Pediatric Nursing Grand Rounds

Amanda Frederick

S.W • 3 ½ year old African American female

• (DOB: 04/14/2010)

• 17.9kg (90th percentile) and 110cm (>97th percentile)

• Full Code, No Known Allergies, No isolation

• Victim of a Non-accidental trauma which resulted in having a traumatic brain injury and CVA leaving her with multiple deficits

• 7B: Rehab • To Optimize functional mobility and ability

Objectives ✔

• Discuss the circumstances that led to her hospitalization and reasons for rehab

• Discuss developmental considerations and abilities that pertain to S.W

• Review exceptional physical assessment data

• Discuss nursing diagnoses and plan of care for S.W

• Identify teaching and discharge planning needs

Client History &

Assessment

Family/Psychosocial History & Culture

• S.W did not have a pertinent birth history and before this hospitalization she had no significant past health history

• Father 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 live

• Due 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.

What led to Hospitalization &

Rehab?• 9/16/2013: found unresponsive

in her home and taken to Chesapeake General where she then was transferred to CHKD’s PICU

• They discovered:• Cerebral edema & occipital

skull fracture• Dissected Left vertebral

artery CVA• Healing right forearm fracture

• After forensics investigated it was determined these injuries were definitely from physical and intentional abuse

• Bolt was inserted to monitor ICP

• 9/17/2013: Head CT done, showed worsening cerebral edema and IICP

• External Ventricular Drain (EVD) placed subsequently

• 10/01/2013: Extubated

• 10/05/2013: EVD removed with improved neurologic exam findings

• 10/08/2013: Stable Rehab

Vertebral Artery

EVD

Reasons for Admission to Rehab

Non - 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 ADL’s.

Expected Developmental

Stage• According to Erickson’s 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 things• Have a vocabulary of about 900 words and talk

incessantly• Play parallel and associative• Be able to copy circles and name what has been

drawn on a piece of paper• Ride a tricycle and stand on one foot for a few

seconds

Considerations

• However 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 Data

• Neurologic• Ptosis in Left eye• Left sided facial drooping• Asymmetric facial movements• + Drooling• Dysphagia• Aphasia• Mimics staff, answers yes or no

questions only, follows simple commands

• GI/GU• Nasogastric tube in Right nare • Diapered

• Psychosocial• No family at bedside

• Skin• Scar on right side of scalp

• Musculoskeletal• Severe Right sided weakness in

both extremities• Impaired gait• AFO (ankle-foot orthoses) on LLE

• Cardiovascular• WNL: pulses palpable and equal

bilaterally, skin warm and dry to touch, no IV’s or lines

• Respiratory• WNL – no supplemental O2, no s/s

of increased WOB. Breath sounds clear bilaterally.

• Fall Risk• High

• Pain• 0 - FLACC

Identification of Nursing

Problems/ Plan of Care

1. Impaired Swallowing

Supporting Data• TBI & CVA• Excessive

drooling• Spitting out food• Constant

reminders to chew then swallow

• Less PO intake• Facial drooping

on left side

Interventions• Pt 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

2. Impaired Physical Mobility & Risk for

Injury Supporting Data

• TBI & CVA• Severe right-sided

weakness (Hemiplegia)

• No use of right arm with activities (healing fracture)

• Drags right leg when in walker

Interventions• Assess 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 (AFO’s) 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 everyday

• Use wheelchair to sit in during the day with straps buckled and Posey bed (restraint) for napping and bedtime to protect from injuryExpected Outcome: Pt will walk 10ft in her walker with minimal

assistance and reach for objects with right hand 3x/shift by discharge

Medications:Diazepam & Lorazepam

3. Impaired Verbal Communication

Supporting Data• TBI & CVA• Mimics staff• Answers only yes

or no questions• Slurred words

and screaming• Hard to

understand

Interventions• Acknowledge patients

frustration with impaired communication and have patience

• Provide clear, simple instructions

• Use prompting cues when talking to patient

• Provide opportunities for spontaneous communication

• Demonstrate 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 Data

• TBI & CVA• Needs maximum

assistance with eating, bathing, dressing, and toileting

• Incontinent (uses diapers)

• Right-sided Hemiplegia

• Gets tired easily

Interventions• Direct 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 Volume

• Supporting Data• Not taking in enough

fluids. Daily maintenance fluids should be ~1400cc. Only taking in between ~ 800 - 1000cc each day

• Urinary Output Low: 0.66ml/kg/hr

• Nutrition is not adequate• Swallowing and chewing

difficulties

• Interventions• Monitor intake and Give NGT feedings

if not meeting recommended requirements of ~1400cc.

• Monitor and document vital signs once daily

• Check weight every Wednesday and Sunday

• Assess skin turgor and mucous membranes for signs of dehydration with head to toe assessment every 8 hours

• Assess color and amount of urine output every 12 hours

• Encourage 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. Anxiety

• Supporting Data• Frustration from

trying to walk evident

• Frustration trying to talk evident

• Huffs and looks away

• Developmental set backs

• Interventions• Acknowledge the awareness

of the pts anxiety• Maintain a calm manner

while interacting with the pt• Orient the pt to the

environment and new experiences or people as needed.

• Use simple language• Reduce 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 week

Medications:Diazepam & Lorazepam

Holistic Care

• General Nursing Interventions• Vital Sign Checks and I&O monitoring• Head to Toe Assessments• Administer Medications as ordered• Interact and develop therapeutic relationship• Allow for Independence

• Collaborative 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 Problems

1. Impaired Swallowing

4. Self-Care Deficit: Bathing, Dressing, Feeding, Toileting

3. Impaired Verbal Communication

2. Impaired Physical Mobility & Risk for Injury

5. Deficient Fluid Volume

6. Anxiety

Teaching and Discharge Planning

Needs• Teaching and Discharge needs would be directed at patient and

family

• Continuous 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 movement

• She needs relearning of ADL’s (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 KEY

Research• Experimental Design Study

• Aimed 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 injuries

• Intervention group & Control group

• Both got pre- and post- test

• Intervention Group: 30 min a day, 5 days a week, 1 month• Modification of the manner of feeding• Positioning and Posture change for Safe Swallowing• Oral Motor Exercises• Interventions to control drooling

• Control group• Routine hospital Care: meds, follow up, feeding either

parenterally or enterally

• Results 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.

Summary

• We’ve Discussed:• S.W and why she is in Rehab• Developmental Considerations• Exceptional Physical Assessment Data• Priority Nursing Diagnoses,

Interventions, and Expected Outcomes• Teaching & Discharge Planning Needs

QUESTIONS

References

Abusaad, 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). Wong’s 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/