PEDIATRIC NURSING GRAND ROUNDS

Natalie Eyer 10/8/13

The Patient KL 15 months old African American female Cystic Fibrosis, no enzyme deficiency Pneumonia

Client History: Past Term SVD “Abnormal” newborn screening Diagnosed with Cystic Fibrosis at 13

months old (2 months ago) with positive sweat test

Client History: Hospitalization

PCP appointment: Parent report cough, more wet than

normal Parent report occasional vomiting Rhinorrhea No fever CXR: left lower lobe pneumonia

Client History: Pathophysiology

Chronic, autoimmune, genetic disorder , CTFR gene Characterized by a increased viscosity of mucous secretions,

elevation of sweat electrolytes, an increase in enzymes of the saliva, an abnormalities of the nervous system

Primary factor responsible for complications with the disease is the viscous mucous secretions

Secretions cause impaired gas exchange as a result of bronchial obstruction

Thick mucus will also make the victim more susceptible to infection

Overtime the destruction of lung tissue leads to fibrotic changes, making the lung much less compliant

(Hockenberyy & Wilson, 2011)

Pneumonia

Treatment plan IV antibiotics: Timentin q6, Nebcin qday Recombinant human Dnase: Pulmozyme

at bedtime Bronchodilator: albuterol qid Chest PT qid Pulse ox q2h Vitals q4h High fat, protein, calorie

Client Assessment: Culture/Psychosocial/Family

Heavy family involvement Always at least three members (usually

more) in the room at all times Great grandmother, grandmother, parents,

aunt, older sister Family worked with the healthcare team

during treatments to calm patient/provide valuable information about patient

Financial issues? 4 other children, time off work

Client Assessment: Developmental Stage

Erikson’s developmental theory “autonomy vs. shame and doubt”

Toddler “gains independence with the family’s encouragement and learns to cooperate with others” (Craven & Hirnle, 2009, p. 248)

Learns self control and independence by learning tasks such as potting training, choosing food preferences, choosing toy preferences

Nurse must understand this stage of development to encourage the independence of the child so that they can master this stage and prevent “shame and doubt.”

Client Assessment: Developmental Norms

Tolerates some separation from parent Asks for objects by pointing Shakes head for “no” Uses cup well Walks without help Constantly casts objects to floor

(Hockenberry & Wilson, 2011)

Client Assessment: Physical

Neuro: alert and oriented Resp: clear sounds bilaterally, occasional wet cough,

RR= 26, regular rhythm, unlabored. O2 sat= 99% RA CV: HR= 87, regular rhythm, no murmurs/extra heart

sounds noted, 2 second cap refill, palpable pulses +2 bilaterally. PICC L upper arm- dry &intact

GI: Bowel sounds X4, reducible umbilical hernia Gu: Diapered Skin: warm, no breakdown noted, moist mucous

membranes Musc/skel: moves extremities X4, anterior fontanelle

open, soft Pain: 0

Identification of Nursing Problems: Concept Map

1. Risk for impaired gas exchange CF Pneumonia Wet cough Worsening cough/WOB 1 week prior to admission Rhinorrhea

AlbuterolDornaseTimentinTobramycin

Identification of Nursing Problems: Concept Map

2. Imbalanced nutrition Higher metabolic demands from CF, pneumonia Stress from new environment Unavailability of child’s preferred soy milk Apple juice frequently Knowledge deficit of parents Weight between 5th and 10th percentile

DuoCal

Identification of Nursing Problems: Concept Map

3. Risk for fluid imbalance On 9/7 an intake of 480ml On 9/8 an intake of 660ml CF; higher metabolic demands Pneumonia; higher metabolic

demands Frequent apple juice: causes faster

loss of stool/urine

Identification of Nursing Problems: Concept Map

4. Risk for infection PICC line Hospital setting Multiple specialists coming in and

out of the room Multiple family members coming in

and out of the room

Identification of Nursing Problems: Concept Map

5. Anxiety (of parents) Child’s recent diagnoses of CF Child’s hospitalization Child’s recent diagnoses of

pneumonia

Plan of Care: Interventions/Expected Outcomes

1. Expected Outcome: Patient will maintain O2 sats greater than or equal to 92% consistently prior to discharge.

Assess O2 sat q2 hrs and prn Focused respiratory assessment q4 hrs and

before/after albuterol & CPT treatments: auscultate breath sounds, monitor for retractions and flaring. Obtain RR. Monitor effort of breathing.

