INTRODUCTION AND OVERVIEW A.S., a 22 month old patient was brought to the ED at Strong Memorial Hospital on 1/16/09 and diagnosed with RSV, increased WOB, hypoxia, and respiratory distress. A.S. was also found to have an upper airway obstruction and was diagnosed with hypernatremia. She was transferred to the pediatric unit 4-1600 and received a tracheotomy in order to maintain an patent airway as well as G-tube placement for feedings and medication administration. As of 2/4/09, she was off RSV precautions and eligible for discharge.
NURSING DELIVERY MODEL Unit 4-1600 is a pediatric infant, toddler, and pre-school age unit that functions on a collaboration between Attending physicians, mid-level providers such as PA’s/NP’s, Residents, Social Workers, and RN’s. There are also disciplines such as PT and OT and ChildLife to assist with the physical, social, emotional, and developmental well-being of the patients and families. RN’s are usually assigned 4-6 patients depending on staffing and shift worked and they are responsible for assessments, medication administration and nursing interventions. Patient Care Technicians assist the nurse in obtaining vital signs as well as various direct patient care activities as needed.
PATIENT HISTORY A.S. has a previous history of: Lobar holoprosececephaly (least severe form): Holoprosencephaly is a disorder caused by the failure of the prosencephalon (the embryonic forebrain) to sufficiently divide into the double lobes of the cerebral hemispheres. In less severe cases, babies are born with normal or near- normal brain development and facial deformities that may affect the eyes, nose, and upper lip (National Institutes of Health, 2007). Central DI –Kidneys unable to conserve water. Lack of ADH. Siezure disorder Severe reflux Laryngomalacia- Laryngomalacia (also called congenital laryngeal stridor) is a congenital (present at birth) anomaly of the larynx (voice box) that causes stridor (noisy breathing). There are many causes of stridor; laryngomalacia is the most common one in infants and is due to an inward collapse of the floppy, soft upper structures of the larynx. Cleft palate
VISUALSLobar Holoprosencephaly Laryngomalacia
DEVELOPMENTAL STAGE ASSESSMENT Evidence to Support TrustErickson vs. MistrustPt. age is within stage of: Autonomy vs. Shame focuses on self-Ego Development control, courage and will. Outcome: Children learn to walk, talk and feed themselves andAutonomy vs. Shame. learn fine motorDue to Hx of developmental development. A.S. is not yet delay, she is within: able to walk and needs assistance to stand andEgo Development reach for objects. She does Outcome: not talk and focuses onTrust vs. Mistrust. visual objects, touch, and trusting her care-takers.
DEVELOPMENTAL STAGE ASSESSMENT CONTINUEDPiaget: Stages of Cognitive Evidence to SupportDevelopment Sensorimotor stage Sensorimotor stage – Six substages: Simple reflexes From birth to age 2. First habits and primary Children in this stage circular reactions Secondary circular are extremely reactions egocentric and cannot Coordination of secondary circular reactions perceive the world from Tertiary circular other viewpoints. They reactions, novelty, and curiosity explore using their 5 Internalization of schemes. senses.
MEDICAL DIAGNOSIS Respiratory Syncytial Virus (RSV) can cause serious problems in young babies and toddlers such as pneumonia and severe breathing problems. In rare cases, RSV can lead to death in premature babies. RSV easily spreads from person to person via direct contact or from infected surfaces (CDC, 2007). According to the American Academy of Pediatrics, RSV infects almost all children at least once before they are 2 yrs. old (2007). Symptoms include: increased WOB, cough, cyanosis, fever, nasal flaring, tachypnea, SOB, stuffy nose, and wheezing. Infants with severe RSV may need to be hospitalized so they can be closely monitored, receive oxygen, humidified air, fluids via IV and appropriate medical treatment.
FAMILY GENOGRAM Father Mother Father Mother Sister Sister A.S. Sister Sister A.S. Genogram Symbols Male Female Male Female
ECHOMAP Healthcare Providers Father Mother Patient A.S. Sister SisterEmotional Relationships Genogram Legend Symbols Slightly Attached Moderately Attached Male Female Very Attached
RSV PATHOPHYSIOLOGY RSV is limited to the respiratory tract and invades the bronchiolar epithelial cells causing inflammation and edema. The membranes of the infected cells fuse with adjacent cells to form a large, multinucleated cell creating large masses of cells. The bronchiole mucosa ultimately begins to swell, and the lumina fill with mucus and exudate. Inflammatory cells infiltrate the area resulting in the shedding of dead epithelial cells, which causes obstruction of small airway passages resulting in hyperinflation and areas of atelectasis. The inflammation and exudate caused by the RSV infection results in bronchiole obstruction during expiration, air trapping, poor exchange of gases, increased work of breathing, and a characteristic expiratory wheezes (Hockenberry, M. & Wilson, D, 2007).
