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Diagnosis #1

Acute pain related to post right hip arthrogram as evidenced by patient's reports of pain

Outcomes

1. Patient is able to use the Wong Baker scale to report a pain level between 0 and 2 an hour after medication is administered

2. Patient will demonstrate non-pharmacological method of pain management before end of shift

3. Patient is able to participate in desired as well as needed activities, such as ambulating to chair, physical therapy, and use of incentive spirometer.

5. Provide anticipatory instruction on pain causes, appropriate preventions and relief measures

1. Administer Toradol 15 mg=1 ml IV INJ Q6H

Rationale: Knowing what to expect can help the patient develop coping strategies.

References

Rationale: Giving medications on schedule rather than just prn and using report of pain level to adjust dosage minimizes changes that pain escalates "out of control"

Diagnostic Tests

Evaluation: Patient was able to use the call light before attempting to move in order to get assistance with any tasks that may involve mobility

Evaluation: 1 hour after medication administration the patient reported pain level of 2. Meeting outcome #1.

3. Assess for pain at beginning of shift and after medication administration: using the Wong Baker scale as well as other signs such as tachycardia, tachypnea, etc.

Rationale: Pain perception and pain relief are subjective, thus pain management is best left to the client's discretion. If the client is unable to provide input, the nurse should observe physiological and nonverbal signs of pain and administer medications on a regular basis

Lab Results

4. Schedule rest periods, provide quiet environment.

2. Educate and teach patient non-pharmacological pain relief measures such as deep breathing

Evaluation: Patients pain was assessed at beginning of shift as a 4 using the Wong Baker scale, after medication administration the pain was evaluated as a 2 using the Wong Baker scale. Before medication administration the heart rate was 130 bpm and an hour after medication administration heart rate was 105 bpm. Meeting outcome #1.

Rationale : Decreases fatigue and conserves energy enhancing coping abilities

Rationale: Promotes relaxation and redirects attention. Relieves discomfort and augments therapeutic effects of analgesia

Evaluation: Allowing the patient time to rest helped him conserve his energy which made it possible for him to participate in physical therapy. Achieving outcome #3.

Evaluation: Patient demonstrated deep breathing before end of shift meeting outcome #2.

Perry, S.E., Hockenberry, M.J.,Lowdermilk, D.L.,& Wilso, D. (2014). Maternaild Nursing Care (5th Ed.). San Louis: Elsvier. ISBN: 0323057209

11/19/15 Red Blood Cell Count

Results: 3.88 Normal Range: 3.9-5.3

The patient has a low RBC which can be attributed to blood loss from surgery, the patient needs to be monitored for weakness and fatigue

11/19/15 Lymphocyte

Results: 19.0 Normal Range: 20-40

The patient is receiving cholecalciferol which is a secosteroid that has the potential to reduce the lymphocyte count

11/19/15 White Blood Cell Count

Results: 6.89 Normal Range 3.5-10.5

This is important to monitor, the patient is at risk of developing an infection

11/17/15 Vitamin D Hydrox

Results: 29.9 Normal Range: 52.75-72.5

The patient has Perthes disease which can lead to low Vitamin D levels, the patient is receiving Vitamin D supplements

Pathophysiology

Perthes Disease

Future Diagnostic Tests

The patient must return monthly for x-rays specifically AP pelvis

What is Perthes disease? (2011). Retrieved November 29, 2015, from http://www.perthes.org.uk/what-is-perthes-disease/

The cause is unknown but there is a disturbance in the circulation to the femoral capital epiphysis which produces an ischemic aseptic necrosis of the femoral head.

Sensory/Perception/Cognition

Risk Factors

Potential

Complications

The patient was awake, alert and oriented at the time of the assessment. His mood was appropriate and his behavior was cooperative. The patient had clear, and appropriate for age speech. The patient rated his pain as a level of 4 using the Faces pain score. The pain was in the right hip and he described it as aching. The patient received Toradol 1 ml via IV injection.

Age:

Most common between ages 4-8

Gender:

Perthes disease is up to five times more common in boys than in girls

Race:

White children are more likely to develop this disorder than any other race

Family history: There is little evidence that it appears to run in families

After surgery the child is at risk for a post operative infection

A complication of Perthes disease can also be irregular contouring, flattening or mushrooming of the had, shortening and broadening of the neck, and flattening of the vertical wall of the acetabulum

Children who have Perthes Disease are at higher risk for developing osteoarthritis and osteoporosis as adults

Hip replacement surgery may eventually be required

Vallerand, A., & Sanoski, C. (2015). Davis's Drug Guide for Nurses (14th ed.).

