1. Grand Rounds Dahlia
Casey Burritt
Name changed*

2. Introduction
Dahlia is a 2 year old girl who I cared for during my two days in the Transitional Care Unit (TCU)
She is expected to be discharged from TCU around the week of December 6 to a long-term care facility
During these days our focuses of care included monitoringher respiratory status and helping her meet her developmental milestones
This presentation will focus on these same goals of care for Dahlia
3. History
Dahlias health history and assessment
4. Dahlias Health History
Congenital encephalopathy manifested by bulbar palsy
History ofboth central and obstructive sleep apnea with manageable desaturations when sleeping
Admitted on September 16 for upper respiratory tract infection which complicated the sleep apnea causing more drastic desaturations
Tracheotomy performed on September 23 to relieve the obstructive apnea
Developmentally delayed developmental age ranges between 2 and 8 months depending on the task
5. Bulbar Palsy
Lower motor neuron syndrome
Partial or total paralysis of jaw, face, pharynx and tongue muscles
Effects articulation, especially consonants
Chewing and swallowing difficulties
Progressive disease that leads to aspiration, malnutrition, dehydration and inability to verbally communicate
McCance & Huether, 2006
6. Family, Psychosocial, and Cultural Considerations
Dahlias family is Spanish-speaking only
This makes educating the parents about her care much more difficult and an interpreter is required on the unit whenever they visit
Dahlia is a twin, her brother was born with no health complications
She also has another brother who is older and who also has not had any major health problems
Her family lives on the Eastern Shore, making it difficult to travel to Norfolk very often.
They do visit nearly every weekend
They occasionally visit during the week if their work and family schedules allow.
7. Hospitalization
Progressive desaturations while sleeping
Worsened by infection
Primary medical diagnoses
Infection
Treatment plan
Secondary diagnoses
Sleep Apnea
Bulbar Palsy
8. Development
9. Developmental Level & Care
A typical 2-year-old would be able to participate in activities in daily living and doing lots of talking
Adaptation of ADLs based on development
Complete dressing
G-tube feedings
Diaper changes
Adaptation of communication
Nonverbal and responded minimally to direction
Physical cues
10. Nursing Care
Nursing Diagnoses and Plan of Care for Dahlia
11. Systems Within Normal Limits
Cardiovascular
Genitourinary
Exceptions to the Normal Limits
Gastrointestinal
Musculoskeletal
Neurological
Psychosocial
Respiratory
Skin
Physical Assessment
12. Concept Map
#1: Respiratory
Ineffective Airway Clearance / Impaired Gas Exchange
Membrane changesSleep apnea
Mechanical ventilationBiPAPTrach
Dahlia will have adequate airway clearance and gas exchange as evidenced by maintaining O2 saturations>90% and clear lungs
#2:Risk for Injury
R/T seizure disorder
Constant flapping around
Dahlia will remain free of physical injury if she experiences any seizure activity
#5: Compromised Family Coping
IllnessSocial isolation
Parents arent close
Dahlias family will actively participate in caring for her
#6:Risk for Altered Nutrition: Less than Body Requirements
Tube feedingIncreased kcalDecreased digestion
Dahlia will continue to receive adequate nutrition as evidenced by remaining between 40% and 60% on the weight/age growth chart
#4:Impaired Verbal Communications
TrachDoesnt make sounds
Dahlia will be able to use some form of communication to relate effectively with her environment
#3: Developmental Delay
Not meeting proper milestones
Current goals are drastically regressed
Dahlia will meet the developmental goals set forth by her occupational therapy team,
13. Respiratory
Risk for Injury
Compromised Family Coping
Impaired Verbal Communication
Developmental Delay
Risk for Altered Nutrition:
Less than Body Requirements
14. Interventions
Impaired Airways Clearance/Impaired Gas Exchange
Careful assessment
Risk for Injury
Close monitoring of safety measures
Developmental Delay
Encouragement to meet goals
Impaired Verbal Communication
Learn her nonverbal cues
Compromised Family Coping
Encourage interactions and understanding
Risk for Altered Nutrition
Monitor I&O
Gulanick & Myers, 2007
15. Institutional Policies
Policy 105-04-NF.06.7: Enteral Feeding
Hand hygiene, gloves and a mask (signs of cold) when handling feeding system
Allow all alcohol-cleaned surfaces to dry first
4 hour expiration
24 hours expiration
16. Teaching
Discharge Planning
Translator
Suctioning
Clean & change trach ties
Desaturations
Respiratory distress
Communication methods
Home cannot support her
Adequate facility with open bed needed
Long-term care unit 12/6
17. Research
100% Oxygenation Yes or No?
18. Research
Experimental self-controlled design with 30 participants
Aims: determine if 100% pre- and post-oxygenation is required to prevent hypoxemia
Inclusion by: 18+ years old, requiring mechanical ventilation, had an arterial line and hospitalized between September & December 2002
Determined that while helpful in increasing oxygenation levels, it wasnt found to be exceptionally necessary in this population
19. References
McCance, K. and Huether, S. (2006). Pathophysiology: The biologic basis for disease in adults and children (5th ed.). St. Louis: Elsevier Mosby.
Demir, F. and Dramali, A. (2004). Requirement for 100% oxygen before and after closed suction. Journal of Advanced Nursing 51(3): 245-251.