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Pediatric Grand Rounds

Pediatric Grand Rounds. By Jamie Martin. Overview. AA female infant Born on 11/20/12 at 26 weeks gestation Chronological age: 16 weeks/ 4 months Adjusted age: 2 weeks. Overview. Client History and Assessment Identification of Nursing Problems and Plan of Care Clinical Teaching

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Pediatric Grand Rounds

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  1. Pediatric Grand Rounds By Jamie Martin

  2. Overview • AA female infant • Born on 11/20/12 at 26 weeks gestation • Chronological age: 16 weeks/ 4 months • Adjusted age: 2 weeks

  3. Overview • Client History and Assessment • Identification of Nursing Problems and Plan of Care • Clinical Teaching • Research

  4. Maternal History • 37 yo G4P0030 mother • Fibroid uterus • Cystic fibrosis • Elevated WBC count

  5. Client History • Extreme prematurity (26 weeks gestation), 920 g • Retinopathy of prematurity • L and R sided MSSA neck abscesses • Respiratory distress syndrome • Large PDA • Anemia of prematurity • Left pnuemothorax • Hypotension • hyperbilirubinemia

  6. Family/Psychosocial History • Mother—student at TCC at time of birth • Father—working in Richmond • Single parent household? • Both parents currently living in Richmond • Have “strong support network”

  7. Cultural Considerations • Physical separation • Emotional detachment

  8. Primary Medical Diagnosis Feeding Intolerance related to prematurity

  9. Pathophysiology • Feeding Intolerance measured by: • Soft abdomen • Absence of abdominal distention • Minimum/no aspirated gastric residual • Presence of bowel sounds • Minimum to no spitting up or vomiting • Infant’s continued interest in feeding • Consistent behavior pattern

  10. Pathophysiology • Feeding success is measured by the infant’s ability to: • Participate in feeding with energy • Coordinate sucking and swallowing with adequate pauses for breathing • Maintain vital signs and oxygenation WNL • Maintain normal muscle tone in face and body • Complete feeding in about 20 to 25 minutes • Manage a liquid fluid bolus with minimum or no loss of liquid from mouth • Sustain alertness for feeding • Maintain strength and endurance for entire feeding • Measure appropriate for age on standard growth curve

  11. Pathophysiology • Anatomic/physiologic disabilities of the premature infant: • Coordination of suck and swallow at 32-34 wks • Poor muscle tone of the cardiac sphincter • Carbs and fats are less tolerated

  12. Secondary Medical Diagnoses • BPD • Aspiration • GERD • Thrush • Very large umbilical hernia

  13. Treatment Plan • Thickened PO feeds as tolerated • OT • Rehab • Medications • Nystatin • Prilosec • Lasix • O2

  14. Treatment Plan • OT/Rehab support • Pattern • Consistency • Nipple type • Jaw and cheek support • Swaddle • Enteral feedings prn

  15. Expected Developmental Age • Newborn Norms: • Can turn head side to side • head lag • Strong grasp reflex • Clenches hand on contact w/ rattle • Follows light to midline • Quiets when hears a voice • Cries to express displeasure • Watches parents’ faces intently as they talk

  16. Developmental Theory • Trust vs. mistrust • Sensorimotor • Oral

  17. Abnormal Physical Assessment Neuro: Fussy at times Respiratory: BPD, upper airway congestion GI: very large umbilical hernia Feeds: inconsistent, PO/enteral Thrush Altered Vision

  18. Feeding Intolerance • Difficulty Taking PO feeds • Aspiration on VSS • Treatments: • PO feeds: 6 per day if awake, Neosure 24 kcal • PO feeds thickened w/ rice cereal • OT • Rehab • Meds: Nystatin, Prilosec

  19. Impaired Gas Exchange • BPD • Upper airway congestion • Hx PDA • Inactive • Treatments: • 1/8L NC • Suction prn • PT • Meds: Lasix

  20. Infection • Candida Albicans (thrush) • Hx MSSA abscess on R and L sides of neck • Long hospital stay • Treatments: • Change pacifier daily • Clean/Sterile technique • HANDWASHING! • Meds: Nystatin

  21. Deficient Knowledge, Family • Parents live in Richmond • Expressed being overwhelmed with information • Daughter hospitalized since birth (Nov. 20, 2012) • Treatment: • Provide education/information via phone • Facilitate contact during visits

  22. Risk for Imbalanced Nutrition • Prematurity • Feeding intolerance • VSS showed aspiration • Treatments: • Neosure 24kcal w/feeds 6 times per day • PT • OT • Rehab

  23. Holistic Nursing Care • Traditional interventions • Assessments • Medication administration • Feedings

  24. Holistic Nursing Care • Complimentary/Alternative Interventions • Respectful approach • Blanket swaddling and nesting • Infant Massage

  25. Holistic Nursing Care • Collaborative Interventions • Feeding • Nursing • OT • PT • Rehab

  26. Relationship between Nursing Dx

  27. Discharge Planning • Family Teaching • Model appropriate feeding techniques • Provide opportunity for feeding • Educate on infant cues and how to measure feeding success • Home oxygen administration • Immunizations • Car seat safety • Medications • Referrals • Home Health Care • Support groups • Plan nursing follow-up

  28. Clinical Teaching • iPhone App • NICU Knowledge Parent Educator https://itunes.apple.com/us/app/nicu-knowledge-parent-educator/id508051096?mt=8

  29. Clinical Teaching

  30. Current Nursing Research

  31. Current Nursing Research

  32. Current Nursing Research

  33. Current Nursing Research

  34. Current Nursing Research Reference Schlittenhart, J. M., Smart, D., Miller, K., & Severtson, B. (2011). Preparing Parents for NICU Discharge. Nursing For Women's Health, 15(6), 484-494. doi:10.1111/j.1751-486X.2011.01676.x

  35. Questions?

  36. The End

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