nursing process record_pediatric

8/7/2019 Nursing Process Record_Pediatric

http://slidepdf.com/reader/full/nursing-process-recordpediatric 1/14

Heidi Heffelfinger, SNContra Costa College

March 8, 2011KOMC – Pediatrics

Trich Overbo & Nancy Maia

PEDIATRIC NURSING PROCESS RECORD

Patient’s Initials: A.T. Room Number: 1009B Age: 14 mon. Sex: F Dates of Care: 03/05 – 03/06/2011

Allergies: NKA Height & Weight Percentile: Wt – 20 th percentile (9.34kg); Ht – 43 rd percentile (75.5cm)

Date of Admission: 03/04/2011 Diagnosis: Cancer: Neuroblastoma, Stage III, Intermediate Risk

Other Health Problems: Formula intolerance; in-utero meth., THC, & tobacco exposure; renal insufficiency

Treatments: Surgery (02/24/2011) – partial resection of pelvic tumor (with gross residual) and placement of ureter

stent, Broviac placement (03/04/2008) – for chemotherapeutic treatments and blood draws. IV therapy of chemotherapeutic agents and fluids. Prophylactic antibiotic treatment.

Pathophysiology: Neuroblastoma is an extracranial, hemorrhagic, solid tumor arising along the sympathetic

nervous system chain from neurocrest cells, often amid the adrenal medulla and paraganaglia andcervical/thoracic chains. Neuroblastoma is the most frequently diagnosed solid tumor cancer in childhood and

the most common cancer diagnosed in infancy and in utero. The most common site for primary tumor development is in the abdomen. Prognosis for neuroblastoma is often poor due to the invasiveness of thetumor, early and wide metastasis to lymph nodes, liver, lungs, and bone, and diagnosis not usually occurringuntil after the tumor has metastasized. The vast majority of neuroblastoma tumors secrete catecholamines.Neuroblastoma is staged into low, average, and high-risk groups with assignment of risk based on tumor celldifferentiation and histology. Low-risk patients often only require resection surgery and minimal to nochemotherapy and radiation. Intermediate-risk patients require resection and chemotherapy and may haveradiation treatment as well. High-risk patients require resection, chemotherapy and radiation. Six stages are also recognized: Stage I – localized primary tumor easily resected; Stage IIA – localized primary tumor withincomplete resection; Stage IIB – localized primary tumor with incomplete resection and lymph involvement;Stage III – unresectable infiltrating across the midline; Stage IV – metastatic to lymph, bone, liver, skin andother organs; Stage IV-S – metastatic with no bone involvement. Although neuroblastoma often has a poor prognosis it is unique in that spontaneous regression does occur with tumor maturation and formation of a

benign ganglioneuroma, but so do relapses often occur later in childhood. Prognosis is good when diagnosedbefore metastasis and treated with radical surgery, chemotherapy, irradiation, and biologic (retinoidsupplementation and bone marrow transplantation).

Signs & Symptoms: Enlarged abdomen, constipation, anorexia, and/or urinary retention caused by growing

abdominal tumor mass presing on abdominal muscles and skin and/or compressing gastrointestinal organsand/or genitourinary organs. Pain, weakness, neurological changes, difficulty sleeping, and irritabilityoccurring from tumors pressing on nerves. Orbital ecchymosis, proptosis, or nystagmus due to tumorsdeveloping peri-orbital. Urinalysis will show catecholamines and/or their metabolites as neuroblastomassecrete catecholamines. Fever, malaise, and leukocytosis due to immunologic system activity. Oftenpatients with early localized tumors are asymptomatic.

Etiology: Research has not been able to identify the actual etiology of neuroblastoma tumors. No

environmental, maternal, or paternal exposures have been identified. Neuroblastoma malignancies havebeen identified as arising from symphoblastoma embryological lines of sympathetic nervous systemneuroblastic cells. It should be noted that 1 to 2% of neuroblastoma patients have a family history of thedisease.

Common Complications: Cord compression from paraspinal tumor, tumor lysis syndrome, hypertension or

renal insufficiency from adrenal involvement and/or organ compression.

Presenting Signs and Symptoms: A.T. presented with gastrointestinal and genitourinary disturbances including

constipation and urinary retention three months prior to diagnosis. Laboratory findings indicated presence of catecholamines and metabolites in urine, mild anemia, and leukocytosis.



Nursing Process Record /

Physical Assessment

Appearance on First Sight: Active, playful toddler, smiling and interacting with mother.

Patient’s/Guardian's Understanding of Illness: Foster mother receptive of education regarding illness. She has a

full grasp of treatments necessary and long-term prognosis. She is actively seeking and engaging in thenecessary learning process.

