the second highest cause of TBIs resulting in death (Centers for Disease Control, 2016).
o
MVA are the main cause of TBI related deaths in children age 5-24 (Centers for Disease Control, 2016).
o
Due to the impact of the accident, Ngoc sustained a severe TBI in which sudden acceleration-deceleration in combination of blunt force impact of the cement caused a intracerebral hemorrhage to form leading to edema and increased intracranial pressure and hypoxia (Ignatavicius & Workman, 2016).
Normal Angiogram Abnormal AngiogramNo perfusion
https://utswim.wordpress.com/2015/05/05/common-confirmatory-tests-in-brain-death/
http://brainlaw.com/brain-injuries/how-the-brain-is-injured/
https://drgo.us/?p=2574
The Family Vivian is a 41 year old divorced, Asian woman who is employed as an esthetician and manicurist. She has two children, Ngoc, a 19 year old son who works part-time and currently attends a community college and Minh, a 13 year old son in the eighth grade. This family is classified as a single-mother family unit. Ngoc and Minh do not have a relationship with their father, Hung, who moved out of state after he divorced Vivian to live with his new girlfriend. Hung is required to pay $495 in child support for Minh each month; however, he is currently three months behind on payment to Vivian. Vivian’s primary language is Vietnamese but she is able to understand some Basic English. Her sons are fluent in both Vietnamese and English. Six years ago when Vivian and her ex-husband divorced, Ngoc began fulfilling the father figure role, assisting his mother with raising Minh as well as financially contributing to the monthly expenses. Vivian works 10 hour shifts five or six days a week and relies on Ngoc to prepare dinner, clean the apartment, and look after his brother. Ngoc also assists his mother by translating English to Vietnamese when communicating at the doctor’s office or other appointments where English is the primary language.
Vivian is in the middle adulthood stage of development, Generality vs. Stagnation. Although she is proud of her two children and takes pride in her work as a manicurist, at times she feels stagnant. She is not completely satisfied with her career primarily due to demanding customers and the long hours. She has not dated or been in a romantic relationship since her divorce from her husband despite the desire to be in one.
http://www.harrycutting.com/ photos_people/adults-334C151-03.htm
Ngoc is just beginning the young adulthood stage of development, Intimacy vs. Isolation. He has developed close relationships with others outside of his family, which have enabled him to gain a sense of commitment and love. During high school he had a girlfriend for 2 years but recently they mutually decided to end the relationship. Ngoc has a few close friends but has been busy with school, work and responsibilities at home. https://www.talkvietnam.com/2016/10/ vietnamese-tennis-player-sets-vietnameseatp-ranking-record/
Minh is in the adolescent stage of development, Identity vs. Role Confusion. He is striving to determine and better understand who he is as an individual and his role in society in the coming years as an adult. Minh loves animals and would like to be a veterinarian when he gets older. He appears to have an idea of his identity even at a young age. http://www.nydailynews.com/news/world/armless-leglesspreacher-wows-vietnam-article-1.1353954
Culture and Religion Family unity is a common theme in Asian cultures, including Vietnamese families (Kaakinen, Coehlo, Steele, Tabacco, & Hanson, 2015). Ngoc and his family practice Taoism and incorporate their beliefs and traditions in their daily lives. Each morning they pay respect to their gods by lighting incense on their shrine and asking for protection and good health. They also honor their grandparents who have past away by praying to their pictures which are placed on the alter. On Sunday Ngoc, Vivian, and Minh attend temple where they gather with monks to pay respect to their gods through chants. Prayer is very significant and whenever a problem or issue arises, the solution begins with prayer. Food is also an important part of the ceremonies practiced in Tao. A variety of traditional vegetarian dishes are shared with one another (M. Q. Tang, personal communication, October 10, 2016).
Family Strengths and Challenges
http://pnpcenter.com/index.php/pnp-overview
Strengths o o o o
Photo taken by M.O. Macal, October 12,2016
Support from friends and members from temple Strength in prayer Vivian and Minh find comfort and strength in each other Ngoc has moved on the after life and is no longer in pain or suffering
Challenges o Difficulty grieving and coping with the death of their son and brother o Financial hardship since Ngoc helped support his family o Role strain - Who will complete the tasks Ngoc performed on a daily basis?
Communication When Vivian and Minh arrived at the critical care unit she was quite distressed, screaming in Vietnamese “ Where is my son?” The neurologist intervened and requested Vivian sit down so he could explain Ngoc’s situation. An interpreter was necessary since Vivian does not speak English and Minh is under the age of 18.