Philadelphia, Pennsylvania: F.A. Davis Company.

Diagnosis #2

Medical Treatments

HEENT

Impaired physical mobility related to decreased strength as evidenced by external fixator on right hip

Signs and Symptoms

Outcomes:

Nonsurgical Treatment:

1. Observation for very young children with regular x-rays

2. Anti-inflammatory medications: reduce inflammation and pain

3. Limiting activity-avoid high impact activities to relieve pain and protect the femoral head

4. Physical therapy exercises: Hip stiffness is common, physical therapy can help restore hip joint range of motion with hip abduction and hip rotation

5. Casting and bracing after an arthrogram or tenotomy. This patient underwent a right hip arthrogram. X-ray images are taken to see the degree of deformity of the femoral head and to make sure the physician positions the head properly. A small amount of dye is used to make the anatomy easier to see.

Surgical Treatment:

Only used if the child is older than age 8 at time of diagnosis, if more than 50% of the femoral head is damaged and if non surgical treatment has not kept the hip in correct position

Most common surgery is an osteotomy. The bone is cut and repositioned to keep the femoral head snug within the acetabulum.

1. Maintain or increase strength and function of affected lower extremity during hospital stay

2. Maintain skin integrity during shift

3. Patient does not have any preventable complications during shift secondary to immobility

Developmental

Limping

Pain or stiffness in the hip, groin, thigh or knee

Pain that worsens with activity and is relieved with rest

Limited ROM of the hip joint

The patient's head was symmetrical, he had full head control and full range of motion. Both his anterior and posterior fontanels were closed. His sclera was clear and his pupils were 3mm with PERRLA. The pupils were brisk, he had no vision complaints and does not wear glasses or contacts. The patient's ears were at less than a 10% angle, the skin was intact and there was no drainage. The nose was not flaring, there was no drainage, the septum was midline and the mucosal lining was pink. The mouth was symmetrical with the palates closed. The gag reflex was present and no lesions were noted. The patient does have a presence of teeth with no discoloration or caries noted. The mucous membranes in the mouth were pink and moist. The patient had no difficulty swallowing and there is no redness, tenderness or edema, the tonsils were not enlarged. The neck was symmetrical and there was no lymph node or thyroid enlargement.

Assessment

Weight: 31kg

Height: 123 cm

BMI: 20.5 kg/m^2

Growth Chart:

85th percentile for weight

16th percentile for height

1. Provide a safe environment. Keep the bed in the lowest position and keep the call light close to the patient

5. Provide good skin care and change patient's position Q2H while inspecting for any skin breakdown

Erikson

Piaget

Rationale: Regular turning distributes body weight and promotes circulation to all areas.

Rationale: Unsafe activity could lead to a fall and lead to further complications of the right hip. It is very important to leave everything within reaching distance of the patient to decrease the possibility of injury and for the patient to know to call if need assistance

Industry vs. Inferiority

The child wants to engage in tasks and activities that they can carry through to completion. Children want and need real achievement and learn to compete and cooperate with others while also learning to follow rules. This child was very cooperative ad performed tasks to reach his daily goals. His goal for this day was to make it to the chair.

Concrete Operations

In this stage the child's thoughts become logical and coherent, the child tends to organize thoughts and problem solve. It was observed that the patient was very logical and he knew that if he wanted to heal he would need to get moving. He would also get rewarded with time on his iPad if he performed certain tasks.

Evaluation: Patient did not develop any skin breakdown during shift, meeting outcome #2

Evaluation: The patient uses the call bell when in need of assistance and the patient did not have any preventable falls during shift. Meeting outcome #3.

3. Encourage lower leg and ankle exercises. Evaluate for edema, erythema of lower extremities and calf pain or tenderness

Rationale: These exercises stimulate venous return, decrease venous stasis and reduce risk of thrombus formation

2. Perform passive ROM exercises and assist with active exercises

4. Administer pain medication on a regular schedule or 30 minutes before anticipated painful activities such as physical therapy

Chief Complaint: The patient is an 8 year old male who was admitted on 11/17/15 with right-sided Perthes disease

Past History: No past medical history, the patient did have an inguinal hernia repair when he was one year old. The patient also has no known allergies.