Respiratory Function: Lungs clear in all lobes bilaterally. R-24. SpO2 100 % RA. Sporatic, strong non-productive

cough, recovering from recent laryngotracheobronchitis (Croup) infection.Cardiovascular Function: S1, S2 audible, AP 140 regular, BP: 109/62 (RL, sitting), cap refill 1 sec., no signs of

edema, good skin turgor,

Sensory Function: A.T. Is receptive to touch on all areas of skin with particular sensitivity noted over broviac site

and ventral surface of both feet.

Neurological Function: Alert & oriented – responds to own name and understands names of objects, and food

items; clapped when asked, “high-fived” both hands, able to freely move head in all direction. PERRLA. Equal& strong bilateral grips, no unilateral deficit in lower extremities.

Rest, Sleep, and Comfort: Mother states A.T. has had inadequate sleep during hospital stay related to irritation of

broviac site, some nausea, and disturbances due to nursing care

Condition of Skin, Hair, Mouth, and Nails: Healthy, clean hair. Nails, clean well-trimmed on hands and feet. Skin

well-hydrated, smooth. Small 2 cm round ecchymotic area on left cheek due to ambulation fall. Bilateral sets of small puncture marks on medial sacral skin from previous bone marrow aspiration. 2 cm circular red scarringon left mid-clavicle skin from broviac-placement surgery. Erythema, rash and pruritis peri-broviac dressing.

Musculoskeletal: Musculoskeletal function is normal.

Ability to Care for Self: Toddler, requires family assistance. Family actively participates in all care.

CSM of Extremities: Good cap refill in all extremities. Equal and bilateral brachial and pedal pulses. Sensationequal in all extremities. Pt able to freely move all extremities.

Condition of Dressings/Wounds: Single-lumen Broviac at left chest, mid-clavicular line superior to nipple. Dressing

is clean,dry, and intact. Free from edema. Erythema and rash located around entire dressing site. A.T. isfrequently patting at chest and pulling at broviac line.

Condition of Tubes and Equipment: All IV tubes, bags, and monitoring equipment functioning properly.

Vital Signs: Temp: 97.9°F HR: 140 RR: 24 BP: 109/62 Intake: 845 mL Output: 625 mL

Diet: regular, finger foods Date of last BM: 03/06/2011 Fluids: D5¼NS, D5½NS, & NS infusing dependent upon

chemotherapeutic regimen. Minimum of 10mL/hr D5¼NS maintained.

Genitourinary Function: Patient's urinary function is normal, with average of 6 wet diapers/day per mother. Some

compliance issues with family saving diapers for weight.

Emesis: One bout on 03/05/2011 @ ~2245 due to late administration of Zofran. Family denies any other emesis.

Gastrointestinal Function: Patient is having constipation with one or two small 1 to 2 cm hard stool fragments

passed once to twice daily.

Complaints: Family denies any complaints at this time.Environment/Safety: lEmergency medication sheet at bedside, weight taken daily for updating of sheet. Suction,

O2 and BVM devices located at bedside. While in crib, rails are up x2 and plastic barriers down x2. Floor clear and dry. Call light and phone within mother's reach. 24 hour family monitoring of A.T. Activity ad lib as able withIV connection. Automatic HR, spO2, B/P, and RR monitoring during chemotherapy.

H. Heffelfinger, SN CCC




Medications (see drug cards pages 9 – 13)

Scheduled Medications:

DRUG/DOSE/ROUTE/FREQUENCYDRUG CLASS

(therapeutic / pharmacological)REASON

sulfamethaxole/trimethoprim (Septra) 24 mg(1)

