Grand Rounds – Dahlia Casey Burritt Name changed*
Introduction Dahlia is a 2 year old girl who I cared for during my two days in the Transitional Care Unit (TCU) She is expected to be discharged from TCU around the week of December 6 to a long-term care facility During these days our focuses of care included monitoring her respiratory status and helping her meet her developmental milestones This presentation will focus on these same goals of care for Dahlia
Dahlia’s Health History Congenital encephalopathy manifested by bulbar palsy History of both central and obstructive sleep apnea with manageable desaturations when sleeping Admitted on September 16 for upper respiratory tract infection which complicated the sleep apnea causing more drastic desaturations Tracheotomy performed on September 23 to relieve the obstructive apnea Developmentally delayed – developmental age ranges between 2 and 8 months depending on the task
Bulbar Palsy Lower motor neuron syndrome Partial or total paralysis of jaw, face, pharynx and tongue muscles Effects articulation, especially consonants Chewing and swallowing difficulties Progressive disease that leads to aspiration, malnutrition, dehydration and inability to verbally communicate McCance & Huether, 2006
Family, Psychosocial, and Cultural Considerations Dahlia’s family is Spanish-speaking only This makes educating the parents about her care much more difficult and an interpreter is required on the unit whenever they visit Dahlia is a twin, her brother was born with no health complications She also has another brother who is older and who also has not had any major health problems Her family lives on the Eastern Shore, making it difficult to travel to Norfolk very often. They do visit nearly every weekend They occasionally visit during the week if their work and family schedules allow.
Hospitalization Progressive desaturations while sleeping Worsened by infection Primary medical diagnoses Infection Treatment plan Secondary diagnoses Sleep Apnea Bulbar Palsy
Developmental Level & Care A typical 2-year-old would be able to participate in activities in daily living and doing lots of talking Adaptation of ADLs based on development Complete dressing G-tube feedings Diaper changes Adaptation of communication Nonverbal and responded minimally to direction Physical cues
Nursing Care Nursing Diagnoses and Plan of Care for Dahlia
Systems Within Normal Limits Cardiovascular Genitourinary Exceptions to the Normal Limits Gastrointestinal Musculoskeletal Neurological Psychosocial Respiratory Skin Physical Assessment
Concept Map #1: Respiratory Ineffective Airway Clearance / Impaired Gas Exchange Membrane changes Sleep apnea Mechanical ventilation BiPAPTrach Dahlia will have adequate airway clearance and gas exchange as evidenced by maintaining O2 saturations>90% and clear lungs #2:Risk for Injury R/T seizure disorder Constant “flapping” around Dahlia will remain free of physical injury if she experiences any seizure activity #5: Compromised Family Coping Illness Social isolation Parents aren’t close Dahlia’s family will actively participate in caring for her #6:Risk for Altered Nutrition: Less than Body Requirements Tube feeding Increased kcal Decreased digestion Dahlia will continue to receive adequate nutrition as evidenced by remaining between 40% and 60% on the weight/age growth chart #4:Impaired Verbal Communications Trach Doesn’t make sounds Dahlia will be able to use some form of communication to relate effectively with her environment #3: Developmental Delay Not meeting proper milestones Current goals are drastically regressed Dahlia will meet the developmental goals set forth by her occupational therapy team,
Respiratory Risk for Injury Compromised Family Coping Impaired Verbal Communication Developmental Delay Risk for Altered Nutrition: Less than Body Requirements
Interventions Impaired Airways Clearance/Impaired Gas Exchange Careful assessment Risk for Injury Close monitoring of safety measures Developmental Delay Encouragement to meet goals Impaired Verbal Communication Learn her nonverbal cues Compromised Family Coping Encourage interactions and understanding Risk for Altered Nutrition Monitor I&O Gulanick & Myers, 2007
Institutional Policies Policy 105-04-NF.06.7: Enteral Feeding Hand hygiene, gloves and a mask (signs of cold) when handling feeding system Allow all alcohol-cleaned surfaces to dry first 4 hour expiration 24 hours expiration
Teaching Discharge Planning Translator Suctioning Clean & change trach ties Desaturations Respiratory distress Communication methods Home cannot support her Adequate facility with open bed needed Long-term care unit 12/6
Research Experimental self-controlled design with 30 participants Aims: determine if 100% pre- and post-oxygenation is required to prevent hypoxemia Inclusion by: 18+ years old, requiring mechanical ventilation, had an arterial line and hospitalized between September & December 2002 Determined that while helpful in increasing oxygenation levels, it wasn’t found to be exceptionally necessary in this population
References McCance, K. and Huether, S. (2006). Pathophysiology: The biologic basis for disease in adults and children (5th ed.). St. Louis: Elsevier Mosby. Demir, F. and Dramali, A. (2004). Requirement for 100% oxygen before and after closed suction. Journal of Advanced Nursing 51(3): 245-251.