Verbal Communication: Vivian screamed at the charge nurse in Vietnamese wanting to know where she could find her son. Vivian asked very few questions when speaking with the neurologist, only wanting to see her son. In Ngoc’s room, Vivian and Minh prayed aloud together and chanted to their gods. Vivian later sang a song while simultaneously crying.
https://www.lifesitenews.com/opinion/state-department-human-rightsreport-condemns-forced-abortions-in-china
Nonverbal Communication: Vivian and Minh appeared to hide their emotions while speaking with the physician but when they entered Ngoc’s room they began crying. Vivian held her son’s hand and kissed his face and eventually laid down in bed with Ngoc in order to hold him one last time. https://www.pinterest.com/moehiet/expressive-faces/
Family Systems Theory
o o
The Family Systems Theory focuses on the family unit as a whole as well as each family member as an individual (Kaakinen et al., 2015). Four integral concepts make up the Family Systems Theory: o All parts of the system are interconnected. Positively and negatively events or conditions impact both an individual and the other members of the family (Kaakinen et al., 2015). o The whole is more than the sum of its parts. “Families are not just relationships between the parent-child but are all relationships seen together� (Kaakinen et al., 2015, p. 77). o All Systems have some form of boundaries or borders between the system and its environment. In an effort to protect the family unit, families regulate what outside information or individuals are able to penetrate the system (Kaakinen et al., 2015). Boundaries may be open, closed or flexible (Kaakinen et al., 2015). o Systems can be further organized into subsystems (Kaakinen et al., 2015). Family subsystems may include mother to son, son to daughter, wife to father. Nurses are able to apply interventions when the subsystems are understood (Kaakinen et al., 2015).
APPLYING FAMILY SYSTEMS THEORY The motor vehicle accident and Ngoc’s subsequent death has a profound affect on his family who now must find a way to alter their pattern of living in order to maintain stability and function. o Ngoc is dramatically affected by the outcome of the motor vehicle accident resulting in his unexpected death. o Vivian has lost a son who financially and emotionally supported his family. Vivian continues to work long hours in order to provide for her family but is now working only 4 days a week. Vivian feels guilty she is not able to be there for Minh as much as she would like. Vivian and Minh moved from there apartment and are now renting a room. o Ngoc fulfilled the role of older brother and father figure to Minh who now has an increased amount of responsibility in the family. Minh is having difficulty coping with the death of his brother evident in his poor grades and lack of social interaction with friends.
o Vivian and Minh remain a single-mother family unit but now count on the assistance of others in their social network in order to survive. Vivian and Minh are a family system experiencing the stress and grief of losing a son and brother. o Routines are interrupted and the family as a whole is forever changed. Vivian and Minh currently have open family boundaries, since they rely on members from the temple to assist them during the grieving process. Temple members offer housing, food, and encouragement.
The subsystems of the family prior to Ngoc’s death included: Motherson, brother- brother, and to a degree mother-father role. Currently Vivian and Minh are classified as mother-son family subsystem.
Family Health Interventions NANDA- Complicated grieving r/t unexpected sudden death of child AEB expressing emotions and feeling inappropriately by screaming at the charge nurse.
Outcome: Family members will appropriately express feelings of guilt, fear, anger and sadness.
Interventions: Schedule and provide bereavement follow up appointments with collaborative team members in order to assist with long term bereavement and coping (Nikkola, Kaunonen, & Aho, 2013).
Intervention: Communicate with family members about organ donation. Family’s grieving process follows a “normative process; with time, grief reactions decrease and personal growth increases” (Hogan, Schmidt, & Coolican, 2014).
Intervention: Encourage the expression of cultural and religious beliefs, norms, and values in the mourning process (Lopez, 2011).
Evaluation: Vivian has begun to express her thoughts and feels regarding the death of her son in has sought assistance from her temple as well as bereavement classes.
Evaluation: Vivian and Minh articulated a sense of comfort by donating Ngoc’s organs to help other patients in need.
Evaluation: Minh was able to begin the bereavement process by seeking strength in his religious practices or chanting and prayer.
References Centers for Disease Control (2016). Traumatic brain injury & concussion. Retrieved October 11, 2016, from http://www.cdc.gov/traumaticbraininjury/get_the_facts.html Hogan, N., Schmidt, L., & Coolican, M. (2014). The bereavement process of tissue donors’ family members: responses of grief, posttraumatic stress, personal growth, and ongoing attachment. Progress In Transplantation, 24(3), 288-293. Ignatavicius, D. D., & Workman, L. M. (2016). Medical-surgical nursing: Patient collaborative care (8th ed.). St. Louis: Elsevier Saunder Kaakinen, J., Coehlo, D., Steele, R., Tabacco, A., & Hanson, S. (2015). Family health care nursing: Theory, practice, and research (5th ed.). Philadelphia: F.A. Davis. Lopez, S. (2011). Culture as an Influencing Factor in Adolescent Grief and Bereavement. Prevention
Researcher, 18(3), 10-13