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Download File - Robyn Lutzkanin Nursing Portfolio ODU
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Pediatric Nursing Grand Rounds Robyn Lutzkanin Focus Client history Client assessment Identification of Nursing problems Plan of care Applicable Research Client R.S. Male Age: 6 years old High functioning Autism ATV accident with a crushing injury Compartment lower leg Syndrome in right Client History and Assessment Past Pertinent Health History R.S. has a history of and is currently diagnosed with: High Functioning Autism Oppositional Defiant Disorder (ODD) Attention Deficit Hyperactivity Disorder (ADHD) Sleep Disorder with mild sleep apnea Cultural Considerations The culture of a little boy: Forming a therapeutic relationship Admitting Diagnosis R.S. had an ATV accident Trapped under ATV Crushing Injury Compartment Syndrome of Right lower leg Pathophysiology Acute compartment syndrome is a medical emergency usually caused by a severe injury Compartment syndrome develops when swelling or bleeding occurs within a compartment (the muscle fascia) Swelling will cause damage to tissues Signs and symptoms Treatment plan Immediate surgery: Fasciotomy Leave wound open until swelling decreases Negative pressure wound therapy & skin graft Secondary Diagnosis Autism ODD ADHD These could have led to the initial injury and also impacts healing Not following instructions Resistance to dressing changes Development For six year olds such as R.S. expected development includes: Social and Cognition Speech and Language Fine Motor / Adaptive Gross Motor Development R.S. is diagnosed with Global Developmental Delay Not reaching two or more developmental milestones in each developmental domain. Speech and Language Social and Cognition Physical Assessment Cardiovascular: +2 Edema in rt. foot Musculoskeletal: altered gait r/t fasciotomy Integument: 5” x 2” surgical incision on right lower leg, bruising on right knee and right ankle Psychosocial: High Functioning Autism Extreme pain in right lower leg Nursing Problems and Plan of Care Concept Map: Acute Pain Assessment: Related to crush injury R.S. crying and screaming when right leg is handled R.S. unwilling to move right leg Multiple surgeries on right leg Acute Pain Nursing Interventions: R.S. is non-verbal Pain assessment Pain management: IV morphine Video games Toys Acute Pain Expected outcomes: Short-term: R.S. no longer crying by fifteen minutes Long-term: R.S. no longer shows signs of pain by the end of shift Outcomes: Met! Concept Map: Risk for Fall Assessment: medications Related to injury and pain Young age Injury of lower right leg (pain) Morphine administered IV New environment Risk for Fall Nursing Interventions: Keep bed in low position Assign sitter to room when his parents weren’t present (R.S. likes to get out of bed!) Keep wanted items within reach Encourage R.S. to ask for help to move Do not rush R.S. to move or walk faster than he is able / willing to do Risk for Fall Expected outcome: R.S. will not experience any falls during his hospitalization Outcome: Met! Concept Map: Risk for Infection Assessment: Related to large surgical incision and IV access Multiple surgeries Hospitals are inherently germy Risk for Infection Nursing Interventions: Assess for fever, elevated HR/RR, chills, lethargy, and increased WBC count Hand hygiene!! Encourage R.S. to drink fluids Avoid unnecessary manipulation of open wound and IV sites Cefazolin (Preventative antibiotic) Risk for Infection Expected outcome: R.S. will not develop an infection as a result of his fasciotomy Outcome: Met! Concept Map: Impaired Verbal Communication Assessment: Related to autism and global developmental delay R.S. will not speak to health care workers R.S. is unable to use any pain rating scales R.S. is unable to verbalize that something is wrong in a way other than screaming and crying Impaired Verbal Communication Nursing Interventions: Anticipate R.S.’s needs through non-verbal cues such as squirming, frowning, fetal positioning Be patient with R.S. Give ample time for and be concrete with directions that R.S. is capable of doing Form a therapeutic relationship with R.S. and his parents Clonidine for ADHD Impaired Verbal Communication Expected Outcome: Short-term: R.S. will be able to point to where he is experiencing pain by the end of shift on Wednesday Long-term: R.S. will be willing to vocalize if and where he is having pain in more than one word by the end of shift on Thursday Outcome: Met! Concept Map: Impaired Physical Mobility Assessment: Related to crush injury of right lower leg Reluctance to attempt movement Limited range of motion of ankle Pain from injury and surgery Fear of pain from movement Impaired Physical Mobility Nursing Interventions: Assess what R.S. was able to do prior to injury from parents Assess what R.S. is willing to do currently Assess elimination status: give Miralax Encourage and facilitate movement Positive reinforcement! Work with physical therapy (Collaborative) Impaired Physical Mobility Expected Outcomes: Short-term: R.S. will partially put weight on his right leg to pivot into sitting chair by end of shift Thursday Long-term: R.S. will be able to move with crutches independently by one week after last surgery Outcome: Partially met Connecting the Dots Acute Pain Impaired Physical Mobility Risk for Fall Impaired Verbal Communication Risk for Infection Discharge Teaching & Planning Pain management Wound management, healing and nutrition Exercises and movement Research Therapeutic play intervention on children's perioperative anxiety, negative emotional manifestation and postoperative pain: a randomized controlled trial. Objective: To see if therapeutic play intervention could reduce preoperative anxiety, postoperative pain, and negative emotional manifestation in general Research Design: Randomized controlled trial Methods: 47 children received routine care (control group) 48 children received 1-hour therapeutic play along with routine care (experimental group) The state of anxiety, pain, and emotional manifestations were measured 24 hours before and 24 hours after surgery Research Results: Children in the experimental group had significantly lower scores of negative emotion prior to surgery and less postoperative pain Conclusion: Therapeutic play is effective in reducing negative emotions and postoperative pain. Research and R.S. R.S. was able to have therapeutic play pre and postoperatively Collaborative care with Child Life at CHKD provided R.S. with many distractions from the clinical reality of his injury A difference in negative emotions was seen with and without play therapy in R.S. Conclusion and Questions Nursing care of R.S. Crushing Injury & Compartment Syndrome Developmental Delays Nursing Diagnosis Effectiveness of Therapeutic Play References He H.-G., Zhu L., Chan W.-C.S., Liam J.L.W., Li H.C.W., Ko S.S., Klainin-Yobas P. & Wang W. (2015) Therapeutic play intervention on children's perioperative anxiety, negative emotional manifestation and postoperative pain: a randomized controlled trial. Journal of Advanced Nursing 71(5), 1032–1043. doi: 10.1111/jan.12608 References Wong, D. (2011). Virtual clinical excursions-pediatrics: For Wong's Nursing care of infants and children, 9th ed. (9th ed.). Maryland Heights, Mo.: Elsevier/Mosby.
