Pediatric Nursing Grand Rounds

1. Pediatric Nursing Grand Rounds Presented By: Delenthia Smith Date: 10/08/2014

2. Focus of Presentation To utilize critical thinking and independent judgments in presenting my holistic plan of care for a past patient.

3. CB is a 3 ¾ year old boy diagnosed with Midgut Volvulus and Short Bowel Syndrome. • Admission Date: 06/08/2014. • Since admission to CHKD, the patient has been hospitalized for four months. • POD# 103- small bowel resection and formation of an ileostomy • POD# 21- take down of ilesotomy; Appendectomy/bowel resection. • POD#13- Exploratory Laparoscopy with complete wound closure and ileostomy. Presented Patient

4. Client History & Assessment CB Past Medical History Includes: • Asthma • MRSA abscess about a year ago (Patient is currently on contact precautions) • RSV Bronchiolitis Family and Psychosocial History • Only child of a single mother. • Mother is in her early 20s • Mother along with family and friends present at bedside throughout hospitalization.

5. Client History & Assessment Reason for Admission On 06/08/2014, CB was admitted to CHKD after complaining of stomach pain and experiencing frequent emesis episodes. The caregiver stated CB had a possible seizure and become lethargic while waiting for medical response after calling 911. After admission to the ED, a physical assessment determined the patient had significant abdominal distention. CB was taken to the OR where he had a small bowel resection and the formation of an ilesotomy. CB was transferred to the PICU for a while before being transferred to 7C. While hospitalized CB continued to have several gastrointestinal related surgeries including a takedown of his ileostomy, an appendectomy, and a bowel resection.

6. Client’s Health & Assessment Recent complication: • On 9/17/2014 patient was suspected of having an abdominal abscess. CB went to radiology for a scheduled drainage of the abscess and unfortunately experienced a bowel perforation. CB was taken immediately to the OR where he had an Exploratory Laparoscopy with complete wound closure and a reformation of an ileostomy. The patient was transferred back to the PICU. • Patient is currently on 7C recovering. • A decision is pending to determine if the patient will need a bowel transplant.

7. Medical Diagnosis Primary Medical Diagnosis is Midgut Volvulus. Patient was diagnosed with Midgut Volvulus shortly after admission to CHKD on 06/08/2014.

8. Do you know what a Midgut Volvulus is?

9. Midgut Volvulus When the bowel twists on its own blood supply it is known as a Volvulus. When this process occurs in the small bowel, it is known as a MIDGUT Volvulus. When blood to the intestines is cut off it, death to the intestinal tissue begins to take place. Symptoms presented: • Vomiting Bile (greenish-yellow digestive fluid) • Shock • Rapid Breathing • Bloody Stools • Abdominal pain • Abdominal swelling • Rapid Heart Rate

10. Video Midgut Volvulus http://www.youtube.com/watch?v=hmitbZ6fQFc

11. Midgut Volvulus Treatment Plan Typically individuals diagnosed with a Midgut Volvulus will need surgical intervention immediately. During surgery the bowel is untwisted and any necrotic parts are removed. If any part of the intestines is surgically removed, a small bowel stoma is required to allow the small bowel to heal.

12. CB Treatment Plan for Midgut Volvulus CB had emergency surgery performed on 06/08/2014 where he had a small bowel resection and formation of an ileostomy for bowel healing. The patient had a placement of a Salium Sump, was put on NPO and was started on TPN/Enteral Infusions through a PICC line. 2. Additional surgery to takedown the ileostomy and remove Salium Sump. A G-tube was placed for drainage. Patient is still NPO and infusing TPN/Lipids via PICC line. 3. Suspected Abscess- additional surgery for drainage. During surgery, patient had a bowel perforation. 4. Exploratory Laparoscopy with complete wound closure and reestablishment of an ileostomy. G-tube no longer draining, patient is now receiving Human Donor Milk through G-tube. TPN/Lipids still infusing through PICC line. 5. A bowel transplant is in question because of reoccurring volvulus episodes.

13. Secondary Diagnosis The patient’s secondary medical diagnosis is Short Bowel Syndrome. Short Bowel Syndrome is when large portions of the small intestines is resected because of an illness or injury. The symptoms and resulting consequences of SBS depend on the site of resection, extent of small bowel removed, time since resection, condition of the remaining intestine, and whether there is bowel continuity.

