PEDIATRIC NURSING GRAND ROUNDS
Natalie Eyer 10/8/13
The Patient
KL 15 months old African American female Cystic Fibrosis, no enzyme deficiency Pneumonia
Client History: Past
Term SVD “Abnormal” newborn screening Diagnosed with Cystic Fibrosis at 13
months old (2 months ago) with positive sweat test
Client History: Hospitalization
PCP appointment: Parent report cough, more wet than
normal Parent report occasional vomiting Rhinorrhea No fever CXR: left lower lobe pneumonia
Client History: Pathophysiology
Chronic, autoimmune, genetic disorder , CTFR gene Characterized by a increased viscosity of mucous secretions,
elevation of sweat electrolytes, an increase in enzymes of the saliva, an abnormalities of the nervous system
Primary factor responsible for complications with the disease is the viscous mucous secretions
Secretions cause impaired gas exchange as a result of bronchial obstruction
Thick mucus will also make the victim more susceptible to infection
Overtime the destruction of lung tissue leads to fibrotic changes, making the lung much less compliant
(Hockenberyy & Wilson, 2011)
Pneumonia
Treatment plan
IV antibiotics: Timentin q6, Nebcin qday Recombinant human Dnase: Pulmozyme
at bedtime Bronchodilator: albuterol qid Chest PT qid Pulse ox q2h Vitals q4h High fat, protein, calorie
Client Assessment: Culture/Psychosocial/Family
Heavy family involvement Always at least three members (usually
more) in the room at all times Great grandmother, grandmother, parents,
aunt, older sister Family worked with the healthcare team
during treatments to calm patient/provide valuable information about patient
Financial issues? 4 other children, time off work
Client Assessment: Developmental Stage
Erikson’s developmental theory “autonomy vs. shame and doubt”
Toddler “gains independence with the family’s encouragement and learns to cooperate with others” (Craven & Hirnle, 2009, p. 248)
Learns self control and independence by learning tasks such as potting training, choosing food preferences, choosing toy preferences
Nurse must understand this stage of development to encourage the independence of the child so that they can master this stage and prevent “shame and doubt.”
Client Assessment: Developmental Norms
Tolerates some separation from parent Asks for objects by pointing Shakes head for “no” Uses cup well Walks without help Constantly casts objects to floor
(Hockenberry & Wilson, 2011)
Client Assessment: Physical
Neuro: alert and oriented Resp: clear sounds bilaterally, occasional wet cough,
RR= 26, regular rhythm, unlabored. O2 sat= 99% RA CV: HR= 87, regular rhythm, no murmurs/extra heart
sounds noted, 2 second cap refill, palpable pulses +2 bilaterally. PICC L upper arm- dry &intact
GI: Bowel sounds X4, reducible umbilical hernia Gu: Diapered Skin: warm, no breakdown noted, moist mucous
membranes Musc/skel: moves extremities X4, anterior fontanelle
open, soft Pain: 0
Identification of Nursing Problems: Concept Map
1. Risk for impaired gas exchange CF Pneumonia Wet cough Worsening cough/WOB 1 week prior to
admission Rhinorrhea
AlbuterolDornaseTimentinTobramycin
Identification of Nursing Problems: Concept Map
2. Imbalanced nutrition Higher metabolic demands from CF,
pneumonia Stress from new environment Unavailability of child’s preferred soy milk Apple juice frequently Knowledge deficit of parents Weight between 5th and 10th percentile
DuoCal
Identification of Nursing Problems: Concept Map
3. Risk for fluid imbalance On 9/7 an intake of 480ml On 9/8 an intake of 660ml CF; higher metabolic demands Pneumonia; higher metabolic
demands Frequent apple juice: causes faster
loss of stool/urine
Identification of Nursing Problems: Concept Map
4. Risk for infection PICC line Hospital setting Multiple specialists coming in and
out of the room Multiple family members coming in
and out of the room
Identification of Nursing Problems: Concept Map
5. Anxiety (of parents) Child’s recent diagnoses of CF Child’s hospitalization Child’s recent diagnoses of
pneumonia
Plan of Care: Interventions/Expected Outcomes
1. Expected Outcome: Patient will maintain O2 sats greater than or equal to 92% consistently prior to discharge.
Assess O2 sat q2 hrs and prn Focused respiratory assessment q4 hrs and
before/after albuterol & CPT treatments: auscultate breath sounds, monitor for retractions and flaring. Obtain RR. Monitor effort of breathing.
