Introduction
Cara Lot is a student at Always Healthy School, and her parents requested formal evaluation due to concerns with social adaptation. The family has recently transferred to the area; thus, the life conditions and school are novel for the girl. She has myelomeningocele, hydrocephalus with a VP shunt, and new onset of depression due to social isolation during COVID-19. She lives with and sees both parents daily; there are no significant medical problems in the family except for the brother, who is diagnosed with ADHD and receives special education.
Assess
Subjective Information
Cara’s significant medical history includes such events as hydrocephaly 24 hours after birth which required placement of a ventriculoperitoneal shunt. During her mother’s pregnancy, one routine fetal ultrasound revealed a myelomeningocele. A referral to the Cleveland Clinic resulted in fetoscopic spina bifida surgery at 24 weeks. Cara had ureteral reimplantation surgery to improve bladder control at five years of age. According to her parents’ report, she has two chronic GI disturbances, including incontinent bowel and constipation, and is currently taking oxybutynin chloride extended-release 25mg QAM. Concerning the diminishment of speaking abilities, concerns include receptive and expressive speech delay. Cara’s parents also noted that she is a very picky eater and has an ongoing latex precaution due to the allergy.
Cara is currently under the care of Dr. Pediatric Neurosurgeon and Dr. Pediatric Neurologist, Dr. Pediatric Nephrologist, an Occupational Therapist, and a Physical Therapist. Her attendance for Always Healthy School has been good, and she frequently visits the school health office for the daily mid-day clean intermittent catheter. In the classroom, the nurse noted that Cara has a quiet demeanor, reserved in peer relations, yet her parents reported that the girl had been outgoing before. The student cannot perform any tasks related to self-catheterization and has identifiable learning deficits; therefore, she receives special education services for academics. In interviewing Cara’s teacher, she concurred with Nurse Nancy’s observations and confirmed the social-emotional concerns (Belmonte-Mann & Gerdes, 2019). The special education teacher was also concerned about Cara missing a large part of critical instruction time each day while in the nurse’s office for spina bifida-related services (catheterization and bowel accident clean-up).
Objective Information
Nurse Nancy completed a thorough medical file review for Cara: her last physical examination was conducted on 11-1-20 and noted stable myelomeningocele; all body systems were within normal limits except an elevated BMI. State-mandated immunizations are up-to-date, and a report from Cara’s pediatric neurosurgeon and pediatric neurologist released her for all physical activity and included an order for PT and OT. The information contained in these reports supported the health history from her parents and the observation that Cara was not yet performing any aspects of self-care related to her spina bifida.
A modified physical examination of Cara by Nurse Nancy displayed that she was a well-nourished girl with a BMI in the obese range. Vital signs were within normal limits, lung sounds were clear to auscultation, and her gait included a significant limp favoring the right leg. Although Cara expresses that she is happy to be back to in-person learning, she confides in Nurse Nancy that she is sad most of the time. She has no interest in self-care practices, including self-catheterization techniques.
Nursing Diagnoses/Outcome Identification
PLAAFP Statement
Because of the ongoing health problems, such as Myelomeningocele, Hydrocephaly, and incontinence of bowel/bladder, Cara experiences severe difficulties due to the speech delay and developed social ostracism of bowel and bladder control. Myelomeningocele – spina bifida of a severe variety, when the membranes and spinal nerves protrude after birth and create a pouch on the infant’s back (Mayo Clinic, 2022). The present academic achievement and functional performance level demonstrate that Cara does not fulfill the basic educational requirements. The girl is socially awkward with her peers, unable to hold a close connection with anyone at school, and prefers minimal interaction. Potential barriers to effective learning for Cara include missing instructional time in the general education classroom for symptoms related to social ostracism of bowel and bladder and care for the intermittent catheter.
Summary of Nursing Services Needed
Nursing diagnoses for Cara include Risk for the lateness in Clean Intermittent Catheterisation, deficient knowledge of self-catheterization as evidenced by her developmental inability to manage her needs, and speech difficulty. Consequently, the needed services are initiating catheterization procedures for her within the school setting and administering necessary medication. In addition, it is crucial to teach the girl about self-catheterization and relevant medical concepts. Cara also will be screened annually and as needed for her speech delay, monitoring for any worsening symptoms, and referral for any changes/concerns. It would be beneficial to immediately address the depression connected to social isolation and interrelated social impairments with the help of a psychiatrist, family, and teachers.
Educationally Relevant Medical Findings that Adversely Affect Learning
It is impossible to ignore the psychological effects of incontinence. If incontinence is not properly handled, the incontinence sufferer may feel rejected, socially isolated, dependent, lose control, and may even start having issues with their body image (Continence, 2020). The child’s inability to comprehend language is referred to as a receptive language delay (Mohan et al., 2021). The child may have an expressive language impairment if they have trouble verbally expressing themselves (Mohan et al., 2021). Both cases seem to persist in the case of Cara Lot. The intervention should concern effective ways to facilitate healthy lifestyle corrections, learning of the self-catheterisation techniques and core knowledge of the Myelomeningocele, Hydrocephaly, Incontinence of bowel and bladder.
Plan and Recommendations
Recommendations and Plan for Accommodations, Modifications, Interventions
The plan should include changes and interventions in every accommodation of Cara’s life because affecting only the school setting will be inefficient. Within the specific classroom context, Cara will get associated nursing care for 120 minutes each week. Another modification is that the school nurse will create an individual health care plan and an emergency action plan, which will be shared with anybody in the school setting which is interested in education. The Healthcare assistant will also collaborate with the school administration to guarantee Cara’s health and safety at school during school hours and related activities.
Annual Goals and Short-Term Objectives
- Cara will demonstrate increased knowledge of self-catheterization.
- Cara will name necessary supplies for the performance of the activity within three months of intervention.
- She will learn the basics that follow how to use a straight catheter for self-catheterization and perform the procedure without assistance within six months of the plan execution.
- Cara will verbalize appropriate treatment of her catheter during the 2022-2023 school year.
- Cara should start practicing self-catheterization on a separate supply and obtaining knowledge from additional nursing care events.
- Developed discipline will help her become more open to others during the school year as her self-confidence improves.
Evaluation
The school nurse will make visits to Cara’s office regularly to educate her about each of her aims and objectives and to instruct him on the subject matter. The goal of demonstrating knowledge of self-catheterization will be evaluated by discussing the process with Cara three months after the intervention’s beginning. If the objectives are achieved, the selected assistance strategy can be effective. The annual goal of treatment verbalization requires quarterly progress reports with data gathered from the nurse’s observations and Cara sharing her experience. Furthermore, including the questions about her interaction with peers may be used as an assessment for the objective of self-confidence.
References
Belmonte-Mann, F., & Gerdes, J. (2019). Special education and school nurses: From assessments to IEPs. iUniverse.
Continence Foundation of Australia. (2020). Psychological impact. Continence. Web.
Mayo Clinic. (2022). Spina bifida. Web.
Mohan, M., Bajaj, G., Deshpande, A., Anakkathil Anil, M., & Bhat, J. S. (2021). Child, parent, and play – an insight into these dimensions among children with and without receptive expressive language disorder using video-based analysis.Psychology Research and Behavior Management, Volume 14, 971–985. Web.