14. Symptoms of Short Bowel Syndrome Typically Short Bowel Syndrome is defined by: • Diarrhea • Steatorrhea • Fluid and Electrolyte disturbances • Malabsorption • Malnutrition

15. Secondary Diagnosis-Short Bowel Syndrome In the case of my patient, CB inquired Short Bowel Syndrome as a result of his many gastrointestinal surgeries, including numerous bowel resections.

16. Short Bowel Syndrome Treatment Plan If the patient is unable to consume adequate nutrients or if enteral nutrition exacerbates symptoms, the patient will need to be put on parenteral nutrition. It is also essential that frequent monitoring of the fluid and electrolyte balance is performed.

17. Physical Assessment I was able to care for the patient on three different days. On each day I was able to perform a physical assessment on the patient.

18. Latest Physical Assessment on 9/30/2014 Neurology: The patient responds to commands and is very interactive with the staff. Respiratory: Patient’s breath sounds were regular bilaterally. The patient’s breathing pattern was unlabored and there was no use of accessory muscles. Cardiovascular: Patient’s heartbeat was regular with both S1 and S2 sounds present. There was no murmurs or other adventitious sounds heard. GI: The patient has an ileostomy in his right lower quadrant. The ileostomy is draining a light, murky brown drainage. The stoma was “beet red” with red irritation surrounding the stoma site.

19. Latest Physical Findings GI: The patient has a G-tube in the upper left quadrant. The patient is infusing Human Donor Milk at 10 mL/hr through the G-tube. Genitourinary: The patient urinates in a diaper. Skin: The patient has one abdominal incision midline near the umbilicus on the abdomen. The incision is in clean and intact with sutures. The patient has a PICC in the left Basillic vein that is currently infusing TPN/Fat Emulsions. The patient has a G-tube in the upper right quadrant that is infusing Human Donor milk at 10 mL/hr. The patient has an ileostomy in the lower right quadrant. The stoma is “beet red” with red irritation encircling the skin surrounding the stoma. Musculoskeletal/Psychosocial: The patient is mobile and is able to move all four extremities. Psychosocial: The patient is very calm and interactive. His mother and family friend were present at the bedside. Pain: The patient is not experiencing any pain as evidenced by a lack of facial grimacing, no complaints, and “O” on the FLACC scale.

20. Developmental StageInitiative Vs. Guilt According to Erikson, my patient falls within the Initiative VS. Guilt developmental stage. The Initiative VS. Guilt stage states that during this stage a child thirst for knowledge will grow. The child will begin to take initiatives to exert control over his or her environment through play, such as make up games or other activities. If repressed, the child will illustrate feelings of guilt which can ultimately slow down the child’s creativity and ability to exercise self-control.

21. Developmental Stage Initiative Vs. Guilt My patient does not fully meet the norms of his developmental stage. The patient has been hospitalized at CHKD for four months. Within those months, the patient has undergone numerous gastrointestinal surgeries that required lengthy recoveries. Those lengthy recoveries require various nursing implications to ensure a healthy recovery process. The frequent nursing procedures, medical interventions, and hospital environment hinders the patient’s ability to explore his surroundings through direct play. However, during most of the patient’s stable days, he is able to engage in various child life activities such as direct play.

22. Developmental StageInitiative Vs. Guilt Based upon the patient’s developmental stage and their increased desire to learn about their environment through play, it is important to incorporate some form of play when implementing certain nursing tasks. For example during one of my physical assessments, I let the patient play with the stethoscope before using it to auscultate his heart and breath sounds. Usually before performing any interventions, I also noticed the nurse made sure to introduce the medical equipment in some interactive way. By doing some you not only build a trusting relationship with the patient, but you also allow the child to gain knowledge of his surroundings, stimulating his developmental growth.

23. Cultural Considerations My patient is within the culture of patients with a stoma, particular an ileostomy. Patients with a stoma require frequent physical assessments to monitor the status of the stoma ensuring that there is an adequate blood flow and no sign of irritation or infection. For nurses taking care of patients with a stoma it is important to provide a focused assessment to ensure the patient is free from infection and other complications.

