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Nursing Grand Rounds

Nursing Grand Rounds. Amanda D. Mosley Nurs 421. Client. 10 month old, female, 7.58kg; 68cm Presented c/o worsening cold symptoms x 3 days & abdominal distention Admitted for Upper Respiratory Infection (viral) Humified O2 ½ L/min NC Gastrojejunostomy (GJ) Tube

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Nursing Grand Rounds

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  1. Nursing Grand Rounds Amanda D. Mosley Nurs 421

  2. Client • 10 month old, female, 7.58kg; 68cm • Presented c/o worsening cold symptoms x 3 days & abdominal distention • Admitted for Upper Respiratory Infection (viral) • Humified O2 ½ L/min NC • Gastrojejunostomy (GJ) Tube • Double Lumen PICC RUE • Pulse Ox

  3. Client History • Birth History • 38 weeks 1 day • 5lbs 7.5 oz • C-Section • Immediate CPAP for WOB • Amniocentesis indicated 11 q 13.3-13.4 deletion • 3rd child with chromosomal disorder • Missed 6 month immunizations

  4. Client Past Medical History • Medical • Chronic Lung Disease • GERD • Chromosome 11 q 13.3-13.4 deletion • Hx of Aspiration • Surgical • Supraglottoplasty @ 3 mos • LaproscopicNissenfuntiplication @ 5 mos • GJ Tube placement @ 5 mos

  5. Client History • Chronic Lung Disease • Progressive • Symptoms • respiratory distress (rapid breathing, flaring of the nostrils, grunting, chest retractions) • continued need for mechanical ventilation or oxygen • Treatment • Medications: Bronchodilators, Steroids, Diuretic, Antibiotics • Oxygen • IV Fluids and Nutrition

  6. Client History • Gastroesophageal reflux disease (GERD) • Chronic, long-lasting • Symptoms • dry, chronic cough • wheezing • asthma and recurrent pneumonia • Nausea &/or vomiting • a sore throat, hoarseness, or laryngitis—swelling and irritation of the voice box • difficulty swallowing or painful swallowing • pain in the chest or the upper part of the abdomen • Treatment • Lap Nissen

  7. Client History • Chromosome 11 q 13.3 – 13.4 Deletion • 4-4.5% DNA in cell • Associated with pituitary tumors • Neurological Delays • Developmental Delay • Couldn’t hold up head • No weight bearing on legs • Could not crawling • Just starting to roll over • Precocious Puberty

  8. Client Cultural Considerations • Families of Chronically ill, developmentally delayed children • Frequent hospitalizations • Quality of Life • Home Nursing Care • Patient and Family Teaching

  9. Client Hospital Admission • Chief Complaint: • Worsening Cold Symptoms x 3 days • Increased WOB • Abdominal Distention • Decreased feeding tolerance • Baseline feeding rate 24 mL/hr • Admission rate 12 mL/hr

  10. Patho-physiology and Treatment • Primary Medical Diagnosis • Upper Respiratory Infection • Transmission of organisms into URT by aerosol, droplet, or direct hand-to-hand contact with infected secretions, with subsequent passage to the nares or eyes. • Onset of symptoms occurs 1 to 3 days after exposure to the infectious agent. • Treatment • Isolation (droplet and contact) • NEBs (Bronchodilator, Corticosteroids) • Diuretics

  11. Treatment (Secondary) • Secondary Medical Diagnosis • Decreased Feeding Tolerance (GJ Tube) • Treatment • Return to baseline (24mL/hr) • Current 15 mL/hr • Increased to 17 mL/hr • Additional nutrition – TPN (450 mL/day) • Nexium, Lactobacillus, Erythromycin

  12. Developmental Stage • Piaget • Sensorimotor • Aware of what is immediately in front of individual • Object Permanence (undetected) • Not crawling or standing • Erikson • Trust vs. Mistrust • Develop a sense of trust when caregivers provide reliability, care, and affection • Important event: Feeding • Communication with Caregiver

  13. Physical Assessment • General • Resting, HOB elevated, horseshoe wedge • No distress, sucking on NUK • Neuro: • Developmental delay r/t chromosome disorder • Alert, responded to voice, touch • Follows with eyes • Resp: • RR 42, no retractions, use of accessory muscles • Breath Sounds: Coarse, “wet” to bases bilaterally • Pulse Ox 100% with ½ L/min O2 via NC • Benign NC