oral solution BID q F/Sa/Su

chlorhexidine gluconate (Peridex) 0.12% 5

mL oral rinse TIDhydrocortisone (Hytone) 1% cream applied

AA BID

ondanestron (Zofran) 1.35 mg(2) IV push q8h

heparin (Hep-Lok) 30 Units(3) IV push q8h

carboplatin (Paraplatin) 167 mg(4) over 60 min

IVPB every day x3 days

etoposide (Vepesid) 36 mg(5) over 60 min

IVPB every day x3 days

polyethylene glycol (Miralax) 3.7 g(6) PO BID

Anti-infectives / Antiprotozoals

Anti-infectives / Antimicrobials

Anti-inflammatories / Corticosteroids

Antiemetics / 5 HT3 Antagonists

Anticoagulants / Antithrombolytics

Antineoplastics / Alkylating Agents

Antineoplastics / Podophyllotoxins

Laxatives / Osmotic Laxatives

Prophylactic for pneumocystic

pneumonia

Prevent oral ulcers

Prevent constipationReduce localized rash & urticaria

Prevent/Treat nausea/vomiting

Prevent clotting in IV line

Destruction of malignancies

Destruction of malignancies

Constipation

(1) Safe dose for 9.34 kg child with renal insufficiency is 18.7 – 28.05 mg/dose

(2) Safe dose for 9.34 kg child is 1.4 mg/dose

(3) Safe dose for 9.34 kg is 10 Units/mL/flush; enough to fill lock-set

(4-5) Dose and schedule depend on protocol and patient response(6) Normal dosing for child >6 mon. is 0.4 g/dose: Dose appears to be high

As Needed (PRN) Medications:

DRUG/DOSE/ROUTE/FREQUENCYDRUG CLASS

(therapeutic / pharmacological)REASON

acetaminophen (Tylenol) 140 mg(1) oral drops

q4h

diphenhydramine (Benadryl) 9 mg(2) IV push

q6h

Antipyretics, Analgesics

Antihistamines, Antiemetics / H1 Antagonists

Mild pain (1-3/10)

Nausea, urticaria, hives, rash

(1) Safe dose for 9.34 kg child is 93.4 – 140.1 mg/dose, NTE 5 doses/day

(2) Safe dose for 9.34 kg child is up to 11.68 mg/dose, NTE 300 mg/day

Psychosocial Assessment

Culture and Its Implications for Care: Caucasian appearing female of mixed African-American and Caucasian

heritage. Biological mother is Caucasian while biological father is of mixed African-American and Caucasianheritage. Foster family, who is intending on adoption, is African-Amerian (AA). In AA families, the extendedfamily structure is important for teaching health strategies and providing support. Women are extremelyimportant with regard to health-care decision making and the dissemination of health information.

How Do You Feel About Caring for this Patient? I really enjoyed caring for this patient and her family, although I

found it to be an emotional experience due to the emotional implications of childhood cancer, cancer of theprimary caregiver, and a child who is a ward of the state.

Describe Parent-Child Interaction: Child and mother interaction was appropriate. Frequent holding, rocking, and

caressing of child was observed. Appropriate play such as “Peek-A-Boo”, “Itsy-Bitsy Spider”, and similar wasobserved frequently. Mother was seen reading to child. Reassuring words and touches were given duringmedical interventions and normal nursing care.

How Did You Include Play Therapy in this Child’s Nursing Care? Although this child is too young to understand

that she is ill, I did include playing with her with gloves on and playing with gloves (tossing up in the air) to helpalleviate her fears of gloved caregivers.

Developmental Assessment: Use Erickson’s Stages

Ethical Issues: lThe foster mother, a paternal cousin, wants to adopt the child, but is herself undergoing

chemotherapy for late stage, metastatic breast cancer. I could help but have in mind her long term prognosis





and if she would be the best choice for permanent guardian. However, this did not affect my care in anymanner.

Spiritual Practices: A.T.'s family is Baptist. The family pastor came to visit on Sunday, 03/06/2011, and stayed for

well over an hour. He spoke to me of the importance for prayer and to give up all worries and concerns to Godas he would ensure the proper outcome. Both A.T.'s mother and the pastor explained to me how A.T. cominginto the mother's life was a god-given grace to heal both A.T. and the mom. The family regularly attends churchservices and is active in many church activities.

Patient History: A.T. presented in November, 2010 with severe constipation and urinary retention requiringintermittent catheterization. On 02/01/2011, an MRI found a pelvic mass presacral in location. A resection wasperformed, as well as a urethral stent placement, on 02/08 however gross residual remained. Pathologydetermined the mass to be intermediate risk, Stage 3 neuroblastoma. A.T. is a ward of the state born to amother abusing methamphetamines, THC, and tobacco. A.T. suffered in utero hypoxia due to a maternalseizure during epidural placement pre-cesarean section. A.T.’s foster mother is a cousin and is herself undergoing treatment for metastatic breast cancer. A.T. no longer needs urinary catheterization due to stentplacement. She is hospitalized at this time for broviac placement and her first round of chemotherapy.

