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The School of Health Sciences, Ngee Ann Polytechnic, Singapore
The School of Health Sciences, Ngee Ann Polytechnic, Singapore
Part 2
Part 2
Case Studies for your learning
Case Studies for your learning
In this section, you can attempt these case studies with answers provided below. These case studies aim to guide your understanding of psychological theories and nursing practices.
Case study 1: Sam's asthma.
Case study 1: Sam's asthma.
Sam was a seven-year-old boy with severe asthma. He has had recurrent chest infections often resulting in frequent hospitalisation of long duration. Furthermore, he frequently required antibiotics therapy in a pediatric hospital. Despite optimal treatment San has severe wheeze and lethargy. Recently, he developed bronchitis.
Sam often refused to take his supplements as he disliked the taste, and his mother reported the use of physical force to make Sam comply with his medication. Due to poor management of diet, Sam has growth problems at less than 3rd percentile for height and weight. In addition, his mother reported that Sam was reluctant to play with children of his age in family and friend gatherings, although his global development had always been normal. He has little friends and his academic performance is poor.
After school hours, Sam spent most of the time at home with his grandmother, as his mother returned to full-time work. Sam’s parents separated, and his father rarely visited him. Sam’s mother found both work and home very stressful. Outside home, she worked long-hour shifts; at home she constantly needed to find ways to make Sam comply with his medication and food. However, when his mother was not home, Sam knew that he could use his tantrum strategy on his permissive grandmother to avoid taking medication
Discussion Questions:
Discussion Questions:
With reference to the Biopsychosocial Model in Chapter 1, list down the possible causes of Sam’s growth problems.
With reference to the Biopsychosocial Model in Chapter 1, list down the possible causes of Sam’s growth problems.
Biological factors: Respiratory system issues, primary medical diagnosis (asthma), secondary medical diagnosis (bronchitis), wheezing and lethargy, low weight and height.
Psychological factors: Poor peer support in school due to missing school regularly for treatment. Social withdrawal (seen in not wanting to socialize with others despite company), poor academic performance and a sense of helplessness from the chronic illness appears to further exacerbate this maladaptive defense mechanism (seen with increased hostility and displacement of anger towards grandmother). There is a close association to depression in children with long term chronic conditions. Depression may present itself as behavioural disturbance, irritability, and anhedonia rather than typical depressive somatic symptoms. If Sam fails to develop a sense of self-worth by refining skills in social interaction and taking control of his disease, he may continue to employ maladaptive defense mechanisms throughout his life .
Social: Poor social support in school due to missed lessons. His small physical self can contribute to decreased self-esteem. Long-term medical adherence is crucial in managing his asthma, but this may be a stressor for Sam. He may see this as a “routine” imposed by his mother, or he may see this as being different from his peers. Besides, the practice of physical punishment by his mother to improve medication compliance induces fear and hostility, who may respond more aggressively to this stimulus. On the other hand, grandmother is too permissive, as medication adherence is crucial in managing chronic illness which has medical as well as psychosocial implications especially on his physical appearance. Moreover, Sam may feel neglected by this style of parenting (permissive from grandmother and authoritarian from mother), and the feeling of insecurity may result in more undesirable behaviour, such as blaming his grandmother for his own mistakes, to seek attention .
Based on your knowledge of Erikson’s Psychosocial Model, identify the stage that Sam is in; and explain possible causes for his behaviour.
Based on your knowledge of Erikson’s Psychosocial Model, identify the stage that Sam is in; and explain possible causes for his behaviour.
Sam is at the Industry VS Inferiority stage.
According to Erikson, children develop numerous skills and competencies in school, at home, and in peer relationships. Developing this sense of industry is essential to healthy psychosocial development. Children learn how to be productive, which leads to a sense of competency. Building a sense of competency is important in developing self-esteem. Also important at this stage is a connection with peers and learning how to communicate with them. Children gather information about the rules and obligations of friendship relationships. They learn the nature of a give-and-take relationship and the nature of a mutual relationship. Comparison with peers becomes increasingly important, and a negative evaluation of one's self compared to others is especially damaging at this time. The danger at this stage lies in a sense of inadequacy and inferiority. If a child feels he or she is unable to develop the skills and tools typical of this age, he or she may have difficulty identifying with his or her peers.
