International Journal of Caring Sciences May-August 2022 Volume 15 | Issue 2| Page 1178

Original Article

Nursing Care of a Child Patient with Congenital Laryngomalacia

Diagnosed with Cerebral Palsy and Acute Lymphocytic Leukemia
According to "Orem's Self-Care Insufficiency Theory":
A Case Report

Fatma Dinc
Lecturer, Bartın University, Faculty of Health Sciences, Department of Nursing, Bartın, Turkey
Aylin Kurt
Lecturer, Bartın University, Faculty of Health Sciences, Department of Nursing, Bartın, Turkey
Dilek Yildiz
Professor, Bartın University, Gülhane Faculty of Nursing, Department of Nursing, Ankara, Turkey
Correspondence: Aylin Kurt, Lecturer, Bartın University, Faculty of Health Sciences, Department of
Nursing, Bartın, Turkey E meil: [email protected]

Abstract
Introduction and Aim: Orem's Self-Care Deficit Nursing Theory is one of the most frequently used theories in
nursing practice. According to Orem, nurses should reduce the individual's needs to a level that they can meet in
case of lack of self-care, increase the individual's self-care abilities, or undertake the care needs themselves in
cases where self-care inadequacy cannot be eliminated. Patients diagnosed with cerebral palsy and acute
lymphatic leukemia and their relatives need supportive and educational nursing approaches and guidance
according to Orem's Self-Care Deficit Nursing Theory.
Methodology: The eleven-year-old male patient was admitted to the hospital with the complaint of high fever.
Patient diagnosed with congenital laryngomalesia and cerebral palsy. The patient was diagnosed with Acute
Lymphocytic Leukemia 5 years ago as a result of further investigations (bone marrow, biopsy, peripheral smear)
with high fever and skin rashes. In this case report, the nursing care of the child patient was examined according
to the "Self-Care Deficit Nursing Theory". Therapeutic self-care needs were determined by evaluating the
patient's self-care agent and self-care power.
Results: Since the self-care needs of the patient with insufficient self-care power will be met by the nurse and
the mother, the 'Completely Deficit Nursing System' and the 'Supportive and Educational Nursing System' were
applied to support the mother and other family members who provide self-care. Nursing diagnoses for the patient
were impaired in the oral mucous membrane, activity intolerance, disruption in sleep patterns, self-care
deficiency syndrome, disruption in the continuity of family processes, and parental role conflict.
Conclusions: It was concluded that Orem's Self-Care Theory can be a useful and effective model in providing
professional care, providing a comprehensive holistic assessment of the child and his family during the care of
patients with cerebral palsy and acute lymphocytic leukemia.
Keywords: Acute Lymphocytic Leukemia, Cerebral Palsy, Pediatrics, Self-Care, Model

Introduction fatigue, hemorrhage, fever, and severe infection

(Kato and Manabe, 2018; Malard and Mohty,
Acute Lymphocytic Leukemia (ALL) is
2020). In the profession of nursing, using theories
characterized by the uncontrolled proliferation of
and models in the fields of education,
bone marrow blast cells, and it is a disease with a
management, practice, and research is important
malignant course. Immature cells cause bone
for the formation of a conceptual framework and
marrow deficiency by infiltrating the bone
provision of guidance for these fields (Şengün
marrow, and this is seen in the blood in the form
Inan et al., 2013). Theories make sense of
of anemia, thrombocytopenia, leukopenia, or
scientific results, allow the systematization of
leukocytosis. These changes are accompanied by
information, and create benefits in the
clinical symptoms in the patient such as paleness,

