Pragmatic Children's Nursing

I want to use this video of a boy in America living with diabetes to explore how one might move through the Pragmatic Children’s Nursing theory and at the same time apply the eight outcome measures1.

So let’s assume Grayson is admitted for assessment with a temperature and a high blood sugar, perhaps he is pyrexial 38.6oC and has a blood sugar of 15mmol/l. Obviously as nurses we would want to stabilise his blood sugar and temperature in Pragmatic Nursing terms stabilise his internal environment. This would involve working with medical colleagues to administer antipyretics and insulin. This would relate to outcome 1 (Health). At the same time nurses would want to promote a stable internal environment over the longer term so would want to understand what has disrupted Grayson’s excellent maintenance regime. With a pyrexia of 38.6oC we might think about an infection and want to look for the source of the infection taking urine sample or sputum and a history from Grayson and his parents which might help to understand why he has acquired the infection and or what other factors have lead to his high blood sugar levels.

Thinking about the external environment might lead nurses to consider if a hospital is the best environment. Many children with type one diabetes are managed in community settings where there are good community children’s nursing services. Facilitating the development and maintenance of such services would help nurses and Grayson meet the second outcome measure in that he could receive nursing services at home in his community and maintain his attendance at basketball ( he might not be able to play but turning up to support would help him maintain his connection to his team and his peers).

As we can see and hear from the video Grayson is a very able self care person (listen to the story of when his mum was late picking him up). His parents are obviously also very able and informed. Negotiating Grayson care is going to involve him, his parents (both mother and father) and the nurse. I want to suggest here that the role of the nurse might be “light touch” from the video one gets the impression that Grayson and his parents have adapted lots of very good strategies and ones which allow him to live a childhood and to live with his diabetes. So the role of the nurse here might well be to encourage and reinforce those strategies, rather than to assume the role of expert and prescribe ways of coping. The outcome measure 3, 4 and 5 would seem to integrate well in this case and need to be addressed together. As the acute phase of care resolves I think the nurse has a role in helping Grayson and his parents to process what happened. This might be as simple as stating that some infections are perhaps unavoidable and reviewing their strategies to detect and treat infections early. It might involve a more detailed intervention looking at practices in the household school, and basketball team to reduce cross infection. I think nurses should also be mindful of the physical, social and psychological pressures that living with diabetes has for Grayson and his carers. His infection and breakdown in diabetic control could be the result of exhaustion on his part or for his parents. Currently we don’t have validated and reliable measures of coping with illness in childhood, but we need some to help nurses to decide when to offer more help and when to support current strategies.

In establishing the objectives of care this video shows some of the advances being made in diabetic care for children, such as use of the continual monitoring. We might consider then outcomes 6, 7 and 8 in unison and relate these to both the objectives of care and the exchange of ideas in communities. The new technologies might give great benefits but we should also be mindful of the risks. Thus safe care (outcome 6) is important to consider along with the evidence base (outcome 7) for the use of new technologies11. The use of such automation also has to be culturally acceptable (outcome 8). While Grayson’s parents seem to be early adaptors of technology others who care for Grayson such as his teachers, school peers and Basketball coach may not be, the nurse can support the use of the new technologies by talking to these other carers and setting out the benefits and strategies for dealing with potential risks.

There are of course aspects of this scenario I have not expanded upon, but I hope you can see how Pragmatic Children’s Nursing can be used to describe current children’s nursing practice and to proscribe new practices to develop nursing care. There are more worked examples in Chapter 6 of the book1

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