Lab Data

DATE TEST DEFINITION NORMALS

(KOMC values)

PATIENT’S

DATAREASON

(see index)

03/04/2011

03/05/2010

03/06/2011

Aspartate Aminotransferase (AST)

Total Bilirubin (TBILI)

White Blood Cell Count (WBC)

Red Blood Cell Count (RBC)

Hematocrit (HCT)

Absolute Neutrophil Count (ANC)

Blood Calcium (Ca++)

Urinalysis (UA)

red blood cells

squamous cell sediments

Blood Sodium (Na+)

RBC

Blood Carbon Dioxide (CO2)

HCT

AnisocytosisPoikilocytosis

Measure of AST enzyme in blood (liver function)

Amount of bilirubin in blood (direct & indirect)

Amount of WBCs per microliter of blood sample

Amount of RBCs per microliter of blood sample

% of volume of blood made of red blood cells

Amount & size of thrombocytes in blood sample

Amount of Ca++ in blood sample

Multiple tests on urine specimen

Amount of red blood cells and casts in urine

Amount of microscopic epithelial cells in urine

Amount of Na+ in blood sample

Measure of CO2 in blood sample

Presence of red blood cells of unequal sizes

Presence of red blood cells of differing shapes

34-110 U/L

0.1-1.1 mg/dL

6-17 K/ μL

4-5.2 M/ μL

33-39%

1.6-8.6 K/ μL

8.4-10.2 mg/dL

negative

0-3/HPF

0-5/LPF

137-145 mEq/L

4-5.2 M/ μL

20-24 mEq/L

33-39%

negativenegative

27 U/L ↓

< 0.1 mg/dL ↓

25.1 K/ μL ↑

3.74 M/ Lμ ↓

32.1% ↓

11.9 K/ Lμ ↑

10.4 mg/dL ↑

positive ↑

6/HPF↑

7/LPF ↑

136 mEq/L ↓

3.76 M/ Lμ ↓

25 mEq/L ↑

32.3% ↓

1+ ↑1+ ↑

(1)

(1)

(2)

(3)

(3)

(2)

(1)

(4)

(4)

(4)

(5)

(6)

(3)(3)

Reasons Index: (1) Indicative of hepatic insufficiency likely due to liver compression from abdominal tumor. (2)

Related to immune system reaction to malignancy. (3) Anemia which could be resultant of poor nutritional status or systemic effects of malignancy. (4) Suggestive of glomerulonephritis related to A.T.'s renal insufficiency. (5)Decrease due to increased sodium loss – in A.T. likely related to renal insufficiency. (6) Increase due to minor hypercapnea possibly result of hospitalization stress, or just a test anomaly.

Diagnostic Studies: None perfomed during current hospitalization.

Nursing Diagnoses:

1) Risk for Infection related to disruption in vascular continuity (Broviac placement) and effects & side effects of chemotherapeutic agents.

2) Deficient Knowledge (Parental) related to Broviac and chemotherapy regimen.

3) Imbalanced Nutrition (Less than Body Requirements) related to increased metabolic rate, insufficient nutrientsavailable for normal cells due to malignancy, anorexia due to malignancy and chemotherapy, and nausea andvomiting due to chemotherapy.

4) Activity Intolerance related to decreased oxygenation to tissues secondary to low hemoglobin.

5) Acute Pain related to treatments, procedures, and medication side effects.





NURSING

DIAGNOSIS

GOAL INTERVENTION –

NURSING ORDERS

RATIONALE EVALUATION

1) Risk for infection related

to disruption in vascular

continuity and effects &

side effects of chemotherapeutic agents

Knowledge of Infection

Control: By 03/05/2011 2100,

A.T.'s family will verbalize

understanding of need for infection control, ways of

preventing infections, and need

to teach and inform others in

contact with the patient.

a) Infection Protection: Monitor vital

signs and lab values.

b) Infection Protection: Teach patient's

family the importance of frequent

hand washing and cleanliness.

c) Infection Protection: Keep patient,

linen, and surrounding area(s)

clean.

d) Infection Protection: Encourage

fluid intake.

e) Infection Protection: Administer

anti-microbial medications.

a) Changing vital signs and lab

values are often the first clinical

sign that an infection has taken

hold

b) Hand-washing is the most

effective means of infection

protection.

c) Each client has a right to expect a

clean environment. Maintaining

cleanliness of patient and

environment will decrease number

of infectious agents patient will

come into contact with.

d) Fluids promote diluted urine and

frequent emptying of bladder;

reducing stasis of urine, in turn,

reduces risk of bladder infection

or urinary tract infection (UTI).

e) Anti-microbial agents are either

toxic to pathogens or retard

pathogenic growth.

Goal/outcome only partial

Patient and family did self

towards hand-washing, ho

needed occasional remindinform new visitors to do t

Pt's family twice seen hand

bottle back to Pt after it dr

onto floor. Family receptiv

education, but needs more

reinforcement.





NURSING

DIAGNOSIS


NURSING ORDERS


2) Deficient Knowledge

(Parental) related to

Broviac and

chemotherapy regimen.