  14. Physical Assessment • CV • Double Lumen PICC URE • Benign, patent • TPN 18.2 mL/hr • HR 140, regular rhythm • Cap refill < 2 Sec • Mucous membranes moist, pink • GI • GJ Tube ULQ • Redness at site (Triamcinolone 0.5%), minimal drainage on split dressing • Continuous feed 17mL/hr • Farrell bag ~ 50 mL light yellow fluid • BS x 4 hypoactive

  15. Physical Assessment • GU: • Voids via diaper light colored, clear urine • U/O appropriate for age (> 1mL/kg/hr) • Skin – warm, pink, intact • Musc/Skeletal • Anterior Fontanel ~ 2.5 cm, open, slightly sunken • Decreased muscle tone

  16. Physical Assessment • Psycho/Social • Mother at bedside; attentive • Pain • 0/10 FLACC Scale • Fall Risk due to ability to roll over • Bed rails up for safety

  17. Nursing Care • Altered Nutrition less than body requirements • Intake less than baseline (24mL/hr) • Severe GERD • Higher metabolic demand r/t chronic lung disease • MEDS • Erythromycin (24mg/0.6mL via J Tube QID) • Nexium (10 mg/15mL via J tube BID) • Lactobacillus (1 cap daily via J Tube)

  18. Nursing Care • Altered Nutrition less than body requirements • Interventions • Assess for and report S/S of malnutrition: • weight below client's usual weight or below normal for client's age, height, and body frame; weakness and fatigue; sore, inflamed oral mucous membrane; pale conjunctiva • Assess daily weights on same scale • Increase feeding as ordered (q 4 hrs) and monitor for reflux/enteral bag drainage q hr • Outcome: • Child will continue to increase nutritional intake until baseline is achieved (24mL/hr) ~ 24-48 hours. • Evaluation: • Child is not tolerating increase in feeds from 15mL/hr to 17mL/hr due to Farrell bag now showing residual fluid.

  19. Nursing Care • Risk for Fluid Volume Deficit • Increased insensible loss r/t infectious process • Decreased intake (less than baseline 24mL/hr) • Increased metabolic rate r/t infectious process • HCO3 – 31 • K+ - 5.8 • PaCO2 – 57 • pH – 7.42 • Meds • Furosemide (Lasix) 8mg/0.8mL via J tube q day • Hyrdochlorothiazide 6.5mg/0.26 tab via J tube q day

  20. Nursing Care • Risk for Fluid Volume Deficit • Interventions • Assess PICC, GJ Tube, & VS q 2 hrs • Assess for signs of adequate hydration (elastic skin turgor, moist mucosa, adequate urine output) q 2 hrs. • Strict intake and output monitoring • Administer IV as ordered to maintain adequate hydration • Outcome • Fluid volume will be maintained: Oral mucosa moist and pink, skin turgor elastic, urine output at least 1 to 2 mL/kg/hr; intake ~ 758mL/day or more during hospitalization. • Evaluation • Child maintained fluid volume w/in range for wt. 7.58kg (~758mL/day) during shift. Oral mucosa was moist & pink. Urine o/p ~ 4mL/kg/hr

  21. Nursing Care • Respiratory • URI • Chronic Lung Disease • Hx of aspiration (GERD) • O2 ½ L NC • Impaired gas exchange r/t increased secretions • Adventigous Lung Sounds (crackles) • MEDS • Pulmicort 0.5mg/2mL NEB TID • Albuterol 2.5mg/3mL NEB TID • Furosemide (Lasix) 8mg/0.8mL via J tube q day • Hyrdochlorothiazide 6.5mg/0.26 tab via J tube q day

  22. Nursing Care • Respiratory • Interventions • Assess respiratory rate, breath sounds, and work of breathing frequently q 2 hrs to ensure progress with treatment and that deterioration can be noted early. • Position with airway open (HOB elevated, horseshoe wedge) • Administer Humidify oxygen per order (1/2 L/min NC) • Ensure adequate fluid intake (intravenous/tube ~ 758mL/day) to help liquefy secretions for ease in clearance. • Use pulse oximetry to monitor oxygen saturation q 2 hrs in the least invasive manner to notice adequacy of oxygenation (>93%) and ensure early detection of hypoxemia. • Outcome: • Child will maintain patent airway, free from secretions or obstruction, easy work of breathing, respiratory rate within parameters for age.(30-60bpm) during shift. • Evaluation • Child maintained patent airway, exhibited easy WOB and maintained RR within parameters for age (30-60 bpm)