CO-MORBIDITIES Seizure disorder Severe reflux Laryngomalacia Cleft palate
SURGICAL TREATMENT Tracheotomy to maintain patent airway – 3.5 Peds Shiley. One size smaller 3.0 Peds Shiley. G-tube – 16 French for medication administration and tube feedings.
MEDICATIONS Phenobarbital 40 mg per GT bid. For tx of seizures. Clonazepam 0.175 mg per GT once at midnight. For tx of seizures. Clonazepam 0.125 mg per GT bid. For tx of seizures. Sucralfate 250 mg per GT qid. For tx of GERD. Miralax 8.5 mg per GT once daily. For tx of constipation. Keppra 150 mg per GT at bedtime. Used as an anti-spastic. Baclofen 5 mg per GT in morning. Used as an anti-spastic. Omeprazole 6 mg per GT qid. For tx of GERD. Reglan 2 mg per GT qid. Enhances gastric emptying. Desmopressin Acetate 0.2 mcg SQ q12 hr. Decreases urine output
LAB VALUES OF SIGNIFICANCE A.S.’s lab values were mostly WNL and her Na+ levels were being closely monitored due to her Hx of hypernatremia from frequent voiding. Her Na+ level on 2/4 was 133mmol/L and came down from 150 mmol/L on 1/26. Her frequent voiding results from her Dx of central DI and close fluid monitoring is necessary in order to maintain normal fluid and electrolyte levels.
NURSING CARE 1ST NURSING DIAGNOSIS Impaired gas exchange related to insufficient oxygenation as a result of inflammation or edema of epiglottis, larynx, bronchial passages. Outcomes: 1) By discharge, client will demonstrate improved ventilation and adequate oxygenation as evidenced by pulse oximetry 92% and higher, blood gas levels within normal parameters for patient. 2) Client will maintain clear lung fields and remain free of signs of respiratory distress.
NURSING CARE 1ST NURSING DIAGNOSISInterventions: 1) Monitor respiratory rate, depth and effort, including use of accessory muscles, nasal flaring and abnormal breathing patterns. Both rapid, shallow breathing patterns and hypoventilation affect gas exchange. Shallow, "sighless" breathing patterns postsurgery (as a result of effect of anesthesia, pain, and immobility) reduce lung volume and decrease ventilation. 2) Auscultate breath sounds every 1-2 hours for crackles and wheezes. 4) Monitor oxygen saturation continuously by pulse oximetry. Note blood gas results as available. Increasing PaCO2 and decreasing PaO2 are signs of respiratory failure. As the patient begins to fail, the respiratory rate will decrease and PaCO2 will begin to rise. Some patients, such as those with COPD, have a significant decrease in pulmonary reserves, and any physiological stress may result in acute respiratory failure.
NURSING CARE 1ST NURSING DIAGNOSIS 1) By discharge, client will demonstrate improved ventilation and adequate oxygenation as evidenced by pulse oximetry 92% and higher, blood gas levels within normal parameters for patient. Evaluation: Effective. Pt. is able to maintain 98% oxygen saturation on RA during day and night. Blood gases WNL 2) Client will maintain clear lung fields and remain free of signs of respiratory distress. Evaluation: Effective. Lung sounds clear to auscultation and Pt. is without signs of respiratory distress.
NURSING CARE 2ND NURSING DIAGNOSIS Risk for infection due to invasive procedure and pooling of secretions. Outcomes: 1) Pt. remains free of infection, as evidenced by normal vital signs and absence of purulent drainage from tubes. 2)Infection is recognized early to allow for prompt treatment.
NURSING CARE 2ND NURSING DIAGNOSIS Interventions: 1)Maintain or teach asepsis for dressing changes and wound care, trach care, catheter care and handling, and peripheral IV and central venous access management. 2)Wash hands and teach other caregivers to wash hands before contact with patient and between procedures with patient. Friction and running water effectively remove microorganisms from hands. Washing between procedures reduces the risk of transmitting pathogens from one area of the body to another (e.g., perineal care or central line care). Use of disposable gloves does not reduce the need for hand washing.
NURSING CARE 2ND NURSING DIAGNOSIS1) Pt. remains free of infection, as evidenced bynormal vital signs and absence of purulent drainagefrom tubes.Evaluation: Effective. At discharge, Pt. has stablevital signs and no purulent drainage from tubes.2)Infection is recognized early to allow for prompttreatment.Evaluation: Effective. Family and Visiting nursestaff are adequately trained to observe for signs ofinfection in A.S.
NURSING CARE 3RD NURSING DIAGNOSISInterrupted Family Processes related to situational transition.Outcomes: 1) Family develops improved methods of communication. 2) Family identifies resources available for problem solving.