Information Processing: By

03/06/2011 2100, A.T.'s family

will demonstrates motivation to

learn, identify perceivedlearning needs, and verbalize

understanding of desired

content.

a) Learning Facilitation: Question

parent regarding previous

experience and health teaching.

b) Learning Facilitation: Determine

patient or caregiver’s self-efficacy

to learn and apply new knowledge.

c) Learning Facilitation: Encourage

repetition of information or new

skill.

d) Learning Facilitation: Provide a

quiet atmosphere without

interruption.

e) Learning Facilitation: Explore

attitudes and feelings about

changes.

a) Adults bring many life experiences

to each learning session. Adults

learn best when teaching builds on

previous knowledge orexperience.

b) Self-efficacy refers to one’s

confidence in his or her ability to

perform a behavior. A first step in

teaching may be to foster

increased self-efficacy in the

learner’s ability to learn the

desired information or skills.

c) Repetition assists in learning and

retention of information as well as

builds confidence.

d) Quiet, interruption-free

atmosphere allows for greater

concentration.

e) This assists the nurse in

understanding how learner may

respond to the information and

possibly how successful the

patient may be with the expected

changes.

Goal/outcome met. Patient

family practiced skills to c

child. Multiple learning se

with 4 different facilitatorsskills. Family not yet profi

skills, but verbalize full

understanding of skills nee





NURSING

DIAGNOSIS


NURSING ORDERS


3) Imbalanced Nutrition

(Less than Body

Requirements) related to

increased metabolic rate,

insufficient nutrientsavailable for normal cells

due to malignancy,

anorexia due to

malignancy and

chemotherapy, and

nausea and vomiting due

to chemotherapy.

Nutritional Status – Nutrient

Intake: By 03/06/2011 2100,

A.T. will not have lost any

additional weight.

a) Nutrition Monitoring: Assess and

document weight daily.

b) Nutrition Therapy : Encouragefamily to bring food from home as

appropriate.

c) Nutrition Therapy: Provide

companionship during mealtime.

d) Nutrition Monitoring: Monitor

laboratory values that indicate

nutritional well-being/deterioration.

e) Nutrition Monitoring: Determine

etiological factors for reduced

nutritional intake.

a) Maintaining or gaining weight

over the short term is indicative of

good nutritional status.

b) Toddlers can have picky appetites,more familiar foods may

encourage greater consumption.

c) Attention to the social aspects of

eating is important in both the

hospital and home setting.

d) Serum albumin - indicates degree

of protein depletion; transferrin is

important for iron transfer and

typically decreases as serum

protein decreases; RBC & WBC

counts are usually decreased in

malnutrition, indicating anemia

and decreased resistance to

infection; potassium is typically

increased and sodium is typicallydecreased in malnutrition.

e) Proper assessment guides

intervention. For example,

patients teething may require

softer foods.

Goal/outcome not met. A.T

9.335 kg at beginning of sh

3/5/11 and 9.224 kg at end

on 3/6/11.





Bibliography:

Ackley, B. J. & Ladwig, G. B. (2009). Pediatric Nursing Care Plans for the Hospitalized Child (3rd ed.). Upper Saddle River,

NJ: Pearson Prentice Hall.

Axton, S. & Fugate, T. (2008). Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care (8th ed.). St. Louis,

MO: Mosby Elsevier.

Deglin, J. H. & Vallerand, A. H. (Eds.). (2007). Davis’s Drug Guide for Nurses (11th ed.). Philadelphia, PA: F. A. Davis.

Eckman, M. & Labus, D. (Eds.) (2010). Fluids & Electrolytes: an Incredibly Easy Pocket Guide (2nd ed.). Philadelphia, PA:

Wolters Kluwer/Lippincot Williams & Wilkins.

Hockenberry, M. J., & Wilson, D. (2011). Wong's Nursing Care of Infants and Children (9th ed.). St. Louis, MO: Mosby

Elsevier.

Myers, T. (Ed.). (2009). Mosby’s Dictionary of Medicine, Nursing, & Health Professions (8th ed.). St. Louis, MO: Mosby

Elsevier.

Pagana, K. D. & Pagana, T. J., (2006). Mosby’s Manual of Diagnostic and Laboratory Tests (3rd ed.). St. Louis, MO: Mosby

Elsevier.

Venes, D. (Ed.). (2001). Taber’s Cyclopedic Medical Dictionary (20th ed.). Philadelphia, PA: F. A. Davis.





Drug Cards – Scheduled Medications





Drug Cards – PRN Medications


nursing process record_pediatric

Documents