Corinne MayerNursing 421

Pediatric Grand Rounds Presentation

Old Dominion University

“Tiny Tim”

2 Months Old

TOF with severe right outflow tract obstruction status post BT shunt

Patient Health History

“Tiny Tim”

2 Month old

Trisomy 21

Gastroesophageal reflux

Chronic lung disease

Anemia of prematurity

Congenital hypothyroidism

Immature retinae

33 week gestation infant

Hospitalized since birth

Psychosocial History and Cultural Considerations

Adopted

One other Trisomy 21 child with TOF

4 other children

CultureCulture of being adopted

Culture of NICU and PICU

Culture of Trisomy 21

Trisomy 21“Down Syndrome”

Most common chromosomal abnormality of a generalized syndrome, occurs in 1 out of 733 live births.

Extra chromosome 21

Cause unknown Genetic predisposition

Exposure to radiation before conception

Immunologic problems

Infection

Age=women over the age of 35 are at greater

risk

Clinical Manifestations

Intelligence—varies from severe CI to low-average intelligence

Social development 2-3 years beyond mental age

“Easy Child” temperament

Sensory problems—ocular problems and hearing loss

Growth--delayed

Congenital abnormalities—40-45% have congenital heart disease. TOF

Tetrology of Fallot

Four heart defects of the heart Ventricular septal defect

Narrowing of the pulmonary outflow tract

Overriding aorta shifted over the right ventricle and ventricular septal defect instead of just the left ventricle

Right ventricular hypertrophy

Symptoms TOF

Cyanosis

Clubbing of fingers

Difficulty feeding

Failure to gain weight

Poor development

“Tet spells”

• Rapid, deep breathing.

• Fainting/loss of consciousness.

Cyanosis of the lips, tongue and

nailbeds

• Irritability or uncontrolled crying.

Surgery

Usually 2 surgeries:

Blalock-Taussig ShuntDecember 28th

Complete TOF repair

Hospitalization at CHKD

Reason for admission: Possible shunt stenting due to

Multiple oxygen saturations in the 60’s%

Serial echocardiograms at NMCP were concerning

Plan of care: Surgery to correct narrowing shunt

Possible complete repair of TOF

Maintenance care until surgery

Developmental Stage

Personal and social Begins to recognize caregivers

Smiles spontaneously

Speech and Language Cries to express displeasure

Make comforting sounds during feeding

Fine Motor Hands predominantly closed

Clenches hands around rattle

Gross Motor Can turn head from side to side when prone

Assumes flexed position with pelvis high but knees under abdomen when prone

Developmental Stage

Developmentally delayed Does not:

Recognize or smile at caregivers

Hold head up unassisted

Swallowing reflex delayed

Make “cooing” sounds or comfort sounds when feeding

Does not follow objects with eyes

G rasp toys or rattles

Developmental Theory

Erik Erikson’s Theory of Psychosocial DevelopmentTrust vs Mistrust

Can I trust caregivers?

CareComfort when crying or agitated

Change diapers promptly

Holding

Talking

Physical Assessment

Respiratory: Maintaining expected oxygen saturation between 75-85

2L High Flow Nasal Canula

Cardiovascular TOF: at risk for “Tet spells”

Systolic murmur

Endocrine Hypothyroidism

GI Failed swallow screen so patient is on NJ tube with

continuous feeding

Physical Assessment

Neuro

Fontanel soft and slightly distended

Patient failed swallow screen, so NJ tube is in place

Musculoskeletal

moves all extremities well, brings hand to mouth

Pain

No s/s of pain or agitation

Psychosocial

Parents not at bedside

Vital signs:

Temp- 36.0, HR- 135, RR- 30, BP- 96/42, O2- 77%

1. CardiovascularV

--TOF

--Ventricular septal defect

--Decreased perfusion

--Decreased cardiac output

--Narrowing BT shunt

--Decreased perfusion

--Systolic heart murmur

--Previous cardiac surgery

--Pulmonary stenosis

--HGB-22 g/dL

--Increased RBC’s

--Aspirin 20.2 mg PO daily

2. Respiratory2. Resp

--Decreased oxygen saturation

--Pulmonary stenosis

--History of “Tet Spells”

--O2 Sats—75-85%

--High flow NC 2L

--HOB up

--Flovent 110 mcg, 2 puffs, daily

Patient Initials: T.L..

