Embed Size (px)
Pediatric Nursing Grand Rounds. Amanda Frederick. S.W . 3 ½ year old African American female (DOB: 04/14/2010) 17.9kg (90 th percentile) and 110cm (>97 th percentile) Full Code, No Known Allergies, No isolation - PowerPoint PPT Presentation
Pediatric Nursing Grand RoundsAmanda Frederick1 S.W 3 year old African American female (DOB: 04/14/2010)17.9kg (90th percentile) and 110cm (>97th percentile)Full Code, No Known Allergies, No isolationVictim of a Non-accidental trauma which resulted in having a traumatic brain injury and CVA leaving her with multiple deficits7B: Rehab To Optimize functional mobility and ability2Objectives Discuss the circumstances that led to her hospitalization and reasons for rehabDiscuss developmental considerations and abilities that pertain to S.WReview exceptional physical assessment dataDiscuss nursing diagnoses and plan of care for S.WIdentify teaching and discharge planning needs
Client History & Assessment4Family/Psychosocial History & CultureS.W did not have a pertinent birth history and before this hospitalization she had no significant past health historyFather was her abuser and he is now incarcerated. Being the victim of abuse is a culture, and if she happens to remember what happened to her it could severely affect her for the rest of her life.Before this incident, S.W was going back and forth between her parents to live because they were split up. Custody was granted to mom, who is in the process of looking for a stable home for her and S.W to liveDue the extent of the injuries that S.W sustained, the physical deficits that resulted, and the developmental set back she experienced, she can now be considered a special needs child, which is also a culture in itself. This is a different way of living for her and its going to take time for her and her family to cope and handle what happened.
5What led to Hospitalization & Rehab?9/16/2013: found unresponsive in her home and taken to Chesapeake General where she then was transferred to CHKDs PICUThey discovered:Cerebral edema & occipital skull fractureDissected Left vertebral artery CVAHealing right forearm fractureAfter forensics investigated it was determined these injuries were definitely from physical and intentional abuseBolt was inserted to monitor ICP
9/17/2013: Head CT done, showed worsening cerebral edema and IICPExternal Ventricular Drain (EVD) placed subsequently10/01/2013: Extubated10/05/2013: EVD removed with improved neurologic exam findings10/08/2013: Stable Rehab
Reasons for Admission to RehabNon - Accidental Trauma (abuse) Traumatic Brain Injury (TBI) & Dissected Left Vertebral Artery Cerebrovascular Accident (CVA) Right sided hemiplegia (paralysis on one side), Aphasia (difficulty expressing/understanding speech), and Dysphagia (difficulty swallowing)A CVA, also known as a stroke, is caused by the interruption of the blood supply to the brain, usually from being blocked by a clot or, in this case, because a blood vessel bursts. When this happens the oxygen and nutrient supply gets cut off, resulting in damage to the brain tissue. Depending on which part of the brain if affected will determine what signs and symptoms are presented (WHO, 2013).So her overall treatment plan is to optimize her functional ability with the assistance from Occupational Therapy and Physical Therapy, who will help with feeding, mobility, speech and other ADLs.
8Expected Developmental StageAccording to Ericksons Psychosocial Stages of Development S.W should be in the Preschool age (3 to 5 years): initiative vs. guilt Should begin asserting control and power over the environment with success in this stage leading to a sense of purpose. Should be exploring situations and thingsHave a vocabulary of about 900 words and talk incessantlyPlay parallel and associativeBe able to copy circles and name what has been drawn on a piece of paperRide a tricycle and stand on one foot for a few seconds9ConsiderationsHowever due to the injuries that S.W sustained, she does not meet the norms and has actually regressed back into the early childhood stages (2 to 3 years). This is where they are toilet training and experiencing the basic conflict of shame and doubt. So she is trying to redevelop a sense of personal control and autonomy.Application to Care:Allowed independence as much as possible and only assisted her when she really needed it because She needs to continue to progress forward so we can optimize as much function as possible. We had to help her getting dressed, bathing, and eating. She had to use diapers for being incontinent and a wheelchair to sit in during the day because of the weakness she experienced. Short and simple language was used to allow for easier understanding.
