Transcript Nursing Grand Rounds - Francesca Vergara Paragas

Pediatric Nursing Rounds
Francesca Paragas
TRUE OR FALSE?
Heat thermal burns are only caused by fire.
TRUE OR FALSE?
Scald burns are cause by something wet, such
as hot water or steam.
TRUE OR FALSE?
Scald burns from hot liquids are the most
common type of burns to children.
TRUE OR FALSE?
Superficial partial thickness burn is different
than a second degree burn.
TRUE OR FALSE?
Nutrition is very important in order to recover
from burns.
Objectives
 Introduction of the patient
 Family/Psychosocial History
 Cultural Considerations of client
 Hospitalization (reason for admission, diagnoses)
 Treatment plan
 Pathophysiology of admitting diagnosis
Objectives (con’t)
 Client’s developmental stage (applied to care)
 Physical Assessment
 Concept Map
 Nursing Care
 Teaching Needs
 Research related to client (interventions)
Focus of Presentation
 Discussion of client history, assessment, plan of care
(concept map), and research
 Techniques:
 Powerpoint
 Quizzes
 Visualizations
 Video
Introduction of the Patient
 Philip W is a 15 year old African American male
admitted to CHKD on 10/27/15 after being
transferred from Sentara Norfolk Hospital. Philip
was diagnosed with superficial partial thickness
burns that affected 15-20% of his body. The client
has no known allergies and currently weighs 41.7
kg.
Past Health Hx
 No Past Medical Hx shown
Birth Hx & Psychosocial Family Hx
 Birth Hx: none present
 Social Hx: Patient lives with mother, sister. Currently
attends high school and is on two basketball teams.
 Family Hx: No pertinent Family Hx
Cultural Considerations
 African American
 Age group- 15 year old
 High school
 Basketball Player
Circumstances that led to
Hospital
 Client’s chief reason for admission
 Grease Burn
 Frying fries at home
 Spilled over
 Address primary medical: Burn (15-20%)
 Partial thickness burns
 Chest/Abdomen
 Left and right hands
 Entire right arm
 Right leg and foot
 Left foot
Pathophysiology of Burns
 Understanding patho is necessary to provide care
 Edema Formation
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Increased capillary permeability
Increased hydrostatic pressure
Loss of water, protein, and electrolytes
Increased in sodium and potassium shift- swelling
 Fluid Loss
 Capillary barriers are disrupted
 Severe depletion of plasma volume
Pathophys (Con’t)
 Cardiac
 Reduce blood flow in burned area (capillary stasis)
 Depressed cardiac output
 Superficial partial thickness burns ceases immediately after
injury
 Can be restored within 24-48 hours
 Renal
 Renal vasoconstriction
 Reduce plasma flow and depressed GFR
 BUN and CR increase
Pathophys (con’t)
 GI System
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Blood flow decreases to GI system
Organ Dysfunction
Ischemia results
Ulcers can form
 Metabolism
 Hypermetabolism
 Protein and lipid catabolism
 Stress places many demands on body
Superficial Partial Thickness Burn
Treatment Plan
 Dressing change, wound debridement skin graft on 11/2
 Scheduled to have another one 11/6
 Foot drop boot
 Allows for better circulation
 Reduces skin and heel pressure
 Reduces risk of further skin shearing
 Monitor VS q4h
 Medications: Emollients (topical), polyethylene glycol
(constipation), morphine (pain), acetaminophen (pain),
 Calorie Counting Diet
Burn Wound Debridement
 https://www.youtube.com/watch?v=YcW4oZyeuZg
Secondary Medical Diagnosis?
 None
 No other medical condition listed
Developmental Stage
Erikson
Piaget
 Formal operation
 11 years and up
 Can think logically about
abstract propositions,
strategize, plan, and
understand concepts
 Become concerned with the
future and ideological
problems
• Ego identity vs. Role
Confusion
• 12 to 18 years
• Children become more
independent, begin to look
at the future
• “Fit in”
• Begin to form identity based
upon outcome of their
explorations
Developmental Stage Application
to Care
 This patient did meet the norms
 Set goals for him to achieve independently
 Ex: Limb exercise to maximize functionality
 Performed exercises on his own throughout day
 Encourage that the pain is temporary and in the future
he will be healed from burns
 Motivated to get better
 Pushed himself appropriately to get better
 Explained why certain procedures needed to be done
 Patient verbalized his understanding
Physical Assessment
 GI: Calorie diet. Patient ate <25% of breakfast (on both
clinical days. Stated that he does not like the food at the
hospital. Must drink Ensure after every meal.
