This essay will critically analyse and discuss the nursing care delivered to a 25-week pre-term infant subject to secondary Pulmonary Hypoplasia (PH) induced by oligohydramnios. This patient shall be referred to as Bilal to preserve patient confidentiality, in accordance with the Nursing and Midwifery Council (NMC), (2015). Bilal’s care was ranked as complex due to the severity of his condition, however, there were also multiple safeguarding concerns that were revealed throughout his care on the Neonatal unit. An all-inclusive, holistic approach will be taken regarding Bilal’s complex needs using the Casey’s Model of Nursing. Followed by a discussion of Bilal’s pathophysiology of his condition, his family’s psychological and social needs and critically debating them relating to his complex care in association with the multi-disciplinary team (MDT).
Post-birth Bilal developed central cyanosis, bradycardia and low oxygen saturations. Bilal’s Apgar score at 1 minute resulted in 1 and remained at that 5 minutes. Resuscitation commenced in the birthing room, and he was sent to the Neonatal Unit. The Apgar score depreciated to 0 in the Neonatal Unit, consequently basic life support was performed, and Bilal was intubated and was under the support of continuous mandatory ventilation (CMV). The initial chest X-ray revealed an insignificant lung volume and reduced lung growth. Bilal was diagnosed with secondary PH induced by oligohydramnios.
Çeliksoy et al (2014) defined PH as the failure of adequate lung development in utero, resulting in hindered lung growth and does not allow for them to reach a sufficient adult size in the future. Post-birth, a newborn will experience the foremost physical force of their lungs extending which is stimulated by their breathing mechanism, however in a 25-week pre-term baby that is not conceivable as their respiratory system is not fully developed (Schmolzer et al., 2009). William et al, (2012) asserts that oligohydramnios decreases the intrathoracic cavity dimensions, consequently disturbing fetal lung development in turn preceding to pulmonary hypoplasia. The ultimate consequence is that the lungs do not have enough tissue and blood circulation for gas exchange to occur. PH is characterised by the reduction in the amount and size of pulmonary airways, alveoli and vessels. As Bilal was a pre-term baby, his lungs are already under-developed, and for key lung development to occur several key factors are required. These vital factors include sufficient amniotic fluid volumes when the fetus is in-utero, adequate thoracic space and size, normal breathing movement and standard fluid within the lung (Shulman, 2009). As Bilal was born at 25 weeks due to premature rupture of membranes (PROM) he conveyed a stress response which consisted of immediate collapse, cyanosis and intercostal recession with tachypnoea. This lead to Bilal suffering from Neonatal Respiratory Distress Syndrome (NRDS). His diagnosis informed us that his life expectancy was low and he would deteriorate rapidly and, due to the complexity of his condition, symptom control was imperative for both Bilal and his family. Bilal’s family was informed of his diagnosis.
Nursing a premature baby requiring assisted ventilation and intensive care is complex and challenging. Newborns who are receiving assisted ventilation and intensive care require a multi-disciplinary care approach provided by nurses, physicians and respiratory therapists ect. The nurses provide a vital link between the patient and the multi-disciplinary team because of their proximity to the patient and their knowledge and skill at interpreting physiological and behavioural information. Bilal would be regularly assessed multiple times throughout the day, nurses would look out for colour change, premature babies are likely to have decreased tone and activity levels, therefore, it was important to notice subtle changes over time. Bilal’s chest would be examined daily for symmetry, shape and movement, attention is given to breathing, use of accessory muscles and chest wall movement.
Complex care is not just the complexity of a patient and their condition; it can also suggest complex social and psychological issues. Bilal’s parents, who will have the pseudonym names of Aisha and Hamza, were related which is not unusual in many cultures. However, Hamza was Aisha’s cousin, Aisha claims that the relationship was fully consensual, but as Aisha was 16 at the time of Bilal’s birth and Hamza was 32. This led to an assumption of possible sexual abuse in the past, another indicator of this was that Aisha was estranged from her family and friends. Good-year Brown (2012) affirms that survivors of sexual abuse are often estranged from families and friends due to the feeling of shame and discomfort that they as well as others frequently feel.
This was a complex situation as Aisha was 16 at the time of Bilal’s birth which suggests that she was underage at the time of intercourse which would advocate jail time for Hamza for having sex with an underage individual. The Nursing and Midwifery Council (2016) dictates to ‘avoid making assumptions and recognise diversity and individual choice’ yet also illustrates to ‘make a timely and appropriate referral to another practitioner when it is in the best interests of the individual needing any action…’. As Aisha and Hamza affirm that it was consensual on both parts and Aisha is 16 years old it made the circumstances a lot more complex. Research studies have found a prominent association between teenage mothers and a sexual abuse history. For instance, in Noll et al’s study (2009) the likelihood of a pregnant adolescent having a history of childhood sexual abuse was a remarkable 4 out of 10. Another study with Betty (2009) researched that those girls who are adolescents when the exploitation and abuse befalls, correspondingly incline to be younger at their first pregnancy. Being sexually active from a young age enhances risks of pregnancy, If girls are being abused, they have even less power over contraception than those who are in consensual relationships, given the differences of inequality and the intimidation involved (Stoltz et al., 2008). Whilst teenage pregnancies are always not the immediate outcome of sexual abuse itself, it may source from effects of former sexual assault. Evidence has shown that frequent sexual activity, with several partners, can originate from misperceived sexual limitations, low self-esteem and dysfunctional behaviour, with significant chance of re-victimisation (Neelson and Mackay, 2015).
Caring for a child with complex needs is difficult enough, but caring for a child when the parent is still a child is even more problematic. Aisha was diagnosed with depression and suicidal tendencies; she made claims that if Bilal died she would take her own life. The nurse documented this and put in a safeguarding referral form for Aisha and Bilal. A 16-year-old jumping from the role of a child to the role of a parent is very difficult for that individual, especially without the support of loved ones around them. Littleton-Gibbs and Engebretson (2013), conveys that child and adolescent bodies and minds have not yet fully matured, and for Aisha to then give birth to a very sick child there is a lot of pressure for her to take in all this new information that she did not expect. Teenage mothers have lower birthweight babies and higher infant mortality rates compared to women who have children later in life (Meadeet al, 2008). This could be since a higher percentage of teenagers and young people come from more socially deprived areas and lack of prenatal care (Chambers et al, 2001)., Aisha was included in these statistics. Today, there is a lot of information available to and from young mothers, however, not everyone has the desire or the ability to access it. This may lead to teenage mothers remaining uneducated about their pregnancy, however, more research is needed in this area to ascertain the degree to which this has had an impact.
One concept Aisha struggled with was Kangaroo Care as Bilal was so diminutive. The connection between parents and their children is the foundation to the consolidation of parenting skills, the growth and development of their child is an important establishment of a bond between parent and child (Fegran et al, 2008). Premature birth and sudden hospitalisation disturb the conventional attachment development between parent and child. Aisha and Hamza were both terrified at the thought of bonding with Bilal through Kangaroo Care in case they hurt him, professionals encouraged parents to hold Bilal as it would benefit them all equally in different ways. Nurses encouraged Aisha to attempt to hold Bilal, but she was petrified of hurting him, mothers’ who were deprived of contact with their infants possibly inhibited the physical stimulation and therefore can delay the attachment process (Luding-Hoe et al, 2007). There is a greater prevalence of depression in parents of preterm infants in comparison to those parents of term babies, this could be elucidated by sporadic mental developments during the antenatal period, a traumatic delivery, anxiety over their child’s comfort, health and neonatal care (Brandon et al, 2011).
Preterm birth and subsequent hospitalisation may have dexterous effects on Bilal’s care such as parent – infant separation, negative physiological responses, infant stress and parental stress and negative feelings. As Aisha had an emergency Caesarean Section it was difficult for her to come down to see Bilal that often, Sarapet et al (2016), proposes that parent-child intimacy and parental participation in caring for their preterm child can expand both parent and child results. Whilst Aisha was recovering from her trauma and the processing of information, due to this the unit made the decision to move her to a family bedroom on the unit so she could be monitored and Aisha could come see Bilal more often. Castle and Abel (2016), illustrate that self-harm and suicidal thoughts are common amongst women suffering from postpartum depression, this lead to a multi-disciplinary team intervention decision of referring Aisha to the mental health team for support.
The nursing model that will be discussed in this essay is Casey’s Model of Nursing, this model concentrates on the nurse working in a multilateral collective collaboration with the Bilal and his family. The five perceptions of this nursing model are child, family, health, environment and the nurse (Pandey, 2007). This model will provide the basic outline of assessment and management whilst allowing the nurse to involve the family in all aspects of the Bilal’s care to ensure that the family are able to carry out his needs and are able to ask for support when needed. If the parents are unable to carry out a specific task due to their reason, the nurse can work with them until they are ready for that specific task. A criticism of this Casey’s model is that it is too vague and many hospitals use this in conjunction with another model (Thurston, 2014).
As Bilal’s case had many complex aspects it was important to assess and manage his care. One of the main problems throughout the duration of Bilal’s care on the Neonatal Unit was that Hamza and Aisha were worried Bilal’s pain level. When parents are scared and worried it can affect their child’s well-being and stress levels, many studies show that babies can feel parent’s anxiety through touch and closeness (Smart, 2011). Hence why it is important as a role of the nurse to talk to the parents and discuss their worries and to find a way to ease their worries as much as can be expected given the situation.
Newborn babies can experience acute pain with numerous medicinal measures, current research validates that managing pain in the newborn is salubrious in improving physiologic, behaviour and hormonal results. Up until 1985, the nervous system of a 25-week neonate was thought out to be underdeveloped for pain sensation (Marchant, 2014). Analgesia to assuage suffering from ‘painful’ treatments in which premature babies were, and still are, exposed to was frequently deemed inconsequential (Marchant, 2014). However, this does not reassure parents like Aisha and Bilal, who are watching their baby undergo many painful procedures in intensive care wondering whether they are feeling pain. Contradictory Linden et al (2014), suggest that even the youngest neonates who are born at 22 and 23 weeks, their sensory nerve fibres are already profuse and connected to the part of the brain called the thalamus. A recent study looked at blood flow in brains of neonates as young as 25 weeks, when their heels were pricked to draw blood, even the youngest neonates had a surge of blood flow and oxygen to their brain, revealing that they may already be conscious of pain.
To assess Bilal’s pain the nurses looked at his heart rate, a higher heart rate suggests a stressor, his oxygen saturations decreases, his brow and forehead bulges, his body may stiffen and arch during painful interventions and he may cry (Linden et al, 2010). The nursing intervention that was used in this complex case was pharmacological and non-pharmacological pain relief. When neonates feel mild pain, a non-pharmacological intervention is best as medications can have dangerous side effects. One of the natural medications that often-helped Bilal when he was in distress was medicinal sucrose. This is also known as sugar water, by providing a minimal dose of one to two drops of sucrose mimics a natural endorphin release within two minutes of oral administration during mild painful treatments for example a blood gas. However, evaluating the effect of sucrose on a 25-week neonate, it can also result in choking vomiting and haemoglobin desaturation (Mokhnach, 2010). Evidence suggests that reasonable precautions during sucrose administration can limit these effects. On the other hand, practice with use of a dropper-style dispenser, and careful administration to the buccal area or anterior tongue can enhance delivery techniques (Mokhnach, 2010). Attention to administration details can reduce the risk of coughing and choking, further, using minimal volume (one to two drops) also reduces such risks (Fanaroff, 2012).
Another route that was used to manage Bilal’s care was to control his stress levels. Following delivery, the external environment is a stark contrast to the uterus environment for any child, hence why the Neonatal Unit has simulated an environment like that of the intrauterine environment and works to reduce environmental stressors that could affect the premature infant (Rick, 2006). The nurses on the unit reduced Bilal’s stress level’s by clustering his care, as premature babies do not always tolerate multiple handling and cares throughout a small period. Cluster cares allowed Bilal to rest for a longer period and all his cares, handling, damp dusting was done by the nurses in a specific time slot, this way less disturbance is required (Altimier and Phillips, 2016). By clustering Bilal’s care, it allowed more time for him to rest and heal. Preterm babies are exposed to bright light in the Neonatal Unit as opposed to the darkness in utero, reduced light may reiterate the benefit of better-quality sleep routines and reduce stress (Chaudhari, 2011). The nurses reduced Bilal’s exposure to light by using incubator blankets to create a dark intrauterine environment. However, one study looked at bright lighting versus dim lighting showed no difference in weight gain and growth in the premature infant (Morag and Ohlsson, 2016). The nursing staff assessed Bilal’s stress levels through clinical observations and documentation.
To ensure holistic and personalised care was achieved the Neonatal Unit ensured that the parents religious needs were met. As Bilal and his family were Muslim, in Islam it is customary for the child to hear the Adhan (Muslim’s call to prayer) as soon as possible after their birth. This is a fundamental factor in a Muslim family’s religion and was imperative that it was carried out as soon as possible. As Bilal was rushed to the Neonatal Unit soon after delivery, this tradition was not carried out till much later, the nurses later arranged for Hamza to read the Adhan in Bilal’s ear and for pictures to be taken up to Aisha as she was recovering from her Caesarean section.
As Bilal’s health was deteriorating Aisha and Hamza requested an Imam from the mosque to be allowed onto the unit to pray for Bilal. This was easily managed and helped improve Aisha’s and Hamza’s anxieties. After discussion with Aisha and Hamza and due to the natural decline of Bilal’s condition upon his health the Neonatal Unit liaised with another trust for a possible transfer to their hospital as they were closer to Aisha and Hamza’s home. As well as this they were a Level 4 unit and would be able to better manage Bilal’s deterioration. Emotional and psychological support were provided to both Aisha and Hamza, through active listening by the nurses and doctors. The Neonatal Unit also recommended attending a support group at the hospital that delivers information, support and emotional assistance for those parents of premature babies. Linden et al (2014), elucidate that 90% of parents benefited from attending support groups as it made them feel like they were not alone.
To conclude, while Bilal’s care was extremely complex for a variety of reasons, the assessment of care was valid for his condition and circumstances. This was due to the management being already complex due to the diagnosis of PH, but the facts pertaining to the parental situation further exacerbated this due to the possible sexual abuse and Aisha and Bilal’s familial relationship. The main points to be taken from this case study can be how to manage a complex condition whilst providing quality care, how interventions such as pain relief and cluster care can minimise anxieties and stressors for not only Bilal but his parents and how nurses worked within a MDT to ensure collaborative holistic support be provided to Bilal and his family.