Pediatric Nursing Grand Rounds

1. Pediatric Nursing Grand Rounds Natalie Eyer 10/8/13

2. The Patient • KL • 15 months old • African American female • Cystic Fibrosis, no enzyme deficiency • Pneumonia

3. Client History: Past • Term SVD • “Abnormal” newborn screening • Diagnosed with Cystic Fibrosis at 13 months old (2 months ago) with positive sweat test

4. Client History: Hospitalization PCP appointment: • Parent report cough, more wet than normal • Parent report occasional vomiting • Rhinorrhea • No fever • CXR: left lower lobe pneumonia

5. 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)

6. Pneumonia

7. Treatment plan • IV antibiotics: Timentin q6, Nebcinqday • Recombinant human Dnase: Pulmozyme at bedtime • Bronchodilator: albuterolqid • Chest PT qid • Pulse ox q2h • Vitals q4h • High fat, protein, calorie

8. 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

9. 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.”

10. 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)

11. 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

12. 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 Albuterol Dornase Timentin Tobramycin

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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.

20. 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

21. 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

22. Plan of Care: Discharge Planning Parent education: • Nutrition teaching • Monitoring weight • Chest PT • Signs and symptoms to report • Routine immunizations • Medication teaching

23. 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

24. 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)

25. References Craven, R., & Hirnle, C. (2009). Fundamentals of nursing. (6th ed.). Philadelphia, PA: WoltersKluwer 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.

26. Questions?