Exceptional Physical Assessment DataNeurologicPtosis in Left eyeLeft sided facial droopingAsymmetric facial movements+ DroolingDysphagiaAphasiaMimics staff, answers yes or no questions only, follows simple commandsGI/GUNasogastric tube in Right nare DiaperedPsychosocialNo family at bedsideSkinScar on right side of scalp
MusculoskeletalSevere Right sided weakness in both extremitiesImpaired gaitAFO (ankle-foot orthoses) on LLECardiovascularWNL: pulses palpable and equal bilaterally, skin warm and dry to touch, no IVs or linesRespiratoryWNL no supplemental O2, no s/s of increased WOB. Breath sounds clear bilaterally.Fall RiskHighPain0 - FLACC
11Identification of Nursing Problems/ Plan of Care1. Impaired SwallowingSupporting DataTBI & CVAExcessive droolingSpitting out foodConstant reminders to chew then swallowLess PO intakeFacial drooping on left side
InterventionsPt will eat 3 times a day with OT to observe for choking or coughing.Make sure pt is adequately rested before mealtime.Removal and reduction of environmental stimuli during feedings.Sit pt in wheelchair during feedings. Frequent reminders to hold mouth close, chew, and swallow will be enforced during feedings.Feedings will be done slowly, alternating between solids and liquids.
Expected Outcome: Pt will exhibit ability to swallow w/o aspiration, coughing, or choking during eating/drinking. No stasis of food in oral cavity after eating, and ability to ingest foods/fluids before discharge 132. Impaired Physical Mobility & Risk for InjurySupporting DataTBI & CVASevere right-sided weakness (Hemiplegia)No use of right arm with activities (healing fracture)Drags right leg when in walker
InterventionsAssess ability to move and change position, to transfer and walk, for fine muscle movement, and for gross muscle movement at least once a shift (PT).Monitor skin integrity for breakdown at least once a shift.Keep splinting devices (AFOs) on feet/ankles to help with clonus/prevent foot drop and perform passive stretching activities daily to help with muscle tone.Frequent activities to increase movement in right arm will be done everydayUse wheelchair to sit in during the day with straps buckled and Posey bed (restraint) for napping and bedtime to protect from injury
Expected Outcome: Pt will walk 10ft in her walker with minimal assistance and reach for objects with right hand 3x/shift by discharge Medications:Diazepam & Lorazepam143. Impaired Verbal CommunicationSupporting DataTBI & CVAMimics staff Answers only yes or no questionsSlurred words and screamingHard to understand
InterventionsAcknowledge patients frustration with impaired communication and have patienceProvide clear, simple instructionsUse prompting cues when talking to patientProvide opportunities for spontaneous communicationDemonstrate to the pt any progress made
Expected Outcome: Pt will label 2 objects and 3 body parts on self before discharge. Pts verbal abilities will continue to increase throughout the stay in the hospital 4. Self-Care Deficit (bathing, dressing, feeding, toileting)Supporting DataTBI & CVANeeds maximum assistance with eating, bathing, dressing, and toileting Incontinent (uses diapers)Right-sided HemiplegiaGets tired easilyInterventionsDirect pt to do as much independently as possible Provide assistance with eating (putting food on the spoon, spacing time between bites, and reminding to chew), walking (gait trainer), communicating (using short, simple language), dressing, and hygiene (brushing teeth and bathing).Provide frequent rest periods and Allow pt adequate time to perform ADLs
Expected Outcome: Pt will increase independence with ADLs each day. She will don on and off socks to BLE using BUE with minimal assistant by discharge 5. Deficient Fluid VolumeSupporting DataNot taking in enough fluids. Daily maintenance fluids should be ~1400cc. Only taking in between ~ 800 - 1000cc each dayUrinary Output Low: 0.66ml/kg/hrNutrition is not adequateSwallowing and chewing difficulties
InterventionsMonitor intake and Give NGT feedings if not meeting recommended requirements of ~1400cc.Monitor and document vital signs once dailyCheck weight every Wednesday and SundayAssess skin turgor and mucous membranes for signs of dehydration with head to toe assessment every 8 hoursAssess color and amount of urine output every 12 hoursEncourage pt to drink during feedings.