  23. Nursing Care • Risk for Infection • r/t to presence of infectious organisms as evidenced by presence of virus (URI) • Increased secretions r/t disease process • TPN • PICC RUE • GJ Tube (skin integrity interruption)

  24. Nursing Care • Risk for Infection • Interventions • Maintain aseptic technique • Practice good hand washing and use isolation requirements (contact/droplet) • Limit number of visitors and screen them for recent illness to prevent further infection. • Teach family preventive measures such as good hand washing, covering mouth and nose when coughing or sneezing, adequate disposal of used tissues to prevent nosocomial or community spread of infection. • Outcomes • Child will exhibit no signs of infection (fever, severe fatigue, redness of skin, increased B/P, RR, HR) during hospitalization. • Evaluation • No signs of secondary infection observed absence of fever, VS stable.

  25. Nursing Care • Psychosocial • Anxiety r/t inability maintain adequate gas exchange • Fear r/t unfamiliar personnel, procedures, and environment • Altered family processes r/t hospitalization of child • Interventions • Anxiety • Establish trusting relationship with child and family to decrease anxiety and fear. • Provide favorite blanket, toy or NUK to patient as comfort measure. • Involve parents in care to help reassure child and decrease fear. • Outcome • Pt’sanxiety will be reduced: as evidenced by decreased episodes of crying, fussing, or restlessness during hospitalization. • Evalution • Child did not exhibit signs of anxiety during shift; remained calm during procedures

  26. Holistic Nursing Care • Therapeutic Play • Involved Parent • Calm Environment • Comfort Measures • Respiratory Therapy • Nutrition

  27. Nursing Care • Altered Nutrition less than body requirements • Risk for Fluid Volume Deficit • Respiratory • Risk for Infection • Psychosocial

  28. Teaching Needs • Assessing Gastrointestinal feeding intolerance to tube feedings • Monitor for frequent regurgitation and aspiration of gastric contents • Increases risk for poor respiratory outcome • Noting abdominal distention, complaints of abdominal pain (crying, guarding), vomiting, aspiration, constipation, diarrhea • Observing for passage of flatus and stool • Monitoring gastric residual volume (Home Health Nurse)

  29. Research • Overview • Data for risk factors for Central-line Associated Blood Stream Infections (CLABSIs) in hospitalized children with PICCs outside ICU. • Method • Medical records/administrative databases • Poisson regression model • 116 CLABSIs occurred (44, 972 catheter-days) • 1.49 per 1000 catheter-days no PICU exposure

  30. Research • Results • Risk Factors identified • Dwell time > 21 days (1.5 x) • Lower extremity as site of insertion • Administration of parenteral nutrition • Younger age • Underlying malignancy • Metabolic conditions • Difference with and without PICU exposure (80%)

  31. Research • Patient • 15 days • Prevention strategies • Hand hygiene • Sterile technique • Clean and dry dressing • Flushing the Catheter • Inspect for infection • S/S of infection – Fever, chills, tachycardia, redness, swelling, or tenderness at the catheter site, drainage from catheter site.

  32. References • Advani, S., Reich, N. G., Sengupta, A., Gosey, L., & Milstone, A. M. (2011). Central Line–Associated Bloodstream Infection in Hospitalized Children with Peripherally Inserted Central Venous Catheters: Extending Risk Analyses Outside the Intensive Care Unit. Clinical Infectious Diseases, 52(9), 1108-1115 • Gulanik, M. & Myers, J. (2011). Nursing Care Plans Diagnoses, Interventions, and Outcomes (7th Edition). St. Louis, MO. Mosby Inc. • Hockenberry, M. J. & Wilson, D. (2011). Wong’s Nursing Care of Infants and Children (9th Edition). St. Louis, MO. Mosby, Inc. • McCane, K., Huether, S. E., Brashers, V. L., & Rote, N.S. (2010). Pathophysiology The biological basis for disease in adults and children (6th Edition). Maryland Heights, MI. Mosby, Inc.

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