 Skin: Skin discolorations due to burns. Superficial partial
burns on right arm, left hand, right leg, right foot, chest, and
abdomen. Pinkish color. Moist with emollient. Skin graft on
right arm. Has dressings on right arm and right leg.
 MS: Unable to assess gait first day. Pt’s right foot was
extremely stiff first day of clinical. 2nd day, patient’s
movement improved and was able to independently stretch
right leg and walk.
Physical Assessment (Con’t)
 P/S: Patient expressed frustration when trying to
stretch and exercise limbs. Began to cry stating that he
is too overwhelmed and that the pain is too much. On
2nd day of clinical, patient was more positive.
 Pain: First day of clinical, patient was in constant pain.
Verbalized that pain is a 6 in right foot when resting.
Stated that morphine helps reduce the pain. Cried when
trying to move limbs with PT because of pain. Could not
walk due or get out of bed due to too much pain. 2nd
day of clinical, pt’s pain improved tremendously. Pt
reported no pain when resting and stated that with
activity pain rises to a 5, which he said is tolerable.
Concept Map- Nursing Problems
 Acute Pain
 Impaired Skin Integrity
 Impaired Physical Mobility
 Imbalanced Nutrition- Less than Body Requirements
 Fear
Acute Pain
 11/3
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Pt verbalized constant pain
Rated pain a 5 on Right foot
Received morphine and pt stated pain decreased to 3
Pt had PT, cried and stated pain was a 10
Blood pressure increased to 144/80
 11/4
 Pt stated pain was a 0 in the morning
 After walking pt reported pain a 5
 After receiving morphine, rated pain back to 0
 Meds: acetaminophen- hydrocodone & morphine
Impaired Skin Integrity
 Warm, moist skin
 Burns present on right arm, right leg, right and left
foot, chest, abdomen, and left hand
 Bright Pink burns
 Left hand shows peeling
 Meds: Emollients- Eucerin topical cream
Impaired Physical Mobility
 11/3
 Pt has not got up from bed
 Pt states that the pain is unbearable on his right foot
 Has limited range of motion in right foot, right elbow, and
left hand- evident in PT
 Asks mother for objects that are out of reach (urinal, cell
phone)
 11/4
 Was able to walk around hospital floor. Got out of bed with
assistance
 Applied moisturizer on self independently
Imbalanced Nutrition Less than
Body Requirements
 11/3
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Pt ate <25% of breakfast
States that he does not like breakfast food
States the he hardly ever has an appetite
Only drinks juice
Drinks 50% of Ensure
 11/4
 Pt ate <25% of breakfast again
 Stated that he will try to eat more for lunch
Fear
 11/3
 Pt expresses fear stating that he is scared to move because of
the pain
 Blood pressure rose slightly from 127/80 to 136/84 right before
exercises with PT
 Pt attempts to stall exercises by being on his phone
 11/4
 Pt fear reduces on exercises since pain diminished
 Has a brighter outlook towards the future
Expected Outcomes
 Acute Pain
 Pt should report satisfactory pain control level of 3 or
below as evidenced by baseline blood pressure,
verbalization of comfort, and effectiveness of medication
by end of the day
 Impaired Skin Integrity
 Pt’s tissue should exhibit skin healing as evidenced by
moisturization of burns, absence of pain to touch, and
dead skin peeling by end of the day.
Expected Outcomes Con’t
 Impaired Physical Mobility
 Pt should be able to perform physical activity within limits
of burn as evidenced by independently stretching limbs,
walking with assistance, and reporting activity as being
tolerable by end of day.
 Imbalanced Nutrition Less than Body Requirements
 Pt should demonstrate need for eating appropriate amount
of food as evidenced by eating at least 75% of meal and
verbalizing importance of eating for recovery by end of
teaching.