Accordingly, children with chronic illness who may not be able to develop the same skills as peers, due to physical or cognitive limitations, may suffer from inadequate connection with peers. Furthermore, children are beginning to recognize differences between individuals and begin to feel these differences will decide one's worth. As a result children begin to judge each other based on similarities and differences.
As the case manager in charge of his case, describe coping strategies and types of social support that the hospital and community service can provide Sam.
As the case manager in charge of his case, describe coping strategies and types of social support that the hospital and community service can provide Sam.
Biological intervention:
a. Respiratory System issues
- Continue daily with adherence to medication by having health professionals educate mother and grandmother. Use operant conditioning for compliance: When Sam shows aggressive behaviour, immediately tell him to stop it and give brief reasons. If he continues, have a “time-out” session in which he is left alone. Reapply if necessary for negative reinforcement. If Sam has done the right thing, give him a reward such as a sticker or take him out to the park. Empower Sam in the process explain to him in plain language his disease and what he can do to make him feel better.
- Regular exercise. Encourage Sam to undertake sport in school, as it can also improve his relationship with his classmates.
b. Low weight & height
- Work with dietician to maintain a balanced diet and good medical control of his asthma.
Psychological factors
a. Maladaptive defense mechanism
- Work with social worker/counsellor in family therapy i.e. Parent management therapy (PMT) to alter the parenting styles of mother and grandmother to discourage maladaptive defense mechanism and encourage appropriate behaviour.
b. Depressive symptoms
- Follow up with child psychiatrist to monitor for depressive symptoms and adjust treatment accordingly.
c. Social support in school
- School counseling service may also be beneficial to help Sam build relationships with peers and adjust to school despite missing lessons regularly
Social factors
a. Family
- Coping strategies for Sam’s mother: single-mother support groups, hospital based support groups for caregivers (e.g. Caregiver Support Programme for Families with Chronically Ill Children on Long-term Home Care in KKH) can empower mother and grandmother to be manage better at home
- Liaise with Social Service Office or Medical Social Worker for financial assistance. This takes the financial burden of mother’s shoulders
b. School
- Provide special classes if Sam cannot keep up with his academic study due to hospitalisation.
- Engage school teachers for school activities and improve peer relationships. Empower Sam by allowing him to take on responsibilities/leadership positions in class/school.
Case study 2: Rachel's diabetes.
Case study 2: Rachel's diabetes.
Rachel is a 14‐ year‐old girl who was diagnosed with type 1 diabetes 3 years ago at the age of 11 years. On this particular visit to the clinic, the nurse noticed that the injection sites on Rachel’s thighs were hardened and red. The nurse asked Rachael to demonstrate how she administered her daily insulin. It became obvious that Rachael was not following the right technique in the preparation of the injection, neither was she rotating injection sites. Rachael had been a diagnosed with Insulin Dependent Diabetes three years ago, and these observations had not been documented on previous visits. The nurse became concerned about the change in the way Rachael administered insulin.
Rachael also mentioned an increase in frequent snacking binges and the difficulty being diabetic in social situations when other teenage friends could eat whatever they wanted. She briefly shared that she felt left out when she could not order popular desserts when with friends. The nurse was concerned about the long‐term effects of high glucose levels on Rachael's health following her urine test showing high levels of glucose.
The nurse decided to be firm with Rachael. She pointed out the high risks of not following her diet, of carelessness about insulin administration, and the possibility of infection. She also told Rachael that she might need to be admitted to hospital for insulin therapy and stabilisation of her diet if Rachael continued to practise the same habits.
Rachael was upset by the nurse’s strong warning and the threat of future hospitalisation. She also objected to the nurse’s repeated suggestion about how she should administer her daily insulin by rotating injection sites. Rachael had never liked injecting herself in her abdomen or arms, so she had decided to make most injections in her thighs. She told the nurse that this was her choice, and that she had the right to decide what to do with her own body.
Discussion Questions:
Discussion Questions:
With reference to the Biopsychosocial Model in Chapter 1, list down the possible reasons for Racheal’s high glucose levels.
With reference to the Biopsychosocial Model in Chapter 1, list down the possible reasons for Racheal’s high glucose levels.