24. 1. Risk for Infection related to: • Multiple broken skin barriers: • PICC in the left Basilic vein that is infusing TPN/Fat Emulsions over 18 hours a day. • G-tube in the left upper quadrant that is infusing the Human Donor Milk at 10 mL/hr • Ileostomy in the right lower quadrant. • Multiple surgeries • PMH of MRSA and is currently on Contact Precautions. • Multiple Surgeries • Expected Outcomes: The patient will remain free from any signs of infection as evidenced by: • A temperature less than 37.4 Celsius • No redness or purulent discharge from the stoma site or PICC area. • Patient’s vital signs will be within normal limits for his age range of 3 ¾ years old • -Respirations between 22-34 • -HR between 80-120 bpm throughout hospitalization. • Interventions: • Assess the patient’s PICC site on the left Basilic vein, G-tube in the upper left quadrant, and the ileostomy on the right lower quadrant for any signs of infection including redness, purulent discharge, and swelling q4h during the physical assessment or PRN. The ileostomy could also be inspected for any signs of infection. • Monitor the patient’s vital signs for any increase in the baseline q4h during the physical assessment or PRN. • Use a sterile technique for when changing the caps to the PICC line. Use a clean technique with any manipulation of the G-tube and ileostomy bag. • Use aseptic technique when changing the TPN infusing tubing and filter.

25. Impaired Skin Integrity related to: • Irritation around the ileostomy site. Upon assessment stoma was “beefy” red with red irritation encircling the skin around the ileostomy. • Patient complained of itching and “frequently” pulls on the ostomy bag. • The ostomy bag is frequently leaking its contents on the patient’s skin. • Expected Outcomes: The irritated area around the stoma will decrease in size and the patient’s pruritus episodes will be decreased throughout hospitalization. • Interventions: • Assess the skin surrounding the ilesotomy for any worsening signs of irritation such as an increased diameter of redness surrounding the ileostomy q4h during physical assessments, PRN, and when changing the ileostomy bag. • Monitor the patient’s ileostomy bag for any sign of leakage PRN and q4h during physical assessments. If the bag is half full proceed to suction out its contents. • Apply Nystatin, a topical powder, during the ileostomy bag changes to prevent itching from the irritation. • Maintain a clean/dry area around the ileostomy to prevent any skin breakdown when changing the ileostomy bag changes and during scheduled baths.

26. 3. Imbalanced Nutrition related to: • NPO status • Multiple surgeries • Downward trend in weight gain. Patient originally was 21 kg on 9/16/2014. On 9/30/2014 patient weighed 20.9 kg. • TPN/Fat Emulsions running for 18 hours a day. • 1st hr: 40 mL/hr • 16 hours: 80 mL/hr • last hour: 40 mL/hr. • Fat Emulsions running at 5.83 mL/hr • Multiple Surgeries • Human Donor Milk at 10 mL/hr. • Meds: • Pantoprazole (Protonix)- 5 mL IV push q24h for gastric suppression • Expected Outcome: The patient will not lose any more body weight but maintain his current weight of 20.9 kg or gain weight throughout hospitalization. • Interventions: • Assess the patient’s weight daily at the same time, with the same clothing, on the same scale everyday to check his daily weight trends. • Assess the TPN pump to make sure it is set correctly on the ordered infusion rate of 40 mL/hr for the 1st hour, then 80 mL/hr for 16 hours, and the last hour at 40 mL/hr q4h during the physical assessments or PRN. Also make sure the TPN is infusing properly through the PICC line q4h during the physical assessments or PRN. • Continue to administer the TPN/Fat Emulsions running over 18 hours a day through the PICC line and the Human Donor Milk running at 10 mL/hr through the G-tube. • Monitor the patient’s abdomen for any sign of distention by measuring the abdominal girth q4h during the physical assessment or PRN. Assess for any signs of increasing residual by measuring the residual level q4h during the physical assessment or PRN.

27. Caregiver Role Strain related to • Severe illness of the child • Patient has been hospitalized since 06/08/2014 • Caregiver personal life is disrupted by demands of the child and his need to be in the hospital. • Single mother • Recent anxiety of the patient’s transfer back into the PICU and then shifting back to 7C. • Expected Outcome: The mother will express satisfaction with the caregiver role, continue to use resources and to withstand the stress of caregiving by rotating beside sitting with other friends/family members throughout hospitalization. • Interventions: • Assess the mother and child relationship for any sign of ineffectiveness or fragmented care as needed. • Refer the mother to the CHKD support services such as social work department to help the mother with coping effectiveness. • Continue to support and encourage the caregiver decision of allowing other family members to come in and provide care for the patient. • Encourage the mother to continue to help with the patient care. The nurse should also provide frequent assistance to decrease the feeling of strain.

