Download Pediatric Grand Rounds - Shelby Lowery Portfolio

PEDIATRIC GRAND
ROUNDS
SHELBY LOWERY
OBJECTIVES
• Introduction of the patient
• Address the patient’s past medical history
• Explore the reasons for the current hospitalization
• Discuss the patient’s developmental stage
• Review the current physical assessment of the patient
• Present and discuss the nursing diagnoses and the holistic care provided
OBJECTIVES
• Discuss the relationship between the nursing diagnoses
• Identify teaching and discharge planning needs of the patient and their
parent(s)
• Review and correlate a nursing research article to the patient and the care
provided
CLIENT HISTORY AND ASSESSMENT
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Introduction
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M.G. is a 4 year old male
Admission weight is 14.50 kg
103 cm tall
History
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Steven-Johnson Syndrome, Toxic Epidermal Necrolysis and Asthma
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Mother has stated that she did not want to keep him
Had a gastric feeding tube removed in September
Complete loss of vision in his right eye and a partial loss of vision in the left eye as a result of
the Steven Johnson Syndrome
CLIENT HISTORY AND ASSESSMENT
• Cultural Considerations
• Chronically ill/Special needs child
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Requires several medical appointments and follow up care
Medications need to be refilled and available
• Housing problem
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Is the mother going to have the funds to provide medications and food?
Will the electricity be on to perform chest physiotherapy (CPT)?
CLIENT HISTORY AND ASSESSMENT
• Reasons for hospitalization
• Mother brought M.G. to the Emergency Department reporting that he was not eating or
acting like himself
• Since his last hospital admission to remove the gastric feeding tube, in September, he lost
about 2 Kg
• Primary Diagnoses
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Failure to Thrive
• Secondary Diagnosis
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Oral Aversions and Asthma
CLIENT HISTORY AND ASSESSMENT
• Reasons for hospitalization
• Pathophysiology of Failure to Thrive
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Absence of endocrine, gastrointestinal or other chronic illnesses that could cause FTT
Most commonly associated with a lack of parental nurturing and economical stressors
For M.G.’s mother stressors could include having an unwanted child, stress of being a single
parent and possibly her own illnesses (McCance, Huether, Brashers & Rote, 2010)
CLIENT HISTORY AND ASSESSMENT
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Treatment Plan
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Administer medications
Encourage him to eat in order for him to gain weight
Collaborate with Child Life, Social Work and Child Protective Services
Relationship between diagnoses
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The oral aversions cause pain when eating (especially acidic foods)
The pain from eating then does not allow for M.G. to eat complete meals in order to gain
weight
Asthma is an ongoing issue
CLIENT HISTORY AND ASSESSMENT
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Developmental Stage
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According to Erikson, M.G. should be in the Initiative vs. Guilt stage
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Being successful in this stage will set M.G. up for having a feeling of purpose in later
developmental stages
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Exploration is a major factor at this stage
M.G. should begin making decisions on their own and have some control over their
environment
Provided options for food and drinks which allowed him to make decisions
M.G. arranged the toys in his room the way he wanted
CLIENT HISTORY AND ASSESSMENT
• Physical Assessment Data
• Neuo
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Right pupil was not able to be seen because of swelling; Left pupil is equal, round and
reactive to light
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Alert to environment and situation appropriately for age
Able to move all extremities with good muscle tone as well as gross and fine motor skills
CLIENT HISTORY AND ASSESSMENT
• Respiratory
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Upper airway draining nasal secretions
Wheezing breath sounds in the upper airways
Slight increase in work of breathing because of the nasal secretions and wheezing
Symmetrical chest expansion
Trachea midline
Respiratory Rate within normal range for age
CLIENT HISTORY AND ASSESSMENT
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Cardiovascular/Neurovascular
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Body temperature within normal limits
Capillary refill less than 2 seconds
Absence of edema
All pulses are palpable
Skin turgor is normal
Absence of abnormal heart sounds
Hear rate occasionally increased
Blood pressure within normal limits
CLIENT HISTORY AND ASSESSMENT
• Gastrointestinal
• Bowel sounds are active in all four quadrants
• Abdomen is soft, round and non-tender with palpitation
• Genitourinary
• Able to urinate without pain or difficulty
• Genitalia has a normal appearance
CLIENT HISTORY AND ASSESSMENT
• Musculoskeletal
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Normal gain when ambulating
Able to move independently
Symmetry of the extremities, hands and feet
Vertebral column straight and absent of deformities
Bone deformities not present
CLIENT HISTORY AND ASSESSMENT
• Skin
• Warm and dry to touch
• Scarring/discoloration of skin on right upper chest and lower neck from Steven Johnson
Syndrome
• Absence of bruising or rashes
• Pain
• Rating of 0 based on the FLACC scale during every assessment
• Absence of verbal and physical signs of pain
CLIENT HISTORY AND ASSESSMENT
• Psychosocial
• Mother has stated that she does not want to keep M.G.
