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Corinne Mayer Nursing 421

Corinne Mayer Nursing 421. Pediatric Grand Rounds Presentation Old Dominion University. “Tiny Tim”. 2 Months Old TOF with severe right outflow tract obstruction status post BT shunt. Patient Health History. “Tiny Tim” 2 Month old Trisomy 21 Gastroesophageal reflux Chronic lung disease

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Corinne Mayer Nursing 421

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  1. Corinne MayerNursing 421 Pediatric Grand Rounds Presentation Old Dominion University

  2. “Tiny Tim” • 2 Months Old • TOF with severe right outflow tract obstruction status post BT shunt

  3. Patient Health History “Tiny Tim” 2 Month old • Trisomy 21 • Gastroesophageal reflux • Chronic lung disease • Anemia of prematurity • Congenital hypothyroidism • Immature retinae • 33 week gestation infant • Hospitalized since birth

  4. Psychosocial History and Cultural Considerations • Adopted • One other Trisomy 21 child with TOF • 4 other children • Culture • Culture of being adopted • Culture of NICU and PICU • Culture of Trisomy 21

  5. Trisomy 21“Down Syndrome” • Most common chromosomal abnormality of a generalized syndrome, occurs in 1 out of 733 live births. • Extra chromosome 21 • Cause unknown • Genetic predisposition • Exposure to radiation before conception • Immunologic problems • Infection • Age=women over the age of 35 are at greater risk

  6. Clinical Manifestations • Intelligence—varies from severe CI to low-average intelligence • Social development • 2-3 years beyond mental age • “Easy Child” temperament • Sensory problems—ocular problems and hearing loss • Growth--delayed • Congenital abnormalities—40-45% have congenital heart disease. • TOF

  7. Tetrology of Fallot • Four heart defects of the heart • Ventricular septal defect • Narrowing of the pulmonary outflow tract • Overriding aorta shifted over the right ventricle and ventricular septal defect instead of just the left ventricle • Right ventricular hypertrophy

  8. Symptoms TOF • Cyanosis • Clubbing of fingers • Difficulty feeding • Failure to gain weight • Poor development • “Tet spells” • Rapid, deep breathing. • Fainting/loss of consciousness. • Cyanosis of the lips, tongue and nailbeds • Irritability or uncontrolled crying.

  9. Surgery • Usually 2 surgeries: • Blalock-Taussig Shunt • December 28th • Complete TOF repair

  10. Hospitalization at CHKD • Reason for admission: • Possible shunt stenting due to • Multiple oxygen saturations in the 60’s% • Serial echocardiograms at NMCP were concerning • Plan of care: • Surgery to correct narrowing shunt • Possible complete repair of TOF • Maintenance care until surgery

  11. Developmental Stage • Personal and social • Begins to recognize caregivers • Smiles spontaneously • Speech and Language • Cries to express displeasure • Make comforting sounds during feeding • Fine Motor • Hands predominantly closed • Clenches hands around rattle • Gross Motor • Can turn head from side to side when prone • Assumes flexed position with pelvis high but knees under abdomen when prone

  12. Developmental Stage • Developmentally delayed • Does not: • Recognize or smile at caregivers • Hold head up unassisted • Swallowing reflex delayed • Make “cooing” sounds or comfort sounds when feeding • Does not follow objects with eyes • G rasp toys or rattles

  13. Developmental Theory • Erik Erikson’s Theory of Psychosocial Development • Trust vs Mistrust • Can I trust caregivers? • Care • Comfort when crying or agitated • Change diapers promptly • Holding • Talking

  14. Physical Assessment • Respiratory: • Maintaining expected oxygen saturation between 75-85 • 2L High Flow Nasal Canula • Cardiovascular • TOF: at risk for “Tet spells” • Systolic murmur • Endocrine • Hypothyroidism • GI • Failed swallow screen so patient is on NJ tube with continuous feeding

  15. Physical Assessment • Neuro • Fontanel soft and slightly distended • Patient failed swallow screen, so NJ tube is in place • Musculoskeletal • moves all extremities well, brings hand to mouth • Pain • No s/s of pain or agitation • Psychosocial • Parents not at bedside • Vital signs: • Temp- 36.0, HR- 135, RR- 30, BP- 96/42, O2- 77%