Biological: Type 1 Diabetes – inability to metabolize increased carbohydrates consumption
Psychological: Stress in managing frequent changes in daily routines while adapting to increased social roles (i.e. managing timing of meals) that may affect glycemic control. Stress from interpersonal conflicts with peers and medical team over management of diabetes. Prolonged stress and incongruence may lead to depression in young adolescents
Social: While transitioning into adulthood, adolescents may struggle with feelings of ambivalence and engage in health compromising behaviours that are associated with poorer metabolic control in type 1 diabetes i.e. smoking, drinking, changes in diet with increased carbohydrates and desserts. Peer pressure as a means of coercing behaviours within peer groups based on social norms can also increase pressure to conform to these behaviours. Attachment to peer groups helps adolescents avoid feelings of alienation and isolation, hence making it more difficult for Racheal to act against social norm.
Based on your understanding of Social Cognition and Erikson’s stage of ‘Identity vs. Role Confusion’, describe the challenges that Rachael faces now that she is an adolescent.
Based on your understanding of Social Cognition and Erikson’s stage of ‘Identity vs. Role Confusion’, describe the challenges that Rachael faces now that she is an adolescent.
Erikson maintained that adolescents between the ages of 12 and 18 face the life stage crisis of identity versus role confusion. They thus have to establish an identity or remain confused about the role they have to play later in life. If they successfully complete this task, they move on to the intimacy versus isolation stage in young adulthood.
Racheal may experience personal conflict due to feeling different from her peers that results from persistent concern over self-monitoring and management of her diabetes. The idea of being different from her peers may result in increased sensitivity towards peers’ views of her illness and decreased self-confidence. She could harbour a fear of stigmatization and rejection from her peers when she does not conform to group behaviour. Rachel is also developing a heightened sense of personal responsibility and autonomy with her transition into adolescents, which may lead to challenging of parental authority or any authority (i.e. nurse). She wants to decide where and how she administers the injections on her body.
Public and social functions can cause stress if she feels singled out from her classmates due to dietary restrictions and regular injections required. Some of the main sources of family conflict are centered on issues of noncompliance and disagreement in adolescent choice of social activities and interpersonal relationships.
As the case manager in charge of this case, describe coping strategies and types of social support that the hospital and community service can provide Racheal.
As the case manager in charge of this case, describe coping strategies and types of social support that the hospital and community service can provide Racheal.
Biological intervention:
a. High glucose levels
- Counseling by nurses or doctors required.
- Routine assessment should be made of developmental adjustment to and understanding of diabetes management, including diabetes-related knowledge, insulin adjustment skills, goal setting, problem solving abilities, regimen adherence, and self-care autonomy and competence. This is especially important during late childhood and prior to adolescence when in many families the child may take on diabetes management responsibilities without adequate maturity for effective self-care.
Psychological factors
a. Stress & peer pressure
- Work with social worker/counsellor in family therapy to increase family support and communication with transitional issues
- Racheal may require additional support in managing peer groups and expectations in school. Counseling can help her manage this transition and normalize fears and anxiety she feels.
b. Social support in group
- Enroll in social support groups for adolescents in the hospital. Being part of a group environment will allow Racheal to learn from the behaviours and practices of others. She may choose to model behaviours from the group.
Social factors
a. Family
- liaise with counselor to increase coping strategies for the family to increase support towards Racheal’s increased independence over her diabetes management.
b. School
- Provide enclosed spaces for Racheal to administer her insulin injections in privacy.
- Engage school nurses and include them in monitoring Racheal’s physical activities and diabetes management in school.
Case study 3: John's heart attack.
Case study 3: John's heart attack.
Jon’ is a 43-year-old male. He is single and lives alone. He works as a free-lance entertainer with casual employment contracts. He has many friends (socially, but no close friends); however he has no children, no partner and his parents deceased. Jon has had few visitors whilst in hospital.
Jon is 2 weeks post-heart attack, and had spent the last 2 weeks as an in-patient at a public hospital. Jon has been recently advised that he will require 3–6 months rehabilitation and lifestyle modification; and describes some ambivalence regarding this.