Expected Outcome: Pt will consume at least 1400mL every day to meet daily maintenance requirements with at least 600mL from liquid PO 6. AnxietySupporting DataFrustration from trying to walk evidentFrustration trying to talk evidentHuffs and looks awayDevelopmental set backs
InterventionsAcknowledge the awareness of the pts anxietyMaintain a calm manner while interacting with the ptOrient the pt to the environment and new experiences or people as needed.Use simple languageReduce sensory stimuli when needed. Expected Outcome: Pt will have decreased screaming episodes and crying, and will not throw or spit out food by the following weekMedications:Diazepam & LorazepamHolistic CareGeneral Nursing InterventionsVital Sign Checks and I&O monitoringHead to Toe AssessmentsAdminister Medications as orderedInteract and develop therapeutic relationshipAllow for IndependenceCollaborative Interventions included:Occupational Therapy: assisted with feeding, encouraged talking and movement in chair (dancing)Physical Therapy: assisted with physical mobility. Gait trainer, tricycle, sitting on side of bench with assistance while playing with toys Complimentary Interventions:Pet Therapy
Interrelatedness Between Problems1. Impaired Swallowing4. Self-Care Deficit: Bathing, Dressing, Feeding, Toileting3. Impaired Verbal Communication2. Impaired Physical Mobility & Risk for Injury5. Deficient Fluid Volume6. Anxiety20Teaching and Discharge Planning NeedsTeaching and Discharge needs would be directed at patient and familyContinuous reinforcement when eating about remembering to chew and swallow may be needed.Reinforcement to stand up when trying to walk and encouraging her to use her left arm (the good arm) to raise her right arm (bad arm) to get movementShe needs relearning of ADLs (toileting, dressing self). Incorporate Independence much as possible.Encourage talking and communicate frequently.Family needs to assist her with stretches of legs and feet. Ex: dorsiflexing the ankle with knee bent and knee unbent and holding it for 30 seconds.Nurses need to educate the family that Patience is going to be KEYResearchExperimental Design StudyAimed to Investigate the effect of NURSING interventions on eliminating feeding problems, which were induced by an oral-motor deficit, among children with traumatic head injuries.60 children (2-11yo) w/ head injuriesIntervention group & Control groupBoth got pre- and post- testIntervention Group: 30 min a day, 5 days a week, 1 monthModification of the manner of feedingPositioning and Posture change for Safe SwallowingOral Motor ExercisesInterventions to control droolingControl groupRoutine hospital Care: meds, follow up, feeding either parenterally or enterallyResults showed a significant improvement in feeding domains amongst the intervention group including better ability to spoon feed, more chewing and better at drinking out of cups, and less drooling.Only some of these interventions were done with S.W and only when she was eating with occupational therapy, like scheduled meal time and pacing feedings. If NURSES were to actually incorporate all of these interventions in their care and be consistent with it across the health care team, S.W could possibly make progress faster and her overall turn out could potentially be better.SummaryWeve Discussed:S.W and why she is in RehabDevelopmental ConsiderationsExceptional Physical Assessment DataPriority Nursing Diagnoses, Interventions, and Expected OutcomesTeaching & Discharge Planning Needs
ReferencesAbusaad, F. E. S., & Kassem, M. A. (2012). The Effect of Nursing Intervention on Eliminating Feeding Problems induced by Deficit Oral-Motor function among Children with Severe Head Injury. Life Science Journal, 9(3), 475-383.Gulanick, M., & Myers, D. (2011). Nursing care plans: Nursing diagnosis, interventions and outcomes, (7th ed.). St. Louis: Mosby.Hockenberry, M., & Wilson, D. (2011). Wongs Nursing Care of Infants and Children (9th ed). St Louis, MO: ELSEVIER.World Health Organization. (2013). Stroke, cerebrovascular accident. Retrieved from http://www.who.int/topics/cerebrovascular_accident/en/