Download Pediatric Nursing Grand Rounds

PEDIATRIC NURSING
GRAND ROUNDS
Natalie Eyer 10/8/13
The Patient





KL
15 months old
African American female
Cystic Fibrosis, no enzyme deficiency
Pneumonia
Client History: Past
Term SVD
 “Abnormal” newborn screening
 Diagnosed with Cystic Fibrosis at 13 months
old (2 months ago) with positive sweat test

Client History: Hospitalization
PCP appointment:
 Parent report cough, more wet than normal
 Parent report occasional vomiting
 Rhinorrhea
 No fever
 CXR: left lower lobe pneumonia
Client History: Pathophysiology



Chronic, autoimmune, genetic disorder , CTFR gene
Characterized by a increased viscosity of mucous secretions, elevation of
sweat electrolytes, an increase in enzymes of the saliva, an abnormalities of
the nervous system
Primary factor responsible for complications with the disease is the viscous
mucous secretions

Secretions cause impaired gas exchange as a result of bronchial obstruction

Thick mucus will also make the victim more susceptible to infection

Overtime the destruction of lung tissue leads to fibrotic changes, making the
lung much less compliant
(Hockenberyy & Wilson, 2011)
Pneumonia
Treatment plan







IV antibiotics: Timentin q6, Nebcin qday
Recombinant human Dnase: Pulmozyme at bedtime
Bronchodilator: albuterol qid
Chest PT qid
Pulse ox q2h
Vitals q4h
High fat, protein, calorie
Client Assessment:
Culture/Psychosocial/Family





Heavy family involvement
Always at least three members (usually more) in the
room at all times
Great grandmother, grandmother, parents, aunt,
older sister
Family worked with the healthcare team during
treatments to calm patient/provide valuable
information about patient
Financial issues? 4 other children, time off work
Client Assessment: Developmental
Stage




Erikson’s developmental theory “autonomy vs. shame and
doubt”
Toddler “gains independence with the family’s
encouragement and learns to cooperate with others”
(Craven & Hirnle, 2009, p. 248)
Learns self control and independence by learning tasks such
as potting training, choosing food preferences, choosing toy
preferences
Nurse must understand this stage of development to
encourage the independence of the child so that they can
master this stage and prevent “shame and doubt.”
Client Assessment: Developmental
Norms






Tolerates some separation from parent
Asks for objects by pointing
Shakes head for “no”
Uses cup well
Walks without help
Constantly casts objects to floor
(Hockenberry & Wilson, 2011)
Client Assessment: Physical