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professionalization of nursing. Therefore, it is randomly from among ALL patients who were
important to use theories and models in the staying at the pediatric oncology inpatient clinic.
profession of nursing (Afrasiabifar et al., 2020; Written consent was obtained from the patient’s
Yuk Chiu Yip, 2021). Making use of models and family, and the family was ensured that
theories while providing care for children with identifying information would be kept
diseases that have a difficult and complex care confidential. The child and his family were also
and treatment process such as ALL will increase informed that participation in this study was
the quality of the care given to these patients voluntary, and it would not affect his treatment at
(Sevgili et al., 2019). the clinic.
In the case reported in this study, congenital Case Report
laryngomalacia was present in addition to ALL.
Patient Information: Name: I.B.E. Age: 11
Laryngomalacia is the most frequently
years Sex: Male Complaint: High fever.Medical
encountered cause of neonatal stridor, and it
history: The patient, who had congenital
constitutes 45-75% of congenital laryngeal
laryngomalacia, also had cerebral palsy related to
diseases. This stridor exacerbates especially with
it. Five years before, the patient had been
feeding, crying, lying in the supine position, and
diagnosed with Acute Lymphocytic Leukemia as
agitation. Symptoms emerge right after birth or
a result of further examinations (bone marrow
within the first weeks. Mild and moderate cases
biopsy, peripheral smear) due to high fever and
recover within 12-24 months. However, severe
skin rashes. The patient presented to the hospital
laryngomalacia patients may not recover
with the complaint of high fever, and the routine
spontaneously, and they may require surgical
peripheral smear test of the patient who had been
intervention. The presence of comorbid
in remission for the last 5 years showed blasts,
neurological diseases increases the severity and
and further examinations led to the diagnosis of
duration of the disease (Gergin, 2019).
relapsed ALL. A femoral vein catheter was fitted
Self-Care Deficit Theory in Nursing to the patient.
“Self-care deficit theory” started to be developed Basic Conditioning Factors
by Dorothea Elizabeth Orem in 1956 as the first
Age: 11 years, 2 months, 1-day Sex: Male.
theory of self-care and was shaped between 1971
Health status: Acute lymphocytic leukemia,
and 2001 (Orem, 2001). It consists of three main
cerebral palsy, and congenital laryngomalacia
components: a wholly compensatory system, a
present. Developmental status: Height: 150 cm
partly compensatory system, and a supportive-
(75th-90th percentile), Weight: 26 kg (3rd-10th
educative system. The main concepts in the
percentile) Head circumference: 43.5 cm (< 3rd
theory are humans, health, nursing, and
percentile)
environment. Other concepts are self-care,
therapeutic self-care, self-care agency, self-care Socio-cultural characteristics: The patient lives in
deficit, self-care demand, nursing agency, and an apartment with his family. He attends a special
nursing system. Self-care involves continuous education center five days a week. He
physical, cognitive, emotional, interpersonal, and participates in physiotherapy and rehabilitation
social developments and functions that need to be two days a week. He has 1 sister who is the
performed by individuals against situations they second child of the family. He does not like noise
encounter in their normal life. Orem’s Self-Care and warm environments at all. He prefers his
Deficit Theory is one of the most frequently used mother cuddling, hugging, and talking to him,
theories in nursing practice. Researchers in the and these make it easier for him to fall asleep.
field of nursing have conducted experimental Healthcare system: The Social Security
studies and case analyses using this theory
Institution (SGK).
(Yildirim Keskin and Cevik, 2016; Khademian et
al., 2020; Tok Yildiz and Kasikci, 2020; Family type: Extended family (living with
Afrasiabifar et al., 2020; Zhang and Pan, 2021). paternal grandparents, sister, mother, and father).
The purpose of this case report is to examine a Living situation: The patient’s basic needs are
pediatric patient with congenital laryngomalacia met by his mother and his grandmother. The
and cerebral palsy diagnosed with acute social lives of the family and child are limited.
lymphocytic leukemia based on “Orem’s Self- He constantly watches videos on the phone when
Care Deficit Theory”. The patient was selected he is not in special education or physiotherapy.