  16. 1. CardiovascularV --TOF --Ventricular septal defect --Decreased perfusion --Decreased cardiac output --Narrowing BT shunt --Decreased perfusion --Systolic heart murmur --Previous cardiac surgery --Pulmonary stenosis --HGB-22 g/dL --Increased RBC’s --Aspirin 20.2 mg PO daily Patient Initials: T.L.. Age:2 months Medical diagnosisDiagnoses: • Trisomy 21 • TOF • Pre-op BT shunt repair 2. Respiratory2. Resp --Decreased oxygen saturation --Pulmonary stenosis --History of “Tet Spells” --O2 Sats—75-85% --High flow NC 2L --HOB up --Flovent 110 mcg, 2 puffs, daily 4. Neuro --Trisomy 21 --Developmental delay --Swallowing difficulty --Continuous NJ tube feeding running 27 callorie/mL at 20 mL/hr 3. GI --Failed swallow screen --NJ tube --Risk for impaired nutrition—less than body requirements due to increased metabolic demands --27 cal/mL formula-20 mL/hour via continuous feeding --Nexium 3 mg PO BID Psychosocialosocial --Adopted --Family not at bedside --Impaired parenting --Impaired bonding --Hospitalized since birth

  17. Expected Outcomes • Cardiovascular • Patient will remain free of tet spells by the end of shift. • Respiratory • Patient respiration rate will remain between 30-60 breaths per minute and oxygen saturation will remain between 75-85% • GI • Patient will receive and tolerate 100% of continuous feedings throughout the shift

  18. Expected Outcomes • Neuro • Patient will remain free from choking spells by end of the shift. • Patient will pass a swallow screen by discharge • Psycosocial • Patient’s parents will assist staff with patient care and comfort pre and post operatively

  19. Patient CareTraditional Interventions • Monitor intake and output • Monitor vital signs every hour per PICU protocol • Monitor respiratory status • Monitor and administer continuous NJ feeding • Perform physical assessment and report any changes • Provide hygiene including diaper changes • Monitor weight • Provide a safe environment • Elevate HOB 30 degrees to encourage gas exchange and cardiac output • Assess skin for breakdown • Administer medications

  20. Complementary Collaborative Communicating changes with healthcare team during rounds. Collaborating care among social work if needed. Assist in coordinating any at home care if needed. • Provide comfort measures such as swaddling and pacifier • Provide a quiet environment • Provide distraction by turning on mobile or playing music • Massage patient during times of anxiety • Provide support to family

  21. Teaching Discharge Planning Support groups Continuity of care Home health care? Where to find or assist in coordingating developmental programs in the area such as Parent to Parent of Virginia • Developmental delays of Trisomy 21 • Post-operative care • Importance of bonding in the hospital • Characteristics of decreased cardiac output • Characteristics of pain

  22. High Flow Nasal Cannula • What is it? • Ordinary nasal cannula that delivers a higher flow of 100% oxygen. • Delivers positive airway pressure • Thermally controlled • Delivers > 95% relative humidity • Benefit • Less restricting than oxygen mask • Better patient tolerance • Minimizes the risk of needing invasive ventilation • Decreases airway inflammation • Hydrates thickened secretions

  23. Research • “Skin Integrity in Critically Ill and Injured Children” • Determine the incidence of skin breakdown in critically ill and injured children 401 stays in the PICU at the Children’s Hospital of Wisconsin • Skin breakdown in 8.5% • Redness in 6.2% • Breakdown and redness in 3.2% • Overall incidence—18% • Younger age and longer stay in the PICU was associated with increased risk. • Also more likely to more at risk to have respiratory illness and require mechanical ventilatory support

  24. Questions??

  25. References • Hockenberry, M. J., & Wilson, D. (2011). Nursing care of infants and children. (9th ed.). St. Louis, Missouri: Elsevier Mosby. • Davis, D., & Clifton, A. (1995). Psychosocial theory: Erikson. Retrieved from http://www.haverford.edu/psych/ddavis/p109g/erikson.stages.html • Leaderstorf, M., Pastore, J., Wagner, S., & Kramer, B. (2010, December 10). High flow nasal cannula; history of usage at wchob. Retrieved from http://www.wchob.org/grandrounds/pdfs/grand_Rounds_121010.pdf • Nasal Cannula. (n.d.). High flow nasal cannula. Retrieved from http://nasalcannula.net/high-flow-nasal-cannula/ • Parent to Parent of Virginia. (n.d.). Resources. Retrieved from http://www.ptpofva.com/4-resources.html • Schindler, C. A., Mikhailov, T. A., Fischer, K., Lukasiewicz, G., Kuhn, E. M., & Duncan, L. (2007). Skin integrity in critically ill and injured children.AmericanJournal of Critical Care, 16(6), 568-574. • Texas Children's Hospital. (2011). Pediatric heart surgery; congenital heart defects: tetralogy of fallot. Retrieved from http://www.texaschildrens.org/carecenters/heart/surgery/tetralogy of fallot.aspx

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