• Absence of other family members that are interested in M.G.’s healthcare
• Mother only at hospital for scheduled meeting with Social workers and Child Protective
Services
• Mother has an indifferent attitude during history recollection and when care is provided
CLIENT HISTORY AND ASSESSMENT
• IV Access
• 22 gauge in the right antecubital with no evidence of inflammation, redness or pain at
the insertion site
• Fall Risk
• Moderate to High fall risk because of:
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Age- always moving at a fast pace and not concerned with safety
Vision- M.G. has adapted his loss of vision in his right eye and partial loss in his left eye but it
still poses a risk for injury
CLIENT HISTORY AND ASSESSMENT
• Fluid Balance
• M.G. is not in fluid balance
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Metabolic demands are increased because of Failure to Thrive
• Should receive 1225 ml/day but was only getting half
• All intake was oral; no IV fluids ordered
IDENTIFICATION OF NURSING PROBLEMS/PLAN OF
CARE
• Imbalanced Nutrition: Less than Body Requirements
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Supporting Data
Loss of 2 Kg since previous discharge in September
Mother reported M.G. having anorexia
Weight is less than 10%
Some foods irritate his mouth
Taking Folic Acid as a home and hospital medication
IDENTIFICATION OF NURSING PROBLEMS/PLAN OF
CARE
• Interventions
• An hourly record of intake and output will be
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kept
Weigh child every morning before breakfast
with the same scale wearing only a hospital
gown and compare with the previous results
Maintain and record the caloric intake and
overall amount eaten at each meal and snacks
Provide foods that are non-acidic to avoid
irritating his mouth
• Outcomes
• The pt.. will eat at least 50% at each meal
and during hospitalization will either maintain
or gain weight
IDENTIFICATION OF NURSING PROBLEMS/PLAN OF
CARE
• Risk for Impaired Gas Exchange
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Expiratory Wheezing
Occasional coughing
Hx of asthma
O2 sats 98% with vital sign assessments and 100% after CPT
Albuterol, Adivair, Montelukast, Cyproheptadine
CPT
IDENTIFICATION OF NURSING PROBLEMS/PLAN OF
CARE
• Interventions
• Assess and record respiratory status by checking breath
sounds, RR, HR, and listening for coughing q4h and prn
• Use the pulse oximeter for O2 saturation which should
be 94-100% on room air q4h with vital signs as well as
after CPT or respiratory medication administration
• When lying in bed, the head of bed should be elevated
30-45 degrees
• Administer medications on schedule and assess for relief
from expiratory wheezing, coughing and tachycardia
• Outcomes
• The pt. will have an oxygen saturation from 94-100%
when assessed via the pulse oximeter on room air at
each check and prior to discharge will not show signs of
expiratory wheezing, coughing and tachycardia
IDENTIFICATION OF NURSING PROBLEMS/PLAN OF
CARE
• Disturbed Sensory Perception: Blindness
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Discharge from eyes
Hold objects in front and close to left eye to be able to see
Swelling around both eyes
Visual disturbance initially caused by SJS but can also be irritated by the administration
of eye drops
• Cyclosporine ophthalmic and Prednisolone ophthalmic
IDENTIFICATION OF NURSING PROBLEMS/PLAN OF
CARE
• Interventions
• Assess the drainage (color, amount) from the eyes and
watch for any change
• Assist the child in wiping from inside out to clean the eye
• Administer eye drop medications and assess for
effectiveness by assessing eye drainage and relief of
any irritation (i.e. itching, redness, swelling) prior to
administration of the eye drops
• Encourage all staff to remain on the pt.'s left side so that
he is able to see with less difficulty
• Outcomes
• The pt.'s eyes will remain free of discharge and will
report relief of any irritating symptoms (i.e. drainage,
itching, etc.)