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Environmental settings: They are constantly in Technical information access and

communication with their relatives. implementation skills: Cannot play computer
games or write, can only look at videos on the
Resource presence-sufficiency: Low economic
screen, and sometimes give loud reactions (low).
status (income lower than expenses). The patient
receives financial and psychological family Perceptual and cognitive status and
support. communication skills: Does not make eye
contact while speaking, verbal communication
Diagnosis and Analysis of the Case According
not possible, indifferent to his environment (low).
to Orem’s Self-Care Deficit Theory:
Self-Care: Self-care involves behaviors learned Skills of managing self-care behaviors to reach
through curiosity, education, and experiences that goals and integrating self-care behaviors into
are started and maintained by individuals individual and social life: The mother performs
themselves to preserve life, health, and comfort most behaviors (dressing, toileting, feeding) in
(Karadag et al., 2017; Pektekin, 2013). his place (low).
According to Orem, a person who is able to
Therapeutic Self-Care Requisites
manage their self-care has self-care agency. The
term agency refers to the capacity of the person I-Universal self-care requisites:
who performs the act. A person who meets the Eating: Has a neutropenic diet during his
care needs of individuals who do not have self-
hospital stay.
care agency is called a dependent care agent
(Yuk Chiu Yip, 2021). Agent of care: As the Oral health: Deformation in the teeth. His oral
child whose case is presented in this report was care is provided with soft oral care swabs due to
not able to perform his self-care activities his thrombocytopenia.
independently or sustain his life healthily, his Activity: He is moved in the room in a
agent of care was his mother. Dependent care wheelchair with the help of his mother due to his
agent: Mostly the mother, sometimes the neutropenia and fall risk.
grandmother.
Sleeping: Sleeps 5 hours at night in total.
Self-Care Agency: It is the status of initiating or Constantly wakes up crying.
implementing health behaviors to maintain life,
health, and well-being (Orem, 2001). According Cognitive perception: His cognitive perception
to Orem, self-care agency is acquired from the is weak. Does not verbally respond to questions.
person’s environment, and the person’s Receives special education.
environment affects their self-care (Kumar, II-Developmental self-care requisites: The
2007). Because the self-care agency and eleven-year-old pediatric patient is in early
perceptual, cognitive, and sensory capacity of the adolescence. This is a period where the person is
patient who had cerebral palsy were very weak, sensitive to physical changes and has a higher
he could not be assessed using the “Self-Care desire for independence. He has been
Agency Scale”. For the same reasons, the hospitalized in the neonatal intensive care unit for
following parameters that could reveal his self- a long duration due to congenital laryngomalacia,
care agency could not be objectively assessed, and due to the cerebral palsy developing in
and the assessment was made solely based on the relation to this condition, he has muscle
observations made of the patient. weakness and deformities in the hands and feet.
Self-confidence and self-respect: Inadequate, He has no communication with peers.
does not make eye contact while speaking, verbal III-Self-care requisites regarding deviation
communication not possible. from health: Orem defined health deviation self-
Energy control and initiation skills: Unwilling. care as a “requirement in conditions of illness,
injury, or disease” (Karadağ, 2017). The patient,
Intellectual capacity: Does not make eye who has congenital laryngomalacia, also has
contact while speaking, verbal communication cerebral palsy related to it. Five years before, the
not possible, indifferent to his environment (low). patient had been diagnosed with Acute
Motivation: Only the mother motivates him. Lymphocytic Leukemia as a result of further
examinations (bone marrow biopsy, peripheral
Self-care decision-making: The mother makes smear) due to high fever and skin rashes. The
all decisions. peripheral smear test of the patient who had been