Before the heart attack, Jon was a very active guy who didn’t let anything slow him down. Jon was an avid golfer and enjoys having beers with the boys and workmates. Jon is a long-term heavy smoker. He has long-term high cholesterol but his adherence to the medication is not 100%. Further, Jon was loves meat and is highly reluctant to make significant dietary changes. There is also a family history of maternal depression, and his maternal aunt was reportedly treated in a long term psychiatric ward.
After his heart attack, Jon is worried about his future work prospects and whether he is able to work again. The hospital nurses report he is very tearful, increasingly less social and more withdrawn during rehab appointments. They report that Jon seems increasingly hopeless regarding his recovering and prospects of returning to pre-heart attack functioning and vitality.
Discussion Questions:
Discussion Questions:
With reference to the Biopsychosocial Model in Chapter 1, list down the possible causes of heart attack in Jon.
With reference to the Biopsychosocial Model in Chapter 1, list down the possible causes of heart attack in Jon.
Biological factors: Age (43), gender (male), hyperlipidemia.
Psychological factors: Increased risk behaviours - inappropriate stress coping methods such as drinking and smoking; family history of depression,
Social factors: Low SES (working as a freelancer with irregular income) may affect access to financial resources to receive medical care. Freelancers may not contribute to CPF, limiting accessing to Medisave funds/Medishield. Loneliness – not married, no close friends, no existing surviving member
Use the Three-stage Model of Appraisal in stress appraisal to explain why Jon seems to have difficulties coping after heart attack.
Use the Three-stage Model of Appraisal in stress appraisal to explain why Jon seems to have difficulties coping after heart attack.
When faced with a challenge, a person appraises the challenge as either threatening or non-threatening [primary], and secondarily in terms of whether he has the resources to respond to or cope with the challenge effectively. If the person does not believe he has the capacity to respond to the challenge or feels a lack of control, he is most likely to turn to an emotion-focused coping response such as wishful thinking (e.g., I wish that I could change what is happening or how I feel), distancing (e.g., I’ll try to forget the whole thing), or emphasizing the positive (e.g., I’ll just look for the silver lining).
If the person has the resources to manage the challenge, he will develop a problem-focused coping response such as analysis (e.g., I try to analyze the problem in order to understand it better; I’m making a plan of action and following it). It is theorized and empirically demonstrated that a person’s secondary appraisal then determines coping strategies.
When applied to Jon, he appears to appraise his recovery post- surgery as a threatening challenge that has rendered him out of job with a prolonged 3 – 6 months rehabilitation period. As a single man, he may not have the socio-emotional support required from support networks to cope with this sudden change in lifestyle. He also does not have access to instrumental social support. He now has to learn how to watch his diet, find alternative non-risky stress relief methods, and take care of his own physical health. Jon is having difficulties coping due to the lack of resources.
As the case manager in charge of his case, describe coping strategies and types of social support that the hospital and community service can provide Jon in his recovery?
As the case manager in charge of his case, describe coping strategies and types of social support that the hospital and community service can provide Jon in his recovery?
Biological intervention:
a. CVD & hyperlipidemia treatment
- Continue daily with adherence to medication
Psychological factors
a. Negative stress coping mechanism
- Work with social worker/counsellor to manage stress and anxiety related to adjustment issues (change in lifestyle, change in diet, out of job for a few months) post-surgery.
b. Support Programme
- Follow up with support programme in the hospital (i.e. Caring Heart Support Group by NUH)
- Support programme empowers through continued education and training support, and provides social support reconnecting with other heart patients
Social factors
a. Financial needs
- Work with Social Service Office or Medical Social Worker for financial assistance and subsidies to ensure that he can be supported despite being a freelancer.
We have come to the end of this week's lesson and also completed Term 1's learning journey. When we return in Term 2, we will explore using sociology to understand why males and females might be exposed to different health risks because of gender socialisation. In that stop of your learning journey, Gender & Health, we will look at how males and females' behaviours are programmed by society. We will also practice how to help patients overcome some of the unintended health issues using the Transtheoretical Model of Behaviour Change.
We have come to the end of this week's lesson and also completed Term 1's learning journey. When we return in Term 2, we will explore using sociology to understand why males and females might be exposed to different health risks because of gender socialisation. In that stop of your learning journey, Gender & Health, we will look at how males and females' behaviours are programmed by society. We will also practice how to help patients overcome some of the unintended health issues using the Transtheoretical Model of Behaviour Change.
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