28. 5. Developmental/Psychosocial Issues of the Child • related to: • Long hospitalization period. Patient has been hospitalized since 06/08/2014. • Hospital environment and frequent medical procedures hinders the child’s developmental process in the initiative vs. guilt stage. • The patient is not able to fully explore his surroundings or exert his own “control” over his learning environment. • Anxiety • Expected Outcomes: The child will continue to have an opportunity to explore his surroundings as evidenced by actively engaging in child life activities such as, playing in the playroom or going on outdoor walks throughout his hospitalization. • Interventions: • Assess the child for signs of regressed behavior such as acting younger than his physical age or expressing lack of interest in certain activities. • Continue to offer options of child play to allow the child to explore his surroundings and express his feelings toward his hospitalization. • After consulting with the patient’s mother, provide bedside teaching to teach the child his colors, numbers, and other topics to stimulate developmental growth. • If permitted allow the child the opportunity to engage in social interactions with other kids so that the patient can be comfortable with interacting with peers.

29. Interrelatedness of the Nursing Diagnoses Risk for Infection Imbalanced Nutrition Infection Impaired Skin Integrity Developmental/Psychosocial Issues of the Child Caregiver Role Strain

30. CB General Interventions Current CB Interventions Include: • TPN/Fat Emulsions being infused over 18 hours a day through a PICC line in the left Basilic Vein. • Human Donor Milk running at 10 mL/hr through a G-tube in the left upper quadrant. • Both of these interventions are to prevent imbalanced nutrition and to stimulate healing. • Ileostomy in the right lower quadrant to help promote bowel healing. • Pending possible decision regarding bowel transplant as a treatment option for short bowel syndrome.

31. Medications • Nystatin topical powder TID for 7 days around skin ileostomy. • Pantoprazole (ProtonixIV): 20 mg= 5mL IV Push q24h gastric acid suppression. • Diphenhydramine (Benadryl): 12.5 mg= 0.25 mL IV push q6h for pruritus. • Hydroxyzine 12.5 mg=6.25 mL PO q12h pruritus. • Morphine 1 mg= 0.5 mL IV push q3h for 7 days PRN for pain.

32. Holistic/Complementary Care Before the patient had his unexpected bowel perforation the patient was on a set schedule. This schedule was the same everyday. The schedule was hung outside of his door. This was an attempt to normalize the patient’s hospitalization and provide structure. In the schedule, the patient had a scheduled play time in the playroom. However after his bowel perforation, the patient has not resumed his daily schedule, but child life services continues to provide activities for the patient. This continues to be an attempt to make the child more comfortable and to gain more control of his hospital stay.

33. Teaching and Discharge Planning The patient will probably go home with his ileostomy bag, G-tube and TPN/Fat Emulsions infusions through his PICC line. • Reinforce the steps to changing the ileostomy bag with the mother. Remind the mother of the importance of using the topical powder to prevent skin irritation. • Provide teaching to the mother on how to maintain a clean technique when manipulating the G-tube or when changing the ileostomy bag, such as performing hand hygiene and wearing gloves.

34. Teaching and Discharge Planning • Provide teaching to the mother on how to maintain a sterile field when changing the caps to the PICC line and when changing the TPN infusion tubing. • Provide teaching to the mother on how to recognize signs and symptoms of a local and systemic infection. -Local: Redness, Swelling, pain, purulent discharge -Systemic: fever or shaking chills, decreased urination, rapid pulse, rapid breathing, nausea and vomiting, and diarrhea. • Provide teaching to the mother on the signs and symptoms associated with a Midgut Volvulus.

35. Research A Descriptive Study of Complications of Gastrostomy Tubes in Children Elizabeth Goldberg RN, MSN, CPNP ⁎ , Sharon Barton APRN-BC, PhD, Melissa S. Xanthopoulos PhD, Nicolas Stettler MD, MSCE, Chris A. Liacouras MD • Main Complications with Gastronomy Tubes • 35 of the 94 patients (37%) had infections. • 64 of the 94 patients (68%) had granulation tissue. • Major Complications: leakage from the stoma, infected fistula, reoccurring granulation tissue.

36. References (2012, August 6th). Midgut Volvulus. [Video File]. Retrieved from: http://www.youtube.com/watch?v=hmitbZ6fQFc (2014, October 10th). Google Images. Hockenberry, M., & Wilson, D. (2011). Wong’s Nursing Care of Infants and Children. St. Louis, MI: Elsevier. Grodner, M., Roth, S., & Walkingshaw, B. (2012). Nutritional Foundations and Clinical Applications: A Nursing Approach. St. Louis, MI: Elsevier. Goldberg, E., Barton, S., Xanthopoulos, M., Stettler, N., & Liacouras, C. (2010). A descriptive study of complications of gastronomy tubes in children. Journal of Pediatric Nursing, 25, 72-80. Retrieved from: http://www.sciencedirect.com/science/article/pii/S0882596308002972