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in remission for the last 5 years showed blasts, • Urinary problems

and further examinations led to the diagnosis of • Sleep disorder
relapsed ALL. The patient has a femoral vein • Social isolation
catheter. • Risk of tissue integrity
Cerebral palsy (does not attend physiotherapy The nursing diagnoses of the case based on
during his hospital stay). his needs according to Orem’s Self-Care
Malnutrition (mucositis present). Deficit Theory are presented in Figure 1.
Dental problems (cavities and fractures present). Nursing Agency: According to the Nanda
Mental retardation (has a history of congenital Nursing Diagnosis Guide, present and
laryngomalacia). potential nursing diagnoses for the case and
his mother were determined.
Sleep disorder (developing secondary to his
disease). • Deterioration of the oral mucosa due
Social isolation (no peer communication due to to inadequate oral nutrition and oral hygiene
lack of appropriate communication capacity). • Activity intolerance caused by
physical movement and posture disorders
Self-Care Deficit: Self-care deficit in the self-
originating from neuromuscular influence as
care agent: The patient with cerebral palsy cannot
meet his self-care needs due to problems a result of brain damage
secondary to his disease. His agent of care is his • Changes in family dynamics related
mother. Dependent care agency: The to having a child with a chronic disease
communication between the mother, who is both • Sleep pattern disorder caused by
the self-care agent and dependent care agent, and problems secondary to the disease
the child is much better than that between the • Inadequacy in the performance of
child and other family members. The mother basic self-care skills caused by
notices the child’s needs and problems and neuromuscular disorder
implements approaches accordingly. Self-care
deficit in the dependent care agent: Although the
• Bleeding risk related to
mother notices the needs and problems of her thrombocytopenia
child and has better communication with him • Risk of injury due to spasticity and
than other family members do, as she also has to uncontrollable muscle movements
take care of her other child, she cannot allocate • Inefficacy of parental role
enough time for the patient. In this case, it was performance due to changes in the daily
seen that the pediatric patient with congenital routine of the mother.
laryngomalacia and cerebral palsy who was
diagnosed with acute lymphocytic leukemia was Nursing Diagnosis 1: Deterioration of the
highly insufficient to meet his self-care needs oral mucosa due to inadequate oral nutrition
according to Orem’s Self-Care Deficit Theory. and oral hygiene
For this reason, nursing interventions to achieve
the patient’s self-care in the scope of the “Wholly • Expected Outcomes: The wounds in
Compensatory” role of the nurse were planned. the mouth of the patient will heal.
Additionally, the mother of the patient, who was • Recommended NIC Interventions:
meeting the self-care needs of the patient, was Improvement of oral health, education.
assessed in the scope of the “Supportive- • Nursing Interventions: Oral mucosa
Educative” role of the nurse, and counseling was was assessed based on the mucositis
planned. classification of WHO every shift change.
Nursing System Oral care was provided 3 times a day with
Problems Identified by the Nurse:
sodium bicarbonate, Tanflex mouthwash, and
Mikostatin. The mother was explained that
• Eating disorder his neutropenia could increase his
• Oral motor problems susceptibility to infections and that oral care
• Dental problems (cavities, fractures)
• Drooling problem

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is important, and she was given applied • Expected Outcomes: The child’s
education on oral care. movement will be facilitated to an extent that
• Evaluation regarding Expected he can tolerate.
Outcomes: Lesions in the mouth showed • Recommended NIC Interventions:
recovery, but oral mucositis continued. • Nursing Interventions: In-bed
Nursing Diagnosis 2: Activity intolerance exercises were applied with an expert
caused by physical movement and posture physiotherapist. Daily self-care needs
disorders originating from neuromuscular including eating, oral care, body hygiene,
influence as a result of brain damage dressing, and undressing were met with the
support of the mother.

Universal Self-Care Requisites Air, water, food, voiding, activity,

resting, social interaction, protection
from danger, state of normalcy (Orem,
2001).

