Transcript File - Robyn Lutzkanin Nursing Portfolio ODU

Pediatric
Nursing Grand
Rounds
Robyn Lutzkanin
Focus
Client
history
Client assessment
Identification of Nursing
problems
Plan of care
Applicable Research
Client
 R.S.
 Male
 Age:
6 years old
 High functioning Autism
 ATV accident with a crushing injury
Compartment
lower leg
Syndrome in right
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:
medications




Related to injury and pain
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 Dots
Acute Pain
Impaired Physical Mobility
Risk for Fall
Impaired Verbal
Communication
Risk for Infection
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.