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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 • Introduction • • • • M.G. is a 4 year old male Admission weight is 14.50 kg 103 cm tall History • • • Steven-Johnson Syndrome, Toxic Epidermal Necrolysis and Asthma • 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 • • Requires several medical appointments and follow up care Medications need to be refilled and available • Housing problem • • 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 • Failure to Thrive • Secondary Diagnosis • Oral Aversions and Asthma CLIENT HISTORY AND ASSESSMENT • Reasons for hospitalization • Pathophysiology of Failure to Thrive • • • 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 • Treatment Plan • • • • 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 • • • 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 • Developmental Stage • • According to Erikson, M.G. should be in the Initiative vs. Guilt stage • Being successful in this stage will set M.G. up for having a feeling of purpose in later developmental stages • • • 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 • Right pupil was not able to be seen because of swelling; Left pupil is equal, round and reactive to light • • 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 • • • • • • 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 • Cardiovascular/Neurovascular • • • • • • • • 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 • • • • • 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: • • 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 • 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 • • • • • • 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 • • • 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 • • • • • • 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 • • • • 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 • Interventions • • • • 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 • Outcome • 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 • • • • 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 • • • • 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 • Take natural risks, cognitive abilities, medical conditions, treatments and medications • Environmental human factors • Noise, temperature, lightening, furniture and harder floors • Biochemical factors • Height, age, sex, BMI RESEARCH • Extrinsic Components • Caregiver and Parent human factors • Stress, working out of habit, having a heavy workload, poor judgment or decision making • System Factors • Staff level of the unit, skill level of staff, shift, activity on unit RESEARCH • 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) • Correlation: • 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