IDENTIFICATION OF NURSING PROBLEMS/PLAN OF
CARE
• Risk for Falls
• Impaired vision in both eyes
• Lack of awareness of environmental hazards
• Unfamiliar setting
IDENTIFICATION OF NURSING PROBLEMS/PLAN OF
CARE
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Interventions
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Adequate lighting will be provided
Non-slip socks will be worn at all times
Be a role model for child by walking and
checking the hallway before stepping
into it
Remain aware of where the child is and
what they are doing
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Outcome
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The pt. will be made aware of the
environment at an age appropriate level
(i.e. where the bathroom is, who the RN
and Clinician 1 are, which bed is his, etc.)
and during hospitalization will remain
free of injuries
IDENTIFICATION OF NURSING PROBLEMS/PLAN OF
CARE
• Impaired Parenting
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Ambivalent feelings about M.G.
Mother expressed that she does not want M.G.
Indifference when interacting with the patient
Failure to plan for future care
IDENTIFICATION OF NURSING PROBLEMS/PLAN OF
CARE
• Interventions
• Assess and record the parent’s interaction with
pt.
• Provide opportunities for the parent to
observe and participate in pt.'s care
• Allow the parent to express feelings
regarding the pt. and their care
• Follow up with social worker to assess needs
of family
• Outcomes
• The mother will show interest in the child’s care
(participating in CPT, and prior to discharge
will be connected with services via the social
worker and child protective services such as
housing and/or grocery assistance programs
IDENTIFICATION OF NURSING PROBLEMS/PLAN OF
CARE
• Holistic Care
• Treating the admitting dx as well as providing emotional support and play time
• Relationship Between Nursing Problems
• Imbalanced Nutrition -> Impaired Parenting
• Risk for Falls -> Disturbed Sensory Perception
IDENTIFICATION OF NURSING PROBLEMS/PLAN OF
CARE
• Teaching and Discharge Planning
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The importance of having all medications filled
How nutrition effects a child’s growth
How to monitor weight
Aid in providing connections to groups that are able to provide assistance with housing
and foods
RESEARCH
• An interdisciplinary momentary confluence of events model to explain, minimize,
and prevent pediatric patient falls and fall-related injuries
• An interdisciplinary team reviewed adverse event reports of 400 pediatric
patients between 2002-2009
• The proposed new fall risk assessment includes both intrinsic and extrinsic
factors
RESEARCH
• Intrinsic Factors
• Child human factors
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Take natural risks, cognitive abilities, medical conditions, treatments and medications
• Environmental human factors
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Noise, temperature, lightening, furniture and harder floors
• Biochemical factors
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Height, age, sex, BMI
RESEARCH
• Extrinsic Components
• Caregiver and Parent human factors
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Stress, working out of habit, having a heavy workload, poor judgment or decision making
• System Factors
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Staff level of the unit, skill level of staff, shift, activity on unit
RESEARCH
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Nursing Implication: Have nurses assess patients using the proposed model or work to
develop a newer model for fall risks and to report all actual and near missed falls
(Ryan-Wenger & Dufeck, 2013)
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Correlation:
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4 year old exploring environment, visual disturbances, eye drops administered, hospital floors,
moving around to stay warm, male, RN very busy, mother was not present to assist monitoring,
pod was separated
RESOURCE
McCance, K. L., Huether, S. E., Brashers, V. L., & Rote, N. S. (2010). Pathophysiology:
The Biological
Basis for Disease in Adults and Children (6th ed., pp. 1528- 1529). Maryland Heights, MO: Mosby
Elsevier.
Ryan-Wenger, N. A., & Dufek, J. S. (2013). An interdisciplinary momentary confluence
to explain, minimize, and prevent pediatric patient falls and
Specialties in Pediatric Nursing, 18, 4-12.
of events model
fall-related injuries. Journal for