Pediatric Nursing Grand RoundsRobyn Lutzkanin

FocusClient history Client assessmentIdentification of Nursing

problemsPlan of careApplicable Research

Client R.S. MaleAge: 6 years oldHigh functioning Autism ATV accident with a crushing injury

Compartment Syndrome in right lower leg

Client History and Assessment

Past Pertinent Health History

R.S. has a history of and is currently diagnosed with: High Functioning Autism Oppositional Defiant Disorder (ODD) Attention Deficit Hyperactivity

Disorder (ADHD) Sleep Disorder with mild sleep apnea

Cultural Considerations The culture of a little boy:

Forming a therapeutic relationship

Admitting Diagnosis R.S. had an ATV accident Trapped under ATV

Crushing Injury Compartment Syndrome of Right lower leg

Pathophysiology Acute compartment syndrome is a

medical emergency usually caused by a severe injury

Compartment syndrome develops when swelling or bleeding occurs within a compartment (the muscle fascia)

Swelling will cause damage to tissues Signs and symptoms

Treatment plan Immediate surgery: Fasciotomy Leave wound open until swelling decreases Negative pressure wound therapy & skin graft

Secondary Diagnosis Autism ODD ADHD These could have led to the initial injury

and also impacts healing Not following instructions Resistance to dressing changes

Development For six year olds such as R.S. expected

development includes: Social and Cognition Speech and Language Fine Motor / Adaptive Gross Motor

Development R.S. is diagnosed with Global

Developmental Delay Not reaching two or more developmental

milestones in each developmental domain.

Speech and Language Social and Cognition

Physical Assessment Cardiovascular: +2 Edema in rt. foot Musculoskeletal: altered gait r/t

fasciotomy Integument: 5” x 2” surgical incision

on right lower leg, bruising on right knee and right ankle

Psychosocial: High Functioning Autism Extreme pain in right lower leg

Nursing Problems and Plan of Care

Concept Map: Acute Pain Assessment: Related to crush injury

R.S. crying and screaming when right leg is handled

R.S. unwilling to move right leg Multiple surgeries on right leg

Acute Pain Nursing Interventions:

R.S. is non-verbal Pain assessment Pain management:

IV morphine Video games Toys

Acute Pain Expected outcomes:

Short-term: R.S. no longer crying by fifteen minutes

Long-term: R.S. no longer shows signs of pain by the end of shift

Outcomes: Met!

Concept Map: Risk for Fall Assessment: Related to injury and pain

medications Young age Injury of lower right leg (pain) Morphine administered IV New environment

Risk for Fall Nursing Interventions:

Keep bed in low position Assign sitter to room when his parents

weren’t present (R.S. likes to get out of bed!)

Keep wanted items within reach Encourage R.S. to ask for help to move Do not rush R.S. to move or walk faster

than he is able / willing to do

Risk for Fall Expected outcome:

R.S. will not experience any falls during his hospitalization

Outcome: Met!

Concept Map: Risk for Infection Assessment: Related to large surgical

incision and IV access Multiple surgeries Hospitals are inherently germy

Risk for Infection Nursing Interventions:

Assess for fever, elevated HR/RR, chills, lethargy, and increased WBC count

Hand hygiene!! Encourage R.S. to drink fluids Avoid unnecessary manipulation of open

wound and IV sites Cefazolin (Preventative antibiotic)

Risk for Infection Expected outcome:

R.S. will not develop an infection as a result of his fasciotomy

Outcome: Met!

Concept Map: Impaired Verbal Communication Assessment: Related to autism and

global developmental delay R.S. will not speak to health care workers R.S. is unable to use any pain rating

scales R.S. is unable to verbalize that something

is wrong in a way other than screaming and crying

Impaired Verbal Communication Nursing Interventions:

Anticipate R.S.’s needs through non-verbal cues such as squirming, frowning, fetal positioning

Be patient with R.S. Give ample time for and be concrete with

directions that R.S. is capable of doing Form a therapeutic relationship with R.S.

and his parents Clonidine for ADHD

Impaired Verbal Communication Expected Outcome:

Short-term: R.S. will be able to point to where he is experiencing pain by the end of shift on Wednesday

Long-term: R.S. will be willing to vocalize if and where he is having pain in more than one word by the end of shift on Thursday

Outcome: Met!

Concept Map: Impaired Physical Mobility Assessment: Related to crush injury of

right lower leg Reluctance to attempt movement Limited range of motion of ankle Pain from injury and surgery Fear of pain from movement

Impaired Physical Mobility Nursing Interventions:

Assess what R.S. was able to do prior to injury from parents

Assess what R.S. is willing to do currently Assess elimination status: give Miralax Encourage and facilitate movement Positive reinforcement! Work with physical therapy (Collaborative)

Impaired Physical Mobility Expected Outcomes:

Short-term: R.S. will partially put weight on his right leg to pivot into sitting chair by end of shift Thursday

Long-term: R.S. will be able to move with crutches independently by one week after last surgery

Outcome: Partially met

Connecting the DotsAcute Pain

Risk for Infection

Impaired Physical Mobility

Risk for Fall

Impaired Verbal Communication

Discharge Teaching & Planning Pain management Wound management, healing and

nutrition Exercises and movement

Research Therapeutic play intervention on children's

perioperative anxiety, negative emotional manifestation and postoperative pain: a randomized controlled trial.

Objective: To see if therapeutic play intervention could reduce preoperative anxiety, postoperative pain, and negative emotional manifestation in general

Research Design: Randomized controlled trial Methods:

47 children received routine care (control group)

48 children received 1-hour therapeutic play along with routine care (experimental group)

The state of anxiety, pain, and emotional manifestations were measured 24 hours before and 24 hours after surgery

Research Results: Children in the experimental

group had significantly lower scores of negative emotion prior to surgery and less postoperative pain

Conclusion: Therapeutic play is effective in reducing negative emotions and postoperative pain.

Research and R.S. R.S. was able to have therapeutic play

pre and postoperatively Collaborative care with Child Life at

CHKD provided R.S. with many distractions from the clinical reality of his injury

A difference in negative emotions was seen with and without play therapy in R.S.

Conclusion and Questions Nursing care of R.S.

Crushing Injury & Compartment Syndrome

Developmental Delays Nursing Diagnosis Effectiveness of Therapeutic Play

References He H.-G., Zhu L., Chan W.-C.S., Liam

J.L.W., Li H.C.W., Ko S.S., Klainin-Yobas P. & Wang W. (2015) Therapeutic play intervention on children's perioperative anxiety, negative emotional manifestation and postoperative pain: a randomized controlled trial. Journal of Advanced Nursing 71(5), 1032–1043. doi: 10.1111/jan.12608

References Wong, D. (2011). Virtual clinical

excursions--pediatrics: For Wong's Nursing care of infants and children, 9th ed. (9th ed.). Maryland Heights, Mo.: Elsevier/Mosby.