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Pediatric Nursing Rounds

Presented By: Bobbi BowmanOld Dominion University – Nursing Program

Born – 09/08/94 Normal delivery / birth history Vaccinations – up to date No prior surgeries / hospitalizations Minor lacerations NKDA

Pertinent Past Medical History

Education Future career Family Cultural consideration

Psychosocial History

Admitting Diagnoses

Primary Intraparenchymal hemorrhages & diffuse

axonal injury (Traumatic Brain Injury)

Secondary s/p post PEG placement for oropharyngeal

dysphagia Global aphasia History of seizures Cognitive deficits

Traumatic brain injury (TBI) is defined by the Brain Injury Association of America as a traumatic insult to the brain capable of producing physical, intellectual, emotional, social, and vocational Changes” (McCance, K. & Huether, S. ,2010,p.583)

Pathophysiology

Treatment Plan

Expected

Current

Communication

Expected Developmental Stage

Neuro Skin Cardiovascular Respiratory GI GU Musculosketal

Physical Assessment

CLINICAL CONCEPT MAP

Pt Initials: BW Age: 18 y/o female Medical Diagnoses: (Include secondary diagnoses)

TBI (intraparenchymal hemorrhages / diffuse axonal injury) Oropharyngeal dysphagia, global aphasia, hx of seizures, and cognitive deficits

1. Impaired Physical Mobility Colace Miralax PT OT

2. Self-care Deficit PT OT Speech therapy

3. Altered Thought Process Ativan

4. Family Process Altered Ativan Speech therapy

5. Risk for Altered Nutrition Colace Diflucan Zantac Miralax PEG tube Swallow study

Impaired Physical Mobility - pt will maintain efforts in achieving optimal independence through therapy (PT/OT) during each session while admitted to rehab unit as evidence by increased gait stability

Self-care Deficit- pt will perform ADLs @ optimal level of functioning during the entire 12 hour shift as evidence by increased independence.

Altered Thought Process - pt will be oriented to person, place, and time with each interaction with staff during 12 hour shift as evidence by appropriate responses when asked.

Family Process Altered - pt will verbalize a reduction / relief of anxiety and stress during clinical experience as evidence by verbal confirmation when asked

Risk for Altered Nutrition - pt will consume adequate calories to maintain health status during each 24 hour period as evidence by I&O flow sheet in chart displaying acceptable calculations

Diagnosis – Expected Outcome

Actual verse potential

Nursing Diagnosis

Traditional

Complimentary

Alternative

Collaborative

Holistic Nursing Care

Teaching/ Discharge Planning

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Prep time

Research Review

Garcia, J., Chambers, E., Clark, M., Helverson, J., & Matta, Z. (2010). Quality of care issues for dysphagia: modifications involving oral fluids. Journal of Clinical Nursing, 19(11-12), 1618-1624. doi:10.1111/j.1365-2702.2009.03009.x

Intervention

References Garcia, J., Chambers, E., Clark, M., Helverson, J., &

Matta, Z. (2010). Quality of care issues for dysphagia: modifications involving oral fluids. Journal of Clinical Nursing, 19(11-12), 1618-1624. doi:10.1111/j.1365-2702.2009.03009.x

McCance, K. & Huether, S. (2010). Pathophysiology: The biologic basis for disease in adults and children. (5th ed.). Philadelphia: Mosby.

Hockenberry, M. & Wilson, D., (2010). Nursing care of infants and children, (9th ed.) . St.Louis, MO. Elsevier.

All images were obtained through the Google Image search engine.