Age: 2 months

Medical diagnosisDiagnoses:

• Trisomy 21

• TOF

• Pre-op BT shunt repair

3. GI

--Failed swallow screen

--NJ tube

--Risk for impaired nutrition—less than body requirements due to increased metabolic demands

--27 cal/mL formula-20 mL/hour via continuous feeding

--Nexium 3 mg PO BID

4. Neuro

--Trisomy 21

--Developmental delay

--Swallowing difficulty

--Continuous NJ tube feeding running 27 callorie/mL at 20 mL/hr

Psychosocialosocial

--Adopted

--Family not at bedside

--Impaired parenting

--Impaired bonding

--Hospitalized since birth

Expected Outcomes

Cardiovascular

Patient will remain free of tet spells by the end of shift.

Respiratory

Patient respiration rate will remain between 30-60 breaths per minute and oxygen saturation will remain between 75-85%

GI

Patient will receive and tolerate 100% of continuous feedings throughout the shift

Expected Outcomes

Neuro Patient will remain free from choking spells by end of the

shift.

Patient will pass a swallow screen by discharge

Psycosocial Patient’s parents will assist staff with patient care and

comfort pre and post operatively

Patient CareTraditional Interventions

Monitor intake and output

Monitor vital signs every hour per PICU protocol

Monitor respiratory status

Monitor and administer continuous NJ feeding

Perform physical assessment and report any changes

Provide hygiene including diaper changes

Monitor weight

Provide a safe environment

Elevate HOB 30 degrees to encourage gas exchange and cardiac output

Assess skin for breakdown

Administer medications

Complementary

Provide comfort measures such as swaddling and pacifier

Provide a quiet environment

Provide distraction by turning on mobile or playing music

Massage patient during times of anxiety

Provide support to family

Collaborative

Communicating changes with healthcare team during rounds.

Collaborating care among social work if needed.

Assist in coordinating any at home care if needed.

Teaching

Developmental delays of Trisomy 21

Post-operative care

Importance of bonding in the hospital

Characteristics of decreased cardiac output

Characteristics of pain

Discharge Planning

Support groups

Continuity of care

Home health care?

Where to find or assist in coordingating developmental programs in the area such as Parent to Parent of Virginia

High Flow Nasal Cannula What is it?

Ordinary nasal cannula that delivers a higher flow of 100% oxygen.

Delivers positive airway pressure

Thermally controlled

Delivers > 95% relative humidity

Benefit Less restricting than oxygen mask

Better patient tolerance

Minimizes the risk of needing invasive ventilation

Decreases airway inflammation

Hydrates thickened secretions

Research

“Skin Integrity in Critically Ill and Injured Children” Determine the incidence of skin breakdown in critically ill

and injured children 401 stays in the PICU at the Children’s Hospital of Wisconsin

Skin breakdown in 8.5%

Redness in 6.2%

Breakdown and redness in 3.2%

Overall incidence—18%

Younger age and longer stay in the PICU was associated with increased risk.

Also more likely to more at risk to have respiratory illness and require mechanical ventilatory support

Questions??

References

Hockenberry, M. J., & Wilson, D. (2011). Nursing care of infants and children. (9th ed.). St. Louis, Missouri: Elsevier Mosby.

Davis, D., & Clifton, A. (1995). Psychosocial theory: Erikson. Retrieved from http://www.haverford.edu/psych/ddavis/p109g/erikson.stages.html

Leaderstorf, M., Pastore, J., Wagner, S., & Kramer, B. (2010, December 10). High flow nasal cannula; history of usage at wchob. Retrieved from http://www.wchob.org/grandrounds/pdfs/grand_Rounds_121010.pdf

Nasal Cannula. (n.d.). High flow nasal cannula. Retrieved from http://nasalcannula.net/high-flow-nasal-cannula/

Parent to Parent of Virginia. (n.d.). Resources. Retrieved from http://www.ptpofva.com/4-resources.html

Schindler, C. A., Mikhailov, T. A., Fischer, K., Lukasiewicz, G., Kuhn, E. M., & Duncan, L. (2007). Skin integrity in critically ill and injured children.American Journal of Critical Care, 16(6), 568-574.

Texas Children's Hospital. (2011). Pediatric heart surgery; congenital heart defects: tetralogy of fallot. Retrieved from

http://www.texaschildrens.org/carecenters/heart/surgery/tetralogy of fallot.aspx