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Nursing Grand Rounds

Transcript: Erik Erikson: "Crises" Theory Autonomy vs. shame and doubt Age: 1-3 years Goal: Assert independence With autonomy comes relinquishing dependence Continued dependency creates doubt followed by a sense of shame Patient actively asserts independence Staging & Types Developmental Considerations Lives with Mom, Dad, and Grandmother in an apartment in Norfolk Young parents Mom: Hx of epilepsy and depressive disorder Family issues Lack of parental involvement History Physical manifestations Peripheral blood smear showing immature forms of leukocytes and low blood counts Bone marrow aspiration Biopsy Lumbar puncture to determine CNS involvement Chief complaint: Fever and malaise (increased fussiness and decreased appetite) Primary Medical Diagnosis: Acute lymphoblastic leukemia Secondary Medical Diagnoses: Anemia r/t chemotherapy/disease process, thrombocytopenia r/t chemotherapy, neutropenia r/t chemotherapy, HSV ("Childhood Leukemia", 2015) Purpose/Focus Nursing Research (Hockenberry & Wilson, 2015) ("Treating Acute Lymphoblastic Leukemia", 2011) Treatment Plan Blood cancer resulting from abnormal WBC accumulating in bone marrow Rapidly progresses Replaces healthy cells (lymphocytes) with leukemia cells that cannot mature properly Leukemia cells can spread via bloodstream to other organs and tissues More lymphatic B cells than T cells (Dock, 2012) (Hockenberry & Wilson, 2015) Acute Lymphoblastic Leukemia ("How is childhood leukemia classified?", 2015) Nursing Grand Rounds Physical Assessment "Nearly 98 of every 100 children with ALL enter remission at the end of the first month of treatment" Jean Piaget: Theory of Cognitive Development "Sensorimotor Phase" Age: 0-2 years Object permanence Cognitive processes develop rapidly Reasoning skills immature Using active experimentation to achieve new goals Tolerating of increased separation Patient actively experimenting and tolerating increased separation Herpes Simplex Virus (HSV) Patients age 1-9=better prognosis <1 and >10= higher risk Better prognosis with no CNS involvement Higher WBC count upon diagnosis= high risk/poor prognosis Subtype Pre-B, common, or early pre-B ALL= better prognosis Gender Girls > cure than boys Race AA < cure than Caucasian Chemotherapy Induction- phase 1 (4 weeks)- kills leukemia cells to allow normal cells to return Consolodation-phase 2 (12-16 weeks)- kills remaining leukemia cells Delayed intensification- phase 3 (8 weeks)- prevents leukemia return Maintenance- final phase (2-3 years) Stem cell transplant Radiation therapy and/or immunotherapy Pathophysiology Respiratory Coarse lung sounds Non patent nasal passages Runny nose/cough Cardiovascular Double L IVAD (implanted vascular access device) Slightly tachycardic at times Gastrointestinal L nare NGT Pain Discomfort noted Fussy References Current Hospitalization Integumentary Skin breakdown Irritation around port r/t chemotherapy chemical spill Lower lip lacerations r/t chemotherapy Posterior scalp lesion (HSV+) Bruising all over extremities and trunk- small in size Reddened spots on the L cheek, forehead, and chest L thigh puncture wound r/t biopsy Itching present Pertinent Medical History Contagious virus Passed from one person to another through direct contact Currently on acyclovir treatment Diagnosed one week postpartum Current active lesions on scalp and possibly other areas of the body Toddler Chronic illness Low socio-economic status Prolonged hospitalization Social isolation r/t contact isolation ("Leukemia Types", 2015) To integrate knowledge from the sciences, developmental theory and physical assessment data for the plan of care of a pediatric client and family in the acute care setting To use critical thinking and personal judgment to present a holistic plan of care for the patient and family Full term vaginal delivery, no complications HSV (herpes simplex virus) MRSA (Methicillin-resistant Staphylococcus aureus) Candidiasis (yeast infection) Katherine Babb ODU Senior Nursing Student Offering choices Avoiding overprotection Allowing unrestricted movement when appropriate Prognosis/Survival Aburn, G., & Gott, M. (2014). Education given to parents of children newly diagnosed with acute lymphoblastic leukemia: the parent’s perspective. Pediatric Nursing, 40(5), 243-256 14p. Childhood Leukemia, (2015). Retrieved November 24, 2015, from http://www.cancer.org/cancer/leukemiainchildren/detailedguide/childhood-leukemia-prognostic-factors Dock, E. (2012). Herpes Simplex. Retrieved November 24, 2015, from http://www.healthline.com/health/herpes-simplex#Causes2 Hockenberry, M. & Wilson, D., (2015). Nursing care of infants and children, (10th ed.). St.Louis, MO. Elsevier How is childhood leukemia classified? (2015). Retrieved November 24, 2015, from http://www.cancer.org/cancer/leukemiainchildren/detailedguide/childhood-leukemia-how-classified "Leukemia Types". (2015). Retrieved from http://www.cancercenter.com/leukemia/types/tab/acute-lymphocytic-leukemia/ Treating Acute

Nursing Grand Rounds

Transcript: Nursing Grand Rounds Kara Schroeder Joseph Keane Branden Boyd Kole Cooper Medical/Oncology 6000 Situation Situation 34 year old female Transferred from ED to 6000 with nausea and constipation Patient had uncontrollable blood sugars Patient was not fully compliant with cares Medical Diagnosis Medical Diagnosis Initial Medical Diagnosis: Uncontollable blood sugars Patient would have drastic drops in her blood sugar levels Abdominal pain Generalized and achey Final Medical Diagnosis Constipation Diagnosis was changed after patient received abdominal x-ray Patient History Patient History Gastric bypass and G-J tube placed in Mexico G-J tube was plugged and not working properly Gastroparesis (2009) Delayed gastric emptying Patient had pancreatic failure Islet cells were transplanted into liver Islet cells create insulin Islet cell transplant was successful, insulin production was good The benefits of pancreatic islet allo-transplantation include improved blood glucose control, reducing or eliminating the need for insulin injections to control diabetes, and preventing hypoglycemia. (NIDDK, 2013) No history of diabetes Further medical history unknown due to patient refused to give consent to send medical records St. Luke's Health System Hourly POCT blood sugars: monitor drops C-peptide & insulin levels: monitor natural insulin production Upper and lower endoscopies: check obstructions r/t abdominal pain Abdominal x-ray: check for obstructions r/t abdominal pain Lab Tests and Findings Lab Tests and Findings Glucose Levels Monitor for hypo-/hyperglycemia Blood sugars unstable Patient unaware she was low or high First drop went from 198 to 53, c-peptide and insulin levels drawn D50 given for immediate correction after lab draw Second drop went from 230 to 58, c-peptide and insulin levels drawn D50 given for immediate correction after lab draw Both drops happened within an hour of each other C-peptide: abnormal findings C-peptide is a substance produced by the beta-cells in the pancreas. C-peptide and insulin are made at the same time, so it is a good indicator of natural insulin production (AACC, 2014). Patient's c-peptide and amount of insulin in body did not correlate