Evaluation: The patient stimulated venous return, decreased venous stasis and did not develop any thrombus formations during shift, meeting outcome # 3

Rationale: enhances circulation, restore or maintain muscle tone and joint mobility, preventing muscle atrophy

Rationale: Client's anticipation of pain can increase muscle tension. Medications can help relax the client, enhance comfort, and improve motivation to increase activity

Evaluation: The patient maintains strength in his non affected extremities and is able to perform limited range of motion in affected lower extremity. Meeting outcome #2

Evaluation: Patient was medicated before attempting to ambulate or perform physical therapy making it easier for the patient to ambulate and improve muscle strength in affected limb meeting outcome #1

Cellular Integrity

At the time of assessment the patient's skin was warm and dry. His skin was pink and appropriate for age. There was no petechia, ecchymosis, infections or scars noted. The patient's skin was elastic and there was no swelling or edema noted. The patient did have an incision on his right hip. It was covered by a dry and intact dressing. There was no drainage and the skin around the incision and dressing was dry and intact.

Acetaminophen: Ofirmev

400 mg=40 ml Injection, IV Q6H

Indication: Fever and pain, the drug is an antipyretic and the child has been spiking fevers since his surgery

Nursing Assessment: Assess fever, note presence of associated signs such as diaphoresis, tachycardia and malaise

Adverse Effects: Agitation, anxiety, headache, fatigue, insomnia, atelectasis, hypertension, hepatoxicity

Contraindications: Previous hypersensitivity involving alcohol, aspartame, saccharin sugar or tartrazine

Mobility

Caring Science theory

Present History : The patient is an 8 year old male who on 8/14/15 began to experience right knee pain. He was then diagnosed with Perthes disease. He has been treated with non surgical treatment and was referred to Dr. Feldman for a second opinion. He received a hip distraction for the right-sided Perthes disease on 11/17/15. The patient receives Motrin PRN for pain at home

Psychosocial History: The patient lives with his parents, and two brothers ages, 12 and 4. His father works as a jeweler and mother works at YMCA. Neither smoke.

The patient weighs 31 kg, he is 123 cm in height and his vitals at the time of assessment were: BP: 109/60, Pulse: 89, RR: 18, Temp: 99.1, and O2: 100%

Calcium Carbonate

What matters most?

1,500 mg=6 ml oral suspension, BID

Indication: This drug is an antacid used for the patient's indigestion.

Nursing Assessment: Assess for heartburn, indigestion and abdominal pain. Inspect abdomen and auscultate bowel sounds

Adverse Effects: Syncope, arrhythmias, constipation, hypercalcemia, diarrhea, nausea and vomitting

Contraindications: Cereals, spinach or rhubarb may decrease the absorption of medication

The patient had pain the right hip joint, there was no heat or swelling noted, and the patient did not have any muscle pains or cramps. There was limited movemenet in the right hip and leg. There were no contractures or deformities. The patient had a +5 strength on his right and left arms, a +5 strength on his right and left hands, a +5 strength of his left leg and a +3 strength on his right leg. The patient was independent in his self care but needed assistance ambulating. The patient had an external fixator to his right hip and femur and did not have a brace.

"What matters most to me is leaving the hospital and being able to play with my brothers and my friends at school."

Medications and IVs

Nursing Response

To create a caring and nurturing environment for this patient it was crucial to give him independence but still make sure he was comfortable to try and ensure a successful and healthy recovery

IV #1 Right Hand 22G -> 5% Dextrose in 1/2 Normal Saline with 20 meq KCl at 70 ml/hour for fluid and electrolyte replacement

IV #2: 22G Left Hand Saline lock for medication administration

Cefazolin

Sharing growth "the caring moment"

500 mg= 12.5 ml injection IV Piggyback Q8H

Indication: This drug was used as a prophylactic antibiotic before the patient went in for surgery

Nursing Assessment: Assess for infection, monitor bowel function, and assess for a skin rash

Adverse Effects: Seizures, diarrhea, nausea, vomiting, pseudomembranous colitis, serum sickness, phlebitis at IV site

Contraindications: hypersensitivity to cephalosporins, and history of GI disease, most specifically colitis

Oxygenation

Regulation

From this situation I learned how to care for a young, active child with a temporary physical immobility. I learned how hard this can be for not only the child but for the whole family. I also learned the importance of evaluating pain with this population. The patient tended to underestimate his pain to seem brave. It was very important to teach him the importance and value of the pain medication.