Teach parents about normal/abnormal respiratory findings, what to report immediately

Plan of Care: Interventions/Expected Outcomes

2. Expected Outcome: Patient will maintain or gain weight throughout hospitalization.

Assess parent’s knowledge of nutrition Provide diet teaching to parents: a

diet that is high in calories, fat & protein. Use of DuoCal in soymilk for added calories and nutrients.

Monitor daily weights

Plan of Care: Interventions/Expected Outcomes

3. Expected Outcome: Patient will exhibit appropriate fluid balance consistently before discharge as evidenced by: capillary refill ≤2 sec, good skin turgor, clear-yellow colored urine, moist mucous membranes and blood pressure 67-106/37-63.

Monitor I&O continually Encourage parents to promote healthy fluid intake Keep drink within reach of the child at all times Assess hydration q4h: color of urine, skin turgor,

blood pressure, intake and output, assess mucous membranes, anterior fontanel, LOC, capillary refill.

Plan of Care: Interventions/Expected Outcomes

4. Expected Outcome: Patient will remain free from secondary infections during entire hospitalization as evidenced by a healthy PICC line site; free from drainage, redness, pain, and swelling.

Assess PICC line site q4 hrs and prn Monitor the child for signs of infection:

restlessness, irritability, change in vital signs, increased work of breathing, fatigue, weight loss

Monitor all vital signs q4h and prn

Plan of Care: Interventions/Expected Outcomes

5. Expected Outcome: Patient’s parents will demonstrate a decrease in anxiety as evidenced by: reporting decreased anxiety, being active with care of patient, and by acknowledging option of support group.

Assess parent’s level of anxiety Provide teaching about patient’s disease

process, status, and changes of status as much as possible

Involve parents in care of the child, such as help with bathing, holding child while administering medications, etc

Refer parents to CF support groups

Plan of Care: Discharge Planning

Parent education: Nutrition teaching Monitoring weight Chest PT Signs and symptoms to report Routine immunizations Medication teaching

Research“The impact of behavioral intervention on family

interactions at mealtime in pediatric cystic fibrosis” Aim: evaluate whether participation in “Be In Charge!”,

a behavioral intervention designed to improve caloric intake and weight gain in children with CF, also results in improved family functioning during mealtimes

Methods: 45 families of CF children 4-12 Intervention group: “Be In Charge”: nutrition education

and child behavioral management strategies Control group: “Nutrition Education”: nutrition

education without behavioral management strategies

Research Data collection: Mealtime Family Interaction Coding

System (MICS), Behavioral Pediatrics Feeding Assessment Scale (BPFAS), child’s weight. Mealtimes videotaped

Results: Behavioral intervention: more positive responders (moving from unhealthy at baseline to healthy), significant improvement in affect management, positive impact on caloric intake

Implications: importance of incorporating entire family when implementing dietary interventions, importance of incorporating praise/withdrawal of attention during meal times(Janicke, Mitchell, Quittner, Piazza-Waggoner, & Stark, 2008)

References Craven, R., & Hirnle, C. (2009). Fundamentals of

nursing. (6th ed.). Philadelphia, PA: Wolters Kluwer Health.

Hocekenberry, J. M., & Wilson, W. (2011). Wong’s Nursing Care of Infants and Children. (9th ed.). St. Louis, MO: Elsevier.

Janicke, M. D., Mitchell, M. J, Quittner, A. L., Piazza-Waggoner, C., & Stark, L. J. (2008). The impact of behavioral intervention on family interactions at mealtime in pediatric cystic fibrosis. Children’s Healthcare, 37(1) 49-66.

Questions?