Portfolio for Community Health Nurses - Case Study Example

PORTFOLIO FOR COMMUNITY HEALTH NURSES Clinical Experience – Learning Portfolio Community health nurses have important and very sensitive role in improving the health by promoting knowledge for improving the health, well being and the quality of life of newborns, the mother and the new mothers. Community nurses are in closest contact with the new parents and especially mothers. Postpartum period is very sensitive period for the mother, she may feel insecure, depressed, unsupported. Also introduction of the new baby in her life has significant effect on heir’s sense of responsibility, she may feel that she’s incompetent “bad mother” that may lead to worsening of the feeling of guilt. Also the newborn baby is going to a process of physiologic changes where the organism is trying to adapt to the new environment, from intrauterine to extrauterine life. This may lead to some manifestations that may worry the new parents. In this article we will try to elaborate 2 cases involving 2 families. We will elaborate the cases, explain the condition of the mother and the child, and explain the role of the nurse in these situations. Case stidy #1 Relevant data The mother is a 21 year old married woman who had recently completed her Degree at the University of Alberta. She and her husband had planned that she would work for 2 or 3 years before they started their family. Instead, she became pregnant within 2 months of her graduation. Her pregnancy was difficult. She had hyperemesis gravidarum throughout the pregnancy, necessitating her leaving her part-time job after only 3 months. Heir’s family was not supportive of this pregnancy. They lived out of province and were disappointed that she became pregnant so soon after graduation. Her parents had even suggested abortion as an option because of her difficult pregnancy. She delivered a healthy 6-pound girl, at 41 weeks gestation by normal vaginal delivery. Because of her familys feelings, the mother and her husband did not ask them to come for a visit after the birth. Her nurse finds her crying as she tries to breastfeed her infant and the mother shares how she is disappointed that she cant share this experience with her Mom. Her husband is back at work, and the mother is on her own with the baby during the day. She is not able to rest while the baby sleeps, as she is doing laundry, dishes, etc. She says she is over the "Baby Blues", and doesnt get upset so easily now. The new mother came to clinic with the baby, appearing well dressed and giving no indication that she was having any difficulty. Breastfeeding was going "great” and the mother expressed satisfaction that she had persisted with it. She filled out the Edinburgh Postpartum Depression Scale (EPDS), and scored a 16 (anything over 10 suggests a possible risk of PPD). She answered "never" to question #10, which asks if "the thought of harming myself has occurred to me". The CHN explored mother’s responses with her partner. The baby had no appetite, even if food was prepared for her; the mother was not able to sleep when the baby was sleeping; did not feel she could leave the baby with her husband, as "she might need to nurse, and wont take a bottle"; and was feeling overwhelmed and tearful every day. Nursing Approach The mother stated that she is in the “baby blues” and that she feels that she doesn’t cope very good with the role of a mother like other mothers she knew. She also stated that she is feeling overwhelmed and have crying spells every day. The community health nurse visiting their home found that the mother feels depressed and showed signs of decreased mood. The CHN spend some time with the mother in order to fully understand the psychological condition of the mother and give her advices to ask for support and start to talk about her problems with her husband and her friends and relatives. The nurse gave her brochures and informative materials to help the mother to understand how she can better cope with her situation, feeling of sadness and incompetence. The nurse suggested the mother to visit the clinic and start visiting support groups for mothers showing signs of postpartum depression. In the clinic she filled the Edinburgh Postpartum Depression Scale and scored 16, which was an induction for potential depression. Every result above 12 is considered as a potential sign of depression. It is a list of 10 questions that was first constructed in Scotland in order to assess the incidence of depression in postpartum women. It is found that it has very good sensitivity (79%) and very high specificity (85%). This means that this is a very useful tool for fast assessment of the psychological condition of young mothers (John 1995). Postpartum depression should be differentiated from the so called “baby blues”. “Baby blues” is a mild and natural reaction and a period of adaptation in the post partum period that affects 50 to 80 % of women and begins about 3 days after delivery. The condition lasts for about 3 weeks and is characterized by feeling of sadness, tiredness, mood swings and other milder symptoms of reduced mood (Sarah et al. 2006). Postpartum depression on the other hand affects 10 to 15 % of woman in the postpartum period and is a more severe condition than the “baby blues”. It is a