The patient's respiratory rate was 18 breaths per minute at time of assessment. The respirations were unlabored and there was no presence of cough. The patient has breath sounds in all fields and the breath sounds were clear in the right upper lobe, the right middle lobe, the right lower lobe, the left upper lobe, the left middle lobe and the left lower lobe. The patient had on O2 saturation of 100% on room air at time of assessment.

Cholecalciferol

The patient is PO and has a regular diet ordered. There were bowel sounds present in the right lower quadrant, the right upper quadrant, the left upper quadrant and the left lower quadrant. The abdomen is soft and flat and his last bowel movement was 11/16/15. The patient had no complaints of nausea, diarrhea, or constipation. The patient urinates freely into a urinal. His total urine output for the shift was 620 ml, the urine was a clear yellow. The calculated 24 hour fluid requirement for this child based on weight was 1720 ml in 24 hours.

2,000 units = 2 tab, Oral, Daily

Indication: This drug is a vitamin and the patient has low levels of Vitamin D due to Perthes disease

Nursing Assessment: Monitor height and weight, montior patient for hypocalcemia, assess patient for bone pain and weakness prior to and during therapy

Adverse Effects: headache, somnolence, weakness, dizziness, malaise, dyspnea, pancreatitis, abdominal pain, bone pain, muscle pain

Contraindications: Hypersensitivity, hepercalcemia, vitamin D toxicity, and malabsorption problems

Ketorolac

Family Teaching

15 mg=1 ml Injection Q6H

Indication: This drug is a non steroidal anti-inflammatory agent and is used to treat the child's short term pain

Nursing Assessment: Assess pain (note type, location and intensity prior to and 1-2 hours following administration. Also assess for rash periodically during therapy

Adverse Effects: Stroke, drowsiness, myocardial infarction,GI bleed, edema, pallor, oliguria, and pruritis

Contraindications: Cross sensitivity with other NSAIDs, active or history of peptic ulcer disease or GI bleed

Family Needs

Cardiovascular

Teach about pin care for external fixator

Explain the importance of follow up X-rays

Need for future surgeries and eventual brace

Educate on medication as well as the medication administration

1. Ensure that the patient has a referral for physical therapy

2. Ensure that their first follow up appointment is scheduled

3. Provide with crutches and/or a wheelchair

4. Provide information on support groups in the area

5. Refer parents to social media support groups: Facebook has one titled: "Perthes Disease Support Group" for caregivers to share their stories

The patient had a regular apical rhythm with S1, S2 and PMI audible. The patient's right and left arms had a less than 2 second capillary refill. His left and right legs also had a less than 2 second capillary refill. The patient had a +3 peripheral pulse on his right and left brachials as well as his right and left radials. The left dorasalis pedis and the left posterior tibial also had a +3 peripheral pulse. The patient's right dosalis pedis and right posterior tibial had a +2 peripheral pulse. There was no clubbing of fingers but the patient did have fatigue on exertion.

Diagnosis #3

Family knowledge deficit regarding recovery related to unfamiliarity with information resources as evidenced by patient's mother requesting information about recovery and future surgeries

Outcome:

1. Mother and child verbalize understanding of condition, prognosis, and potential complications by time of discharge

2. Mother verbalizes understanding of therapeutic regimen and rational for actions by time of discharge

3. Mother and child both participate in the learning process

1. Provide written instructions and schedules for activity, medication and other important facts

5. Encourage adequate rest periods with scheduled activities

Rationale: Provides visual reinforcement and reference source after discharge

Evaluation: Mother uses these instructions and asks questions as necessary meeting outcome #3.

Rationale: Rest prevents fatigue, conserves energy and facilitates recovery

Evaluation: The patient took many naps throughout the day and rest was highly emphasized for the patient's recovery. He needed naps in order to gain the energy to ambulate and perform physical therapy.

3. Include family in discussions and teaching

Rationale: These individuals will be providing support and care and have great impact on patient's quality of life

4. Review disease process and future expectations

2. Refer to and reinforce importance of follow-up care by rehabilitation team, such as physical therapists

Evaluation: The patient's mother and father

are both very active in his recovery needs meeting outcome # 3

Rationale: Open discussion regarding the disease and clinical expectations provides knowledge base for client and family to make informed decisions

Rationale: Diligent work may eventually overcome or minimize residual deficits

Evaluation: The patient and family verbalize understanding of a future brace and needs of follow-up care with regular x-rays meeting outcome #1

Evaluation: The patient is being seen by a physical therapist in the hospital and has an appointment set up for after discharge meeting outcome #2

PEDIATRIC CONCEPT MAP

by: Jessica Barlow

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