Expected Outcomes (con’t)
 Fear
 Pt should exhibit reduced feelings of fear as evidenced by
verbalization of reduction in fear, hopefulness to the
future, and verbalizing positive outcomes.
Nursing Care
 Pt participated in PT and OT once daily in the morning
 Encouraged and motivated pt to get better
 Provided a calm environment
 Assessed patient q4h (focused on skin and pain)
 Calorie Count- Promote healing
 Administered medications and assessed need for PRN
meds
 Alternative intervention: Music therapy
Interrelatedness
 Impaired skin integrity from the burns can cause Acute
Pain towards the patient. Philip’s main complaint during
clinical was constant pain. The pain interfered with the
patients ability to move. This caused him to have
impaired physical mobility. The pain became so
intolerable that the patient developed fear from
moving. This fear also interfered with the patient’s
mobility. The patient expressed that he did not eat
because he never had an appetite. This fear of pain
distracts him throughout the day from eating, which
leads to Imbalanced Nutrition: Less than Body
Requirements.
Teaching/Discharge
 Importance of moisturizing burn wounds
 Must eat foods high in calories and protein
 Continue physical therapy at home
 Change dressing as directed
 Avoid sun exposure
 Sunscreen if neccessary
Teaching/Discharge (con’t)
 Call for any signs or symptoms of infection
 Fever, excessive pain, redness, swelling, new
drainage
 Do not pick wounds
 Avoid strenuous activity, heavy lifting, and contact
sports until cleared by doctor
 Do not wear tight fitting clothes that may rub against
burn areas and cause friction blisters and skin damage
Research
 Title: Functional Independence in Teenage Patients with
Burns
 Purpose of Study: To see if FIM instrument can
effectively assess the functional independence of
teenagers undergoing a process of rehabilitation
Research
 Methods:
 Cross-sectional study
 63 burn patient teenagers (12-20 years old)
 Going through a process of rehabilitation
 Functional Independence Measurement instrument
 Motor
 Self-care, sphincter control, transfers, and locomotion
 Cognitive
 Communication & social cognition
 O (full dependence) to 7 (completely independent)
 All data interpreted by researchers
Research Findings
 Results:
 Most teenagers scored 7
 14.3% of them scored 6
 Still needing family
 FIM exhibited internal consistency and reliability
 as observed by Cronbach’s reliability test
 FIM can appraise extent of handicap, dysfunction, and
social limitations of teenagers during rehabilitation
process.
Correlation Research Findings
with Interventions for Client
 Nursing Diagnosis: Impaired Physical Mobility
 Interventions include promoting physical mobility
 Performing passive or active assistive ROM exercises to all
extremities
 Encourage early ambulation when possible
 Provide pain medications as necessary
 Utilize a physical activity tool to evaluate mobility
 Utilizing a physical activity tool can help provide baselines
of performance. This tool (such as the FIM) will allow
nurses and other healthcare members develop a routine
care plan with realistic goals that will enhance and
maximize the patient’s mobility and functionality.
Quiz!
Are you still awake?
Quiz!
Which layers of the skin are affected with
superficial partial thickness burns?
Quiz!
What should a burn patient include in their
diet?
Quiz!
Name a discharge teaching that a burn
patient should have.
Quiz!
 Based on the Pathophysiology given, name a
nursing diagnosis that can apply to a burn patient
other than the ones I used.
(Acute pain, impaired skin integrity, impaired
physical mobility, Imbalanced nutrition, fear)
Summary
 Understanding of Burns
 Cultural Considerations for the patient
 Expected developmental stage of the patient
 Care Map for patient with Superficial Partial Thickness
Burns
 Research related to patient and interventions
References
 http://www.learningandteaching.info/learning/piaget.h
tm
 http://hospitals.unm.edu/burn/discharge.shtml
 Nicolosi, J. T., de Carvalho, V. F., Sabatés, A. L., &
Paggiaro, A. O. (2014). Functional independence in
teenage patients with burns. British Journal Of Nursing,
23S20-6 1p.
 Wong, Donna L., Marilyn J. Hockenberry, and David
Wilson. Wong's Nursing Care of Infants and Children. 9th
ed. St. Louis, MO: Mosby/Elsevier, 2007. Print