depression that is not different from the clinical depression seen in general population. The symptoms can start any time in the period after delivery and up to 1 year after. It is characterized with symptoms of feeling sadness, hopelessness, low levels of self esteem, feeling of guilt and feeling overwhelmed, sleep deprivation and feeling of exhaustion, emptiness, and frustration. Mothers feel that are incompetent to care about their child and have increased events of panic attacks and crying spells (Spinelli 2004). Because of these symptoms and the general psychological condition of the mother this condition can have negative effect on the quality of childcare and the quality of life of the mother also. Women diagnosed with this condition tend to focus on the negative aspects of child care that leads to increased levels of stress and anxiety. According to the McGill model for continuous education and knowledge for the patients in the case of suspicion of “baby blues” or postpartum depression there are two approaches that the nurse should do: - she should assess the risk factor for developing postpartum depression in the mother and - she should conduct a routine screening for postpartum depression. The nurse in the above mentioned case helped the mother to reduce the level of stress, get support, help her to recognize that she has a problem and she needs help. The mother started taking some time alone and time for herself, she started discussing her problems with her husband and started to be assured that her husband will be supportive and help her in caring for the infant when she wasn’t home and he will help in feeding and care of the child when she was not home. She also arranged some of her friends to baby sit for her when she had to leave home to complete some task. She started visiting support group (New mom’s network) where she started to feel accepted and shared her feelings and fears with other moms and understand that she is not alone with her problems, and that other moms also have difficulties with childcare, but learned to ask for help and support when they needed it. She started and completed the sessions and educations with mental health nurse and now she is feeling that she overcome the depression and she is confident that is capable to be a good mother and parent. She is now also aware that she may develop depression in her next pregnancies that she plan to have, but now she knows that can ask for support from her husband, family, friends and support groups. Health Promotion Practices The Community Health Nurses Association of Canada (CHNAC) promotes standards of practice and knowledge that nurses can use to define what kinds of approaches can be used in practice. Health is a resource for everybody, and nurses can promote health and wellbeing with the process of effective teaching, follow-up, and collaboration with the patients. In the in the above mentioned case the mother had some predisposing factors for postpartum depression and the nurse recognized the signs of depression. She was familiar with the factors that have been found that are associated with postpartum depression. Most important factors that are found to predispose to postpartum depression are: - lack of support and low social acceptance, low self esteem, unplanned pregnancy, marriage relation problems, prenatal anxiety, health problems with the infant and breastfeeding, formula feeding of the child instead of breast feeding, cigarette smoking, history of previous depression, method of delivery and other risks (Sarah et al. 2006). In the above case the nurse recognized that the mother had low support from her family and her partner. There are a number of indications for this: - her parents disapproved her early pregnancy and even suggested an abortion, also they didn’t came to visit and help her. - her husband was working during the day and was coming home late. - the pregnancy was unplanned and lead to drastic changes in her life-plans and social status and was forced to take care of the child by herself with very little help from anyone. She also had problems with breastfeeding and maybe in some cases used formula feeding, she had prenatal anxiety and some signs of anxiety during the pregnancy because the opposition from her parents and their suggestion for abortion. She was burdened by washing, ironing, cleaning and when she visits the hospital she denied any problems and showed signs of venting her real emotions. There are several mechanisms of coping with postpartum depression that can be recognized in the mother’s behavior. One of them is avoidance, where the mother will try to ignore the crying of the child and will not “respond” to every cry and sound, and she will try to function normally as there is no change in her life. This will lead to even greater feeling of incompetence and guilt that will make the situation worse. The second coping mechanism is problem-focused coping. Where the mother is over concentrating on other things and doesn’t enjoy caring about the child, she is focused on work, child care, trying to react on every sound and cry, often mechanically because in this process of coping the mother tries to forget the problem by excessive work and over-employment. This coping mechanism is usually accompanied by process of venting and denial of emotions (Honey 2003). The mother tries to suppress her feelings of sadness and anxiety and this on the other hand can lead to decreased emotional bondage with the child. The best coping mechanism is the support coping, when the mother tries to find support in her husband, relatives, friends and professional care. This is the best coping mechanism and the nurses should encourage the mothers to seek help, and talk about heirs problems because research shows that lack of support and social acceptance are maybe the most important factors for manifestation of postpartum depression and most women with lack of support, especially from their partner will develop signs of postpartum depression (O’Hara 1985) (Gotlib et al. 1991). Current Resources The symptoms that are identified in the mother mentioned in the above case can lead to problems in the relation between the mother and the child. It is found that in mothers that show results above 12 in Edinburgh Postnatal Depression Scale signs of poor mother-child relations are observed. The children of these mothers show signs of avoidance and show less joy and react with fewer emotions when interacting with the mother (Edhborg 2001). This can lead into problems with emotional development of the child and increase the stress on the mother. There are very good resources for nurses for improving the personal education regarding recognition and treatment of postpartum depression. “Interventions for postpartum depression” (2005) is excellent resource for learning and continuous education for nurses and new mothers regarding self care. Other resources beneficial for this case are “Supporting and strengthening families through expected and unexpected life events” (2006), “Crisis Intervention” (2006), “Caregiving strategies for older adults with delirium, dementia and depression” (2004). Practice challenges There are many challenges in the effort to prevent postpartum depression. A clinic visit is usually very short and the mother will often try to hide her real feelings and may stay unrecognized by the community health nurse. This is why the CHN must pinpoint specific questions by asking about how things are going and encouraging the mother to start talking about her problems. This is why visits from community health nurse must include screening and investigation of the condition of the mother in the natural habitat, where she is feeling more secure and more open to talk about her problems. The nurses also must be very familiar with the risk factors that may lead to postpartum depression. Lack of social support is the main and most important factor as was mentioned above. If there are some indications for depression the nurse should make a suggestion to the mother to complete the Edinburgh Postnatal Depression Scale and asses the condition. We like to encourage this practice as it provides a chance for better recognition of this condition earlier in the childcare and prevent development of more severe case of postpartum depression. Case study #2 Relevant data The new parents were both 25 years old when they had the baby, their first child remained very healthy during her pregnancy and went into labor at 9:00 a.m., just 3 days after her due date. Delivery went quite smoothly, and that evening, mother and child rested comfortably. Two days later, the baby and the mother were released from the hospital. That evening at feeding time, mother noticed that the whites of baby’s eyes seemed just slightly yellow, a condition that worsened noticeably by the next morning. The mother called the pediatrician and made an appointment for that morning. Upon examining the baby, the pediatrician informed the parents that the infant had neonatal jaundice, a condition quite common in newborns and one that need not cause them too much concern. The physician explained that neonatal jaundice was the result of the normal destruction of old or worn fetal red blood cells and the inability of the newborn’s liver to effectively process bilirubin, a chemical produced when red blood cells are destroyed. The physician told the parents he would like to see the baby every other day in order to monitor blood bilirubin concentration until the bilirubin concentration dropped into the normal range. He recommended that the mother should feed the baby frequently and instructed them to place the baby in sunlight whenever possible (David et al. 2002). Nursing Approach In the above mentioned study the nurse explained to the parents that the jaundice on their child is probably not a sign of disease but a normal physiological process in the newborn babies. She assessed the level of jaundice and concluded that it is not spread over the face, trunk and the limbs, but is only affecting the sclera of the eyes. Because of this she suspected that the jaundice is physiological and there was no need for concern. Nevertheless she advised them to expose the baby to sunlight and she stated that she will be visiting them in the following days to monitor the condition of the baby. Neonatal jaundice is normal, physiologic condition that affects about 60 % of the newborns, and is visible in up to 80% of premature born infants. It usually starts in the second or third day after delivery but is important to know that physiologic jaundice doesn’t appear in the first 24 hours after