Pediatric Nursing RoundsPresented by: Marc Manucal

Old Dominion University – Nursing Program

Trespasser VS TrainsState of Virginia

Casualties2009- 14

2010- 13

2011-15

2012- 11(Federal Railroad

Administration, 2012)

Pertinent Past Medical History 10 year old African American male Born on 30DEC11 Normal delivery/birth history Vaccinations up to date No prior surgeries/hospitalizations Asthma

-exercise induced-uses rescue Albuterol inhaler

NKDA

Psychosocial History Education

-currently in 5th grade-well rounded student

Family-only child-lives one mother in 2 bedroom apartment

Cultural Consideration-low socio-economic status-amputee

Circumstances Leading to Hospitaliation

JH was playing with friends on railroad track near home

He decided to run across tracks prior to oncoming train

JH’s foot gets caught in the tracks

Suffers a BKA of left leg

Admitting DiagnosesPrimary Traumatic below the knee amputation of

left leg

Secondary Debridement and wound vac placement

to left leg PICC line insertion

PathophysiologyAmputations may be elective or traumatic.

Elective amputations are related to peripheralvascular disease and arteriosclerosis. Complications result in ischemia in distal areas ofthe lower extremity. Traumatic amputations aremost often the result of an accident from machinery,motor vehicle accidents, or industrial machinery. Traumatic amputations are also increasing during thewars in Afghanistan and Iraq due to roadside bombs(Ignatavicious & Workman, 2010).

Treatment PlanOCCUPATIONAL THERAPY PHYSICAL THERAPY

Expected Developmental Stage

Erickson’s Industry VS Inferiority

Current Developmental Stage

Industry VS Inferiority-growing sense of

independence-building new skills-develops a sense of

accomplishment-seeks extrinsic sources

of reinforcement that provide encouragement and stimulation

Physical Assessment Neuro Skin Cardiovascular Respiratory GI GU Musculoskeletal

Concept MapPt Initials: JHAge: 10Medical Diagnosis: Left below knee amputationSecondary Diagnosis: Debridement and wound vac placement

1. Acute PainBelow knee amputation9/10 pain without medsPhantom painWound vac draining serosanguinous fluidTENS electrodesHR 115, BP 128/84

OxycodoneGabapentin

2. Impaired physical mobilityRestricted movement of LLEDecreased ROM of LLEPain with movement of extremityWound vac attached to LLEUse of assistive devices (walker, wheelchair)

Use walker, wheelchairRegular OT/PT visitsPerform ADL’s without assistance

3. Risk for infectionDebridement/wound vac placementPICC lineOpen woundImmobility

RBC-3.23, WBC-6.8, Plt-695

4. Ineffective CopingInability to make decisionsLack of goal directed behaviorInadequate problem solvingPoor concentrationNightmares of accidentFatigue

Child LifeSocial workChaplain

5. Disturbed body imageRequest for amputation site to be wrapped with acewrapRefusal to discuss amputationActual change in structure of LLERefusal to look at amputation siteCovers site with blankets or clothing

Child lifeSocial work

Expected OutcomesAcute Pain- patient will have pain controlled as evidenced by

a pain level below 3/10 on pain scale.Impaired physical mobility- patient will maintain efforts in

achieving optimal independence through therapy (OT/PT) during each session as evidenced by increased gait stability.

Risk for infection- use of aseptic technique throughout shift. Patient and family will be able to verbalize signs and symptoms of infection by end of shift.

Ineffective coping- patient will be able to demonstrate coping strategies such as expressing feelings, deep breathing exercises, and guided imagery.

Disturbed body image- patient will verbalize concerns about body image throughout hospitalization.

Holistic Nursing CareTraditional- providing for basic healthcare

needs

Complimentary- OT, PT, Childlife

Alternative- use of dry erase boards at bedside

Collaborative- patient goal orientation with family members

Discharge Teaching

Transcutaneous Electrical Nerve Stimulation (TENS) Unit

TENS Unit

Nursing ResearchLIU, F., WILLIAMS, R., LIU, H., & CHIEN, N. (2010). THE LIVED EXPERIENCE OF PERSONS WITH LOWER

EXTREMITY AMPUTATION. JOURNAL OF CLINICAL NURSING, 19(15-16), 2152-2161.

DOI:10.1111/J.1365-2702.2010.03256.X

Questions?

ReferencesFederal Railroad Administration Office of Safety Analysis. (2012).

Trespasser Casualties (Deaths and Injuries). Retrieved December 4, 2012, from http://safetydata.fra.dot.gov/OfficeofSafety/publicsite/Query/castally4.aspx

Ignatavicious D. D., & Workman, M.L., (2010). Medical-Surgical Nursing: Patient-Centered Collaborative Care (6th ed.). St. Louis, MO: Elsevier.

Liu, F., Williams, R., Liu, H., & Chien, N. (2010). The lived experience of persons with lower extremity amputation. Journal Of Clinical Nursing, 19(15-16), 2152-2161. doi:10.1111/j.1365-2702.2010.03256.x

TensUnit. (2012). How does a TENS work?. Retrieved December 4, 2012, from http://www.tensunits.com/INFO.html#1