Nurse

Wholly compensatory system

Supportive-educative
Partly compensatory system
system

-Deteriorated oral mucosa -Disruption in the continuation of

-Activity intolerance family dynamics

-Sleep pattern disorder -Parental role conflict

-Self-care deficit
-Risk of bleeding
-Risk of trauma

Figure 1. Concept Map According to Orem’s Self-Care Deficit Theory

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• Evaluation regarding Expected Nursing Diagnosis 5: Inadequacy in the

Outcomes: The child’s performance of in- performance of basic self-care skills caused
bed exercises was facilitated. by neuromuscular disorder
• Recorded: Education, exercise. • Expected Outcomes: The child will
Nursing Diagnosis 3: Changes in family cooperate with the care process and display
dynamics related to having a child with a calm behaviors.
chronic disease • Recommended NIC Interventions:
Intervention to increase self-care.
• Expected Outcomes: Task sharing in
• Nursing Interventions: Activities of
the family will be facilitated, support systems
daily living (eating, body hygiene, bedsheet
will be determined, the family members will
change) were held with the mother. The
be ensured to share opinions and make
patient’s privacy was ensured.
mutual decisions, they will be encouraged to
express their feelings about the current • Evaluation regarding Expected
situation, and they will become able to cope Outcomes: The child displayed calmer
with the child’s disease effectively. behaviors in the care process.
• Recommended NIC Interventions: • Recorded: Interventions.
Improvement of the coping mechanism. Nursing Diagnosis 6: Bleeding risk related
• Nursing Interventions: The family to thrombocytopenia
was guided towards support groups. They
• Expected Outcomes: Precautions
expressed their feelings about the disease.
will be taken against the potential of
• Evaluation regarding Expected bleeding.
Outcomes: It was ensured that the mother
• Recommended NIC Interventions:
joined support groups. The duties and
Prevention of bleeding.
responsibilities of the family were
• Nursing Interventions: The vital
determined.
signs of the patient (body temperature, heart
• Recorded: Observations,
rate, respiratory rate, blood pressure) were
interventions.
monitored. Laboratory findings indicative of
Nursing Diagnosis 4: Sleep pattern disorder bleeding risk (hemoglobin, platelets,
caused by problems secondary to the disease prothrombin time, INR, aPTT values) were
• Expected Outcomes: Sleep quality followed. Safety precautions were taken to
avoid trauma that could lead to injury
and duration will be increased.
(removal of bed rails, sharp, penetrating
• Recommended NIC Interventions:
objects that could induce trauma). Oral care
Increased sleep quality and duration.
was provided with soft oral care swabs
• Nursing Interventions: Factors instead of a toothbrush.
reducing the sleep quality of the patient
• Evaluation regarding Expected
(hourly medication at night, treatment
Outcomes: The patient did not have
interventions, frequent aspiration procedures
vomiting or active bleeding in his urine,
due to intensive secretion, blood drawing)
stool, phlegm, gums, or femoral vein
were identified.
catheter. Vital signs, Blood pressure: 100/65
• Evaluation of Expected Outcomes:
mm Hg, respiratory rate: 28/min, Heart rate:
Factors reducing the sleep quality of the
108/min, Temperature: 36.8 °C. Laboratory
patient were identified. Practices to facilitate
findings, aPTT: 31.4 sec, INR: 1.1. PT: 13.4
his sleep (calming music, ensuring the
sec, Hb: 10.2 g/dl, PLT: 10,000/mm3.
darkness of the setting, and minimum noise)
• Recorded: Interventions.
were applied.
• Recorded: Observations, Nursing Diagnosis 7: Risk of injury due to
interventions. spasticity and uncontrollable muscle
movements