delivery. The jaundice is first visible on the face and the forehead, best visible on the conjunctiva on the eyes. After this the jaundice spreads on the trunk and last on the lower extremities (Purcell and Beeby 2009). According to the McGill model for continous education of the family and the new parents the best way to notice if the infant has jaundice is to check the sclera on the eyes because the white color of the sclera is excellent contrast to recognize the mild yellow color. The assessment of the color intensity can also be done on the toes, best in natural light against the window. Other very helpful method is to press the skin over bony prominences and then to watch for change in color immediately after reenlistment of pressure, when yellowish color is best visible before the blood is re-circulated. The peak of the jaundice is 2-3 days after in or 4-5 days after delivery for pre-term newborns and usually subsides in 1-2 weeks. In premature infants the jaundice may be present up to a month. Health Promotion Practices The nurse that was visiting the home in the above case study knew that neonatal jaundice can be caused by several factors. The jaundice in essence is caused by higher levels of bilirubin. Bilirubiin is the end product of hemoglobin metabolism and degradation. Newborn baby has high concentrations of erythrocytes and hemoglobin because the placenta is not as effective in transporting oxygen as developed, normal human lungs. Also in newborn baby there are higher concentrations of the so called fetal hemoglobin that is degraded after birth. This degradation of fetal hemoglobin results in production of higher concentrations of bilirubin that enters the blood of the newborn baby. This bilirubin is than metabolized in the liver and excreted in the stool and in smaller percentages in the urine. The second cause for neonatal jaundice is believed to be immaturity of the liver in infants. The liver is incompetent to process all released bilirubinand as a result of this the concentration of the bilirubin starts to rise in the blood and starts to deposit, first in the upper areas of the body (first and consequently in the lower parts, trunk and lower extremities (Maisels and Gifford 1986). This is very important information because appearance of jaundice in the lower extremities is usually a sign that the bilirubin is very high and blood test is needed to check for bilirubin levels. Neonatal jaundice is different from jaundice that appears in infants that are breastfeed. Jaundice assotiated with breastfeeding starts at the end of the first week after delivery and overlaps the neonatal jaundice and can last for longer periods of up to 2 months. It is believed that is caused by inadequate and insufficient breastfeeding. As a result of this the bowel movement in the infant are reduced and so less bilirubin is excreted with the stool and higher concentrations remain in the blood. Other factors also contribute to breast milk jaundice. Normally bacteria that are present in the intestines of adults are still undeveloped in the newborn, also some substances in the natural milk reduce the degradation of bilirubin (Maisels and Gifford 1986). It is important to know that breastfeed jaundice occurs exclusively in breastfeed newborns and doesn’t appear in formula feed children (where in a case of jaundice after 1-st week other causes of jaundice must be assumed). Current Resources The nurse knew that neonatal jaundice appears after the first 24 hours after delivery, and because the jaundice in the infant started the next day was another factor why she didn’t suspect more serious cause for the jaundice because the concentrations of bilirubin are maybe high in physiological neonatal jaundice, but they don’t cause any symptoms in the newborn. In the case when the jaundice appears in the first 24 hours after delivery or in a case where the jaundice is intensive, spreads in the lower extremities and is intensive in color further examination is necessary (Sarici et al. 2004). High levels of bilirubin can cause kernicterus that is a condition where the bilirubin is deposited in the brain cells and can cause irreversible damage in the brain, seizures and even death in most severe cases (Bhutani et al. 2004). Higher than normal levels of bilirubine can be caused by more benign conditions like incompatible RH actor between the mother and the baby, cephalehematoma on the head that is formed during the delivery or may be a result of some more serious disease or malformation that is present in the newborn (like obstructed billiary ducts, blood infection called sepsis, hepatitis B, arterial and vein malformations and a number of other conditions). There are several methods nurses can check the levels of bilirubin in the blood. The fastest and easiest method is to use simple visual assessment using color latter. This is not very accurate method but absence of jaundice is easily detected by visual examination. Using transcutaneous bilirubinometry is achieved by using handheld devices that use light at a certain frequency and sophisticated mathematical algorithms to calculate the bilirubin concentrations. Even though these methods can give us some information’s about the bilirubin levels in the blood the best method is direct measurement of bilirubin in the capillary