NURSING CARE 3RD NURSING DIAGNOSIS Interventions: 1) Provide opportunities to express concerns, fears, expectations, or questions. This promotes communication and support. Explore feelings: identify loneliness, anger, worry, and fear. The feelings of one family member influence others in the family system. Encourage family members to seek information and resources that increase coping skills. Practical information and positive role models can be very effective.
NURSING CARE 3RD NURSING DIAGNOSIS1) Family develops improved methods ofcommunication.Evaluation: Effective. Pt.’s family understandsneed to express concerns to each other and tohealthcare providers.2) Family identifies resources available for problemsolving.Evaluation: Effective. Pt’s family understands theneed to use resources such as Visiting NurseService in order to provide the best care possiblefor A.S. while at home.
EVIDENCE BASED PRACTICE According to the Journal of Maternal-Fetal & Neonatal Medicine: Educational programs on RSV infection and hygienic barriers are recommended and should be aimed at parents and healthcare workers. Preventative measures include avoiding children being exposed to cigarette smoke and contagious environments. Enforce effective hand washing. Use disposable tissues. (2006)
ETHICAL CONCERNS If parents/caretakers smoke around their infant and the infant is later diagnosed with RSV, should the blame be given to the parents/caretakers? Should there be any disciplinary action taken by the healthcare team?
RISK MANAGEMENT Promote effective family coping patterns and decrease stress of family and care-givers. Promote effective teaching for A.S’s trach and G- tube care at home. Maintain adequate Na+ levels. Encourage A.S.’s appropriate cognitive, emotional, and physical development. Educate family about good hand hygiene practices and the importance of a clean environment and using clean and appropriate supplies for A.S.’s care.
RISK MANAGEMENT CONTINUEDMONITORING/SURVEILLANCE FOR POTENTIAL PROBLEMS Utilize Visiting Nurse Services for assistance in caring for A.S. at home. Involvement of Social Service agencies in order to assist family in obtaining necessary resources for daily living/A.S.’s care. Encourage compliance with A.S.’s PCP appointments and lab visits.
TEACHING PLAN AND EVALUATION Discuss RSV with Pt.’s family. Discuss reasons for A.S.’s Tracheotomy and G-tube placement. Social support while in hospital. Assist family in ways to promote A.S.’s cognitive, emotional, social, and physical development. Discuss with family how to prevent communicable disease.
DISCHARGE PLAN AND EVALUATION Evaluate overall care of Pt. and outcomes. Develop an appropriate schedule with Visiting Nurse Services. Teach parents how to perform proper tracheotomy and G-tube care at home. Teach parents what medications A.S. is taking, how to administer, the reasons she is taking them, and possible side effects. Encourage compliance with follow-up appointments. Teach parents signs and symptoms of hypernatremia and what to do if they suspect it.
PROFESSIONAL ACCOUNTABILITY AND RESPONSIBILITY OF NURSE Role as a Coordinator of Care – Nurse as a “front runner” in Pt’s care and is responsible for notifying appropriate healthcare team members to act in the care of A.S. Role as a Collaborator in Care/Team Member – Nurse is responsible for encouraging collaboration and communication between multidisciplinary staff. Role as an Advocate – Nurse must always advocate for the patient and raise concern if a Pt.’s care is being compromised. Role as delegating and assigning care – Nurse is responsible for carrying out appropriate nursing interventions and assign tasks to assistive personnel and other healthcare team members in order to effectively manage time and productivity.
ANALYSIS AND SUMMARY Pt. was scheduled to be discharged in the afternoon of the day of care provided by Student Nurse. Pt. is able to maintain stable VS, including adequate oxygenation. Pt. mantains adequate Na+ levels. Parents willing to learn new care techniques for A.S. while at home. Affect of Pt. satisfactory and enjoys social interaction with Student Nurses during play activities.
REFERENCESDomenech, E., Fuster, P., Fernandez, J., Villafruela, C., Mesa, J. (2006). Recommendations for the Prevention of RSV Infection. Journal of Maternal – Fetal & Neonatal Medicine. May 2006;19 pg. 50. Retrieved February 17, 2009 from ProQuest Nursing & Allied Health Source.Kaneshiro, N. (2008). Respiratory syncytial virus (RSV). National Institutes of Health. Retrieved February 17, 2009 from: http://www.nlm.nih.gov/medlineplus/ency/article/001564.htmCenter for Disease Control and Prevention. (2008). Respiratory Syncytial Virus (RSV) Overview. Retrieved February 17, 2009 from: http://www.cdc.gov/RSV/Hockenberry, M. & Wilson, D. (2007). Wong’s Nursing care of Infants and Children, (8th ed.). Mosby Elsevier: St. Louis.