Neuro: alert and oriented
Resp: clear sounds bilaterally, occasional wet cough, RR= 26,
regular rhythm, unlabored. O2 sat= 99% RA
CV: HR= 87, regular rhythm, no murmurs/extra heart sounds
noted, 2 second cap refill, palpable pulses +2 bilaterally.
PICC L upper arm- dry &intact
GI: Bowel sounds X4, reducible umbilical hernia
Gu: Diapered
Skin: warm, no breakdown noted, moist mucous membranes
Musc/skel: moves extremities X4, anterior fontanelle open, soft
Pain: 0
Identification of Nursing Problems:
Concept Map
1. Risk for impaired gas exchange
 CF
 Pneumonia
 Wet cough
 Worsening cough/WOB 1 week prior to admission
 Rhinorrhea
Albuterol
Dornase
Timentin
Tobramycin
Identification of Nursing Problems:
Concept Map
2. Imbalanced nutrition
 Higher metabolic demands from CF, pneumonia
 Stress from new environment
 Unavailability of child’s preferred soy milk
 Apple juice frequently
 Knowledge deficit of parents
th
th
 Weight between 5 and 10 percentile
DuoCal
Identification of Nursing Problems:
Concept Map
3. Risk for fluid imbalance
 On 9/7 an intake of 480ml
 On 9/8 an intake of 660ml
 CF; higher metabolic demands
 Pneumonia; higher metabolic demands
 Frequent apple juice: causes faster loss of
stool/urine
Identification of Nursing Problems:
Concept Map
4. Risk for infection
 PICC line
 Hospital setting
 Multiple specialists coming in and out of the
room
 Multiple family members coming in and out of
the room
Identification of Nursing Problems:
Concept Map
5. Anxiety (of parents)
 Child’s recent diagnoses of CF
 Child’s hospitalization
 Child’s recent diagnoses of pneumonia
Plan of Care: Interventions/Expected
Outcomes
1. Expected Outcome: Patient will maintain O2 sats
greater than or equal to 92% consistently prior to
discharge.
 Assess O2 sat q2 hrs and prn
 Focused respiratory assessment q4 hrs and
before/after albuterol & CPT treatments: auscultate
breath sounds, monitor for retractions and flaring.
Obtain RR. Monitor effort of breathing.
 Teach parents about normal/abnormal respiratory
findings, what to report immediately
Plan of Care: Interventions/Expected
Outcomes
2. Expected Outcome: Patient will maintain or
gain weight throughout hospitalization.
 Assess parent’s knowledge of nutrition
 Provide diet teaching to parents: a diet that is
high in calories, fat & protein. Use of DuoCal in
soymilk for added calories and nutrients.
 Monitor daily weights
Plan of Care: Interventions/Expected
Outcomes
3. Expected Outcome: Patient will exhibit appropriate fluid
balance consistently before discharge as evidenced by:
capillary refill ≤2 sec, good skin turgor, clear-yellow
colored urine, moist mucous membranes and blood
pressure 67-106/37-63.
 Monitor I&O continually
 Encourage parents to promote healthy fluid intake
 Keep drink within reach of the child at all times
 Assess hydration q4h: color of urine, skin turgor, blood
pressure, intake and output, assess mucous membranes,
anterior fontanel, LOC, capillary refill.
Plan of Care: Interventions/Expected
Outcomes
4. Expected Outcome: Patient will remain free from
secondary infections during entire hospitalization as
evidenced by a healthy PICC line site; free from
drainage, redness, pain, and swelling.
 Assess PICC line site q4 hrs and prn
 Monitor the child for signs of infection: restlessness,
irritability, change in vital signs, increased work of
breathing, fatigue, weight loss
 Monitor all vital signs q4h and prn
Plan of Care: Interventions/Expected
Outcomes
5. Expected Outcome: Patient’s parents will demonstrate
a decrease in anxiety as evidenced by: reporting
decreased anxiety, being active with care of patient,
and by acknowledging option of support group.
 Assess parent’s level of anxiety
 Provide teaching about patient’s disease process, status,
and changes of status as much as possible
 Involve parents in care of the child, such as help with
bathing, holding child while administering medications,
etc
 Refer parents to CF support groups
Plan of Care: Discharge Planning
Parent education:
 Nutrition teaching
 Monitoring weight
 Chest PT
 Signs and symptoms to report
 Routine immunizations
 Medication teaching
Research
“The impact of behavioral intervention on family interactions at mealtime
in pediatric cystic fibrosis”
 Aim: evaluate whether participation in “Be In Charge!”, a behavioral
intervention designed to improve caloric intake and weight gain in
children with CF, also results in improved family functioning during
mealtimes
 Methods: 45 families of CF children 4-12
 Intervention group: “Be In Charge”: nutrition education and child
behavioral management strategies
 Control group: “Nutrition Education”: nutrition education without
behavioral management strategies
Research



Data collection: Mealtime Family Interaction Coding System
(MICS), Behavioral Pediatrics Feeding Assessment Scale
(BPFAS), child’s weight. Mealtimes videotaped
Results: Behavioral intervention: more positive responders
(moving from unhealthy at baseline to healthy), significant
improvement in affect management, positive impact on caloric
intake
Implications: importance of incorporating entire family when
implementing dietary interventions, importance of
incorporating praise/withdrawal of attention during meal
times
(Janicke, Mitchell, Quittner, Piazza-Waggoner, & Stark, 2008)
References
Craven, R., & Hirnle, C. (2009). Fundamentals of nursing. (6th ed.).
Philadelphia, PA: Wolters Kluwer Health.
Hocekenberry, J. M., & Wilson, W. (2011). Wong’s Nursing Care
of Infants and Children. (9th ed.). St. Louis, MO: Elsevier.
Janicke, M. D., Mitchell, M. J, Quittner, A. L., Piazza-Waggoner,
C., & Stark, L. J. (2008). The impact of behavioral intervention
on family interactions at mealtime in pediatric cystic fibrosis.
Children’s Healthcare, 37(1) 49-66.
Questions?