170 PART 2 Application
perceptual accuracy is important to the interaction process, the nurse validates with Debbie her own perceptions and interpretation of Debbie’s perceptions. Deb-bie’s perceptions might be influenced by her emotional state, stress, or pain. The nurse’s perceptions are influenced by culture, socioeconomic status, age, knowl-edge (of Debbie’s diagnosis and treatment), and professional skill (King, 1981).
Perceptions form the basis for development of the self. According to King (1981), the self is the conception of who and what one is and includes one’s sub-jective totality of attitudes, values, experiences, commitments, and awareness of individual existence. Debbie reveals important information about self. She is tear-ful and expresses fear, concern, uncertainty, and blame. Debbie’s past neglect of her health influences her present feelings. Feelings about self and situation are clearly psychological stressors. Debbie has physical and interpersonal stressors as well.
Physical stressors result from the illness and surgery. Bladder function, pain, and nausea are identified as immediate problems, and radiation treatment may result in other changes in physical status.
In the interpersonal system, Debbie identifies a distant and sometimes abusive husband, which constitutes a major lack of emotional support during this very dif-ficult time. He is unemployed, and she is unable to work; therefore, financial trou-bles and lack of other basic resources are likely to be stressors as well. Her husband’s inability to provide basic emotional and material support most likely contributes to Debbie’s concern for her children, especially with changes that may occur in her own role with them. Her living situation is another stressor. It is unsanitary and seems quite crowded. Further nursing assessment of the situation can clarify whether her home situation truly will interfere with necessary postoperative care. It is also possible that the lack of personal—and perhaps family—space contributes to stress. Coping with personal and interpersonal stressors is likely to influence both health and illness outcomes. Debbie may need additional resources to help her cope with the immediate situation and the future.
Communication is the key to establishing mutuality and trust between Debbie and the nurse and is the means to validating perceptions, establishing patient pri-orities, and moving the interaction process toward goal setting. Debbie is expected to participate in setting goals. However, Debbie’s overwhelming needs and lack of resources likely may necessitate direction from the nurse, especially in setting in-termediate goals. Nurses can find direction for assisting patients to identify goals based on the assumptions that underlie King’s conceptual system. For example, the overall goal of nursing is to assist persons to function in their roles (King, 1981).
Debbie has expressed major concerns about her children. These concerns may in-volve the maternal role. However, Debbie is also in the patient role—one that may change based on the recovery, progression, or remission of cancer. Another basic assumption is that nurses assist patients to adjust to changes in their health status.
Decisions about goals must be based on the capabilities, limitations, priorities of the patient, and situation. In this situation the priority goal seems to be control of postoperative pain and nausea, although this needs to be validated with Debbie.
A subsequent goal will be to prepare Debbie to perform self-catheterization.
It is important to determine the extent to which Debbie’s fears, worries, and anxi-eties interfere with her ability to participate in goal setting or to identify and participate
172 PART 2 Application
in actions to meet goals. If these problems do interfere, the first nursing action would be to obtain psychological consultation. Other important actions might be directed to-ward mobilizing resources, especially family support. Although Debbie’s mother may not be a very good housekeeper, she may be a good source of emotional support and direct aid and service such as transportation to and from outpatient treatments. It is possible that professional goals and patient goals may be incongruent. Continuous analysis, synthesis, and validation are critical to keep on track.
In addition to decisions about goals, Debbie is expected to be involved in de-cisions about actions to meet goals. Involving Debbie in decision making may be a challenge because of her sense of powerlessness over the illness, treatment, and ability to contribute to family functioning. Yet empowering Debbie is likely to in-crease her sense of self, which in turn can reduce stress, improve coping, change perceptions, and lead to changes in her physical state.
Goal attainment requires ongoing evaluation. Follow-up with Debbie on pain, nausea, and bladder function soon after discharge will be necessary. One way to do this might be to arrange for in-home nursing services, which would constitute a nursing action to meet a goal. Having a professional in the home also contributes to further assessment of the family, validation of progress toward goals, and modifica-tions in plans to achieve goals.
According to King, if transactions are made, goals will be attained. Goal attain-ment can improve or maintain health, control illness, or lead to a peaceful death.
If goals are not attained, the nurse needs to reexamine the processes of nursing, critical thinking, and transaction. Unmet goals may result from an incorrect or incomplete data, perceptual errors, lack of knowledge, lack of mutuality in the rela-tionship, goal conflict, and other nurse, patient, or system factors.
CASE HISTORY OF CLARE
Clare was born on March 31, 1999, at 37 weeks’ gestation by an emergency cesarean section because of a late deceleration pattern in fetal heart rate during labor. This was her mother’s second pregnancy. She had received prenatal care, and both pregnancies were uneventful.
Clare’s mother is 33 years old, and her father is 35. Their first child is a 6-year-old boy who was hospitalized at birth and now has severe developmental delays. He requires constant care but is in a special program during the daytime hours.
At birth Clare weighed 3665 g (about 8 pounds) and had Apgar scores of 8 and 9, which indicated that she was in good condition. However, respiratory distress developed several hours after birth. Clare was intubated and placed on a ventilator, but she required increasing amounts of oxygen and pressure, and blood gases did not improve. At 36 hours of age, she was transferred to a tertiary-level neonatal intensive care unit (NICU), and within 2 hours she started receiving extracorporeal membrane oxygenation (ECMO). During the next few days she experienced sepsis, seizures, and renal failure. One or both of Clare’s parents visited daily.