Pediatric Nursing Rounds Presented by: Marc Manucal Old Dominion University – Nursing Program

1. Pediatric Nursing RoundsPresented by: Marc ManucalOld Dominion University – Nursing Program

2. Trespasser VS Trains State of Virginia Casualties 2009- 14 2010- 13 2011-15 2012- 11 (Federal Railroad Administration, 2012)

3. Pertinent Past Medical History • 10 year old African American male • Born on 30DEC11 • Normal delivery/birth history • Vaccinations up to date • No prior surgeries/hospitalizations • Asthma -exercise induced -uses rescue Albuterol inhaler • NKDA

4. Psychosocial History • Education -currently in 5th grade -well rounded student • Family -only child -lives one mother in 2 bedroom apartment • Cultural Consideration -low socio-economic status -amputee

5. Circumstances Leading to Hospitaliation • JH was playing with friends on railroad track near home • He decided to run across tracks prior to oncoming train • JH’s foot gets caught in the tracks • Suffers a BKA of left leg

6. Admitting Diagnoses Primary • Traumatic below the knee amputation of left leg Secondary • Debridement and wound vac placement to left leg • PICC line insertion

7. Pathophysiology Amputations may be elective or traumatic. Elective amputations are related to peripheral vascular disease and arteriosclerosis. Complications result in ischemia in distal areas of the lower extremity. Traumatic amputations are most often the result of an accident from machinery, motor vehicle accidents, or industrial machinery. Traumatic amputations are also increasing during the wars in Afghanistan and Iraq due to roadside bombs (Ignatavicious & Workman, 2010).

8. Treatment Plan Occupational therapy Physical therapy

9. Expected Developmental Stage Erickson’s Industry VS Inferiority

10. Current Developmental Stage Industry VS Inferiority -growing sense of independence -building new skills -develops a sense of accomplishment -seeks extrinsic sources of reinforcement that provide encouragement and stimulation

11. Physical Assessment • Neuro • Skin • Cardiovascular • Respiratory • GI • GU • Musculoskeletal

12. Concept Map 1. Acute Pain Below knee amputation 9/10 pain without meds Phantom pain Wound vac draining serosanguinous fluid TENS electrodes HR 115, BP 128/84 Oxycodone Gabapentin Pt Initials: JH Age: 10 Medical Diagnosis: Left below knee amputation Secondary Diagnosis: Debridement and wound vac placement 2. Impaired physical mobility Restricted movement of LLE Decreased ROM of LLE Pain with movement of extremity Wound vac attached to LLE Use of assistive devices (walker, wheelchair) Use walker, wheelchair Regular OT/PT visits Perform ADL’s without assistance 3. Risk for infection Debridement/wound vac placement PICC line Open wound Immobility RBC-3.23, WBC-6.8, Plt-695 4. Ineffective Coping Inability to make decisions Lack of goal directed behavior Inadequate problem solving Poor concentration Nightmares of accident Fatigue Child Life Social work Chaplain 5. Disturbed body image Request for amputation site to be wrapped with acewrap Refusal to discuss amputation Actual change in structure of LLE Refusal to look at amputation site Covers site with blankets or clothing Child life Social work

13. Expected Outcomes Acute Pain- patient will have pain controlled as evidenced by a pain level below 3/10 on pain scale. Impaired physical mobility- patient will maintain efforts in achieving optimal independence through therapy (OT/PT) during each session as evidenced by increased gait stability. Risk for infection- use of aseptic technique throughout shift. Patient and family will be able to verbalize signs and symptoms of infection by end of shift. Ineffective coping- patient will be able to demonstrate coping strategies such as expressing feelings, deep breathing exercises, and guided imagery. Disturbed body image- patient will verbalize concerns about body image throughout hospitalization.

14. Holistic Nursing Care Traditional- providing for basic healthcare needs Complimentary- OT, PT, Childlife Alternative- use of dry erase boards at bedside Collaborative- patient goal orientation with family members

15. Discharge Teaching

16. Transcutaneous Electrical Nerve Stimulation (TENS) Unit

17. TENS Unit

18. Nursing Research Liu, F., Williams, R., Liu, H., & Chien, N. (2010). The lived experience of persons with lower extremity amputation. Journal Of Clinical Nursing, 19(15-16), 2152-2161. doi:10.1111/j.1365-2702.2010.03256.x

19. Questions?

20. References Federal Railroad Administration Office of Safety Analysis. (2012). Trespasser Casualties (Deaths and Injuries). Retrieved December 4, 2012, from http://safetydata.fra.dot.gov/OfficeofSafety/publicsite/Query/castally4.aspx Ignatavicious D. D., & Workman, M.L., (2010). Medical-Surgical Nursing: Patient-Centered Collaborative Care (6th ed.). St. Louis, MO: Elsevier. Liu, F., Williams, R., Liu, H., & Chien, N. (2010). The lived experience of persons with lower extremity amputation. Journal Of Clinical Nursing, 19(15-16), 2152-2161. doi:10.1111/j.1365-2702.2010.03256.x TensUnit. (2012). How does a TENS work?. Retrieved December 4, 2012, from http://www.tensunits.com/INFO.html#1