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• Expected Outcomes: Risk factors of the patient’s self-care agency were determined,
trauma will be determined, and precautions and his therapeutic self-care needs were
to mitigate the risks will be taken. identified. As the self-care needs of the patient,
who had inadequate self-care agency, would be
• Recommended NIC Interventions:
covered entirely by the nurse and the mother, the
Education, risk identification. ‘wholly compensatory system’ was implemented.
• Nursing Interventions: Soft toys that Moreover, to support the mother and other family
would not harm the child were preferred. Bed members who were meeting the self-care needs
rails were removed to prevent falling. The of the patient, the ‘supportive-educative system’
bed was lowered to make it easier for getting was implemented. The nursing diagnoses that
in and off the bed. The family was informed were examined for the patient included
that they should alert the nurse in the case of deterioration of the oral mucosa, activity
their child having a seizure and not leave the intolerance, sleep pattern disorder, inadequacy in
child unattended. the performance of self-care, changes in family
dynamics, and parental role conflicts.
• Evaluation regarding Expected
Outcomes: Bed rails were removed. The patient was diagnosed with deterioration of
• Recorded: Interventions. the oral mucosa due to inadequate oral nutrition
and oral hygiene. Oral mucositis develops
Nursing Diagnosis 8: Inefficacy of parental frequently in ALL patients due to chemotherapy,
role performance due to changes in the daily inability to have oral nutrition, and inadequate
routine of the mother hygiene. Because of oral mucositis, patients have
problems in eating, and their immune systems
• Expected Outcomes: Support will be may deteriorate even further. As it can
provided for the mother’s adjustment, and significantly delay the course of chemotherapy
support groups will be determined. and increase the hospital’s supportive care costs,
• Recommended NIC Interventions: oral mucositis should be prevented or
Supporting role and performance, developing appropriately managed (Garrocho-Rangel et al.,
a support system. 2018). In the case in this study, the oral mucosa
• Nursing Interventions: The mother of the patient was evaluated based on the
mucositis classification of WHO. Oral care was
was encouraged to express her feelings about
provided 3 times a day with sodium bicarbonate,
the child’s condition. She was guided Tanflex mouthwash, and Mikostatin, and the
towards talking to other mothers at the clinic mother was given education about the importance
who were experiencing the same problems. and implementation of oral care. As a result of
• Evaluation regarding Expected the nursing interventions, the lesions of the
Outcomes: The mother stated that she patient showed recovery, but oral mucositis
experienced stress regarding tools and continued.
treatment with which she was not familiar The patient had inadequacy in the performance
(infusion machine, drugs, emergency of basic self-care skills caused by neuromuscular
equipment) and was afraid of harming her disorder. The self-care skill levels of pediatric
child. Care routines were determined to ALL and cerebral palsy patients may be low
ensure the ability of the mother to provide because of inadequate motor functions and harsh
care within the hospital’s arrangements. treatment conditions. The families of these
• Recorded: Interventions. children may also experience difficulties in
meeting the self-care needs of their children
Discussion while coping with the treatment process. In
This case report presents a nursing care example children in this population, the child and the
involving multiple nursing diagnoses and family should be considered together in the
problem areas that was based on “Orem’s Self- assessment and management of self-care skills
Care Deficit Theory” and provided a holistic and and needs (Andrews et al., 2020). In this case, the
systematic approach regarding a pediatric patient self-care agency of the patient and his perceptual,
with congenital laryngomalacia and cerebral cognitive, and sensory capacity were very weak.
palsy who was diagnosed with acute lymphocytic As the patient was completely unable to perform
leukemia. The agent of care for the patient and his self-care behaviors, all his care needs were

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being met by nurses and his mother. The concluded that Orem’s Self-Care Deficit Theory
activities of the patient requiring self-care such as can be beneficial and effective in providing
eating, body hygiene, and bedsheet change were professional healthcare for the child diagnosed
carried out with the mother, and the necessary with acute lymphocytic leukemia in the patient
education was provided. care process as it allows the evaluation of both
the child and the family. The degree of the
Another nursing diagnosis in the case in this
preparedness of children in this population and
study was activity intolerance. Because
their families for meeting self-care needs after
leukemic cells infiltrate the bone marrow, and the
discharge from the hospital should be
disease has extramedullary manifestations,
investigated. It is needed to determine the self-
activity intolerance is among the most prevalent
care needs and self-care capacities of children
symptoms in ALL patients. Activity intolerance
diagnosed with cerebral palsy and acute
makes it more difficult for the patient to perform
lymphocytic leukemia and support parents
their self-care behaviors (Erbey, Kömür, Bayram,
regarding the self-care of their child.
& Tanyeli, 2018; Ghanbari & Pouy, 2018). Due
to neuromuscular involvement, the patient in this References
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