Teach parents about normal/abnormal respiratory findings, what to report immediately
Plan of Care: Interventions/Expected Outcomes
2. Expected Outcome: Patient will maintain or gain weight throughout hospitalization.
Assess parent’s knowledge of nutrition
Provide diet teaching to parents: a diet that is high in calories, fat & protein. Use of DuoCal in soymilk for added calories and nutrients.
Monitor daily weights
Plan of Care: Interventions/Expected Outcomes
3. Expected Outcome: Patient will exhibit appropriate fluid balance consistently before discharge as evidenced by: capillary refill ≤2 sec, good skin turgor, clear-yellow colored urine, moist mucous membranes and blood pressure 67-106/37-63.
Monitor I&O continually Encourage parents to promote healthy fluid intake Keep drink within reach of the child at all times Assess hydration q4h: color of urine, skin turgor,
blood pressure, intake and output, assess mucous membranes, anterior fontanel, LOC, capillary refill.
Plan of Care: Interventions/Expected Outcomes
4. Expected Outcome: Patient will remain free from secondary infections during entire hospitalization as evidenced by a healthy PICC line site; free from drainage, redness, pain, and swelling.
Assess PICC line site q4 hrs and prn Monitor the child for signs of infection:
restlessness, irritability, change in vital signs, increased work of breathing, fatigue, weight loss
Monitor all vital signs q4h and prn
Plan of Care: Interventions/Expected Outcomes
5. Expected Outcome: Patient’s parents will demonstrate a decrease in anxiety as evidenced by: reporting decreased anxiety, being active with care of patient, and by acknowledging option of support group.
Assess parent’s level of anxiety Provide teaching about patient’s disease
process, status, and changes of status as much as possible
Involve parents in care of the child, such as help with bathing, holding child while administering medications, etc
Refer parents to CF support groups
Plan of Care: Discharge Planning
Parent education: Nutrition teaching Monitoring weight Chest PT Signs and symptoms to report Routine immunizations Medication teaching
Research
“The impact of behavioral intervention on family interactions at mealtime in pediatric cystic fibrosis”
Aim: evaluate whether participation in “Be In Charge!”, a behavioral intervention designed to improve caloric intake and weight gain in children with CF, also results in improved family functioning during mealtimes
Methods: 45 families of CF children 4-12 Intervention group: “Be In Charge”: nutrition education
and child behavioral management strategies Control group: “Nutrition Education”: nutrition
education without behavioral management strategies
Research
Data collection: Mealtime Family Interaction Coding System (MICS), Behavioral Pediatrics Feeding Assessment Scale (BPFAS), child’s weight. Mealtimes videotaped
Results: Behavioral intervention: more positive responders (moving from unhealthy at baseline to healthy), significant improvement in affect management, positive impact on caloric intake
Implications: importance of incorporating entire family when implementing dietary interventions, importance of incorporating praise/withdrawal of attention during meal times(Janicke, Mitchell, Quittner, Piazza-Waggoner, & Stark, 2008)
References
Craven, R., & Hirnle, C. (2009). Fundamentals of nursing. (6th ed.). Philadelphia, PA: Wolters Kluwer Health.
Hocekenberry, J. M., & Wilson, W. (2011). Wong’s Nursing Care of Infants and Children. (9th ed.). St. Louis, MO: Elsevier.
Janicke, M. D., Mitchell, M. J, Quittner, A. L., Piazza-Waggoner, C., & Stark, L. J. (2008). The impact of behavioral intervention on family interactions at mealtime in pediatric cystic fibrosis. Children’s Healthcare, 37(1) 49-66.
Questions?
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