blood of the infants. The blood is taken from the foot of the baby, where a small puncture with lancete is made and the blood is collected in special bilirubin tubes that are than tested in the laboratory. Family Medicine Exam Orientation Manual (2010) is excellent resource for nurses to better understand the physiology and recognition of neonatal jaundice. Practice challenges The nurse in the above case suggested the parents to expose the baby to sunlight because she knew the benefit of sun exposure. This was discovered by accidence by a nurse Rochford Hospital in Essex, England who firmly believed that premature infants benefit from the sun exposure in the hospital courtyard. A number of studies later confirmed the benefit of sun exposure, especially blue light is helping in converting the bilirubine into water soluble form (called conjugate bilirubine) that is then excreted through the urine and the stool (Hansen 1997). So based on all of the data mentioned above the nurse concluded that the baby in our sample study had a benign neonatal jaundice because the jaundice manifested on the third day after delivery. However the baby was monitored by the nurse in the next few days to see the extent of jaundice that he will develop and the time of duration of the jaundice. In the case where the baby is breastfeed then she could expected that breastfeed jaundice will develop if mother doesn’t produce enough milk or there is other cause for insufficient breastfeeding (this can afterwards be corrected with support and advices from the nurse). If the nurse suspected that there is non-physiologic cause for the jaundice she would inform the pediatrician. Every baby is controlled and checked in the first visit from the public health nurse on the first home visit. Public health nurse will check for jaundice, make the initial assessment of severity of jaundice and if there is a need she will suggest additional monitoring and control examination. Public health nurses also conduct education and teaching about neonatal jaundice, they are available and can answer any question regarding normal evolution of neonatal jaundice, possible problems and complications, they can deliver publications and brochures in order young parents to be informed and feel confident about the health and condition of the newborn infant. Refereces: Bhutani VK, Johnson LH, Maisels MJ, et al. (2004), Kernicterus: epidemiological strategies for its prevention through systems-based approaches. J Perinatol. 2004;24:650-62. David Shier, Ricki Lewis, Jackie Butler (2002), Case Study: Neonatal Jaundice, Holes Human Anatomy & Physiology, 9/e, 2002 McGraw-Hill Higher Education, available online at http://highered.mcgraw-hill.com/sites/0070272468/student_view0/chapter14/case_studies.html Edhborg, Maigun (2001), The long-term impact of postnatal depressed mood on mothers + child interaction: a preliminary study, Journal of Reproductive and Infant Psychology 19 (2001):61–71. Gotlib, I.H., Whiffen, V.E., Wallace, P.M., and Mount, J.H.( 1991), Prospective investigation of postpartum depression: factors involved in onset and recovery. Journal of Abnormal Psychology 100:122–132, 1991. Honey, Kyla (2003), A Stress-Coping Transactional Model of low mood following Childbirth, Journal of Reproductive and Infant Psychology 21 (2003): 129–143. Hansen TW (1997), Acute management of extreme neonatal jaundice--the potential benefits of intensified phototherapy and interruption of enterohepatic bilirubin circulation. Acta Paediatr. Aug 1997;86(8):843-6 John L. Coxa, , Gail Chapmanb, Declan Murrayc and Peter Jonesd (1995), Validation of the Edinburgh postnatal depression scale (EPDS) in non-postnatal women, Journal of Affective Disorders, Volume 39, Issue 3, 29 July 1996, Pages 185-189 doi:10.1016/0165-0327(96)00008-0, Received 6 October 1995; revised 22 December 1995; accepted 22 December 1995. ; Available online 12 March 1999. Maisels MJ, Gifford K (1986), Normal serum bilirubin levels in the newborn and the effect of breast- feeding. Pediatrics. Nov 1986;78(5):837-43. O’Hara, M.W (1985), Depression and marital adjustment during pregnancy and after delivery. American Journal of Family Therapy 13:49–55, 1985. Purcell N, Beeby PJ (2009), The influence of skin temperature and skin perfusion on the cephalocaudal progression of jaundice in newborns. J Paediatr Child Health. Oct 2009;45(10):582-6 Kendell RE, Chalmers JC, Platz C (1987), Epidemiology of puerperal psychoses. Br J Psychiatry. May 1987;150:662-73. Spinelli MG (2004), Maternal infanticide associated with mental illness: prevention and the promise of saved lives. Am J Psychiatry. Sep 2004;161(9):1548-57 Sarah J. Breese McCoy et al. (2006). "Risk Factors for Postpartum Depression: A Retrospective Investigation at 4-Weeks Postnatal and a Review of the Literature". JAOA. Retrieved 2008-07-04. Sarici SU, Serdar MA, Korkmaz A, et al. (2004), Incidence, course, and prediction of hyperbilirubinemia in near-term and term newborns. Pediatrics. 2004;113:775-80 Sarah J. Breese McCoy et al. (2006). "Risk Factors for Postpartum Depression: A Retrospective Investigation at 4-Weeks Postnatal and a Review of the Literature". JAOA. Retrieved 2008-07-04. The Boston Womens Health Book Collective: Our Bodies Ourselves, pages 489–491 (2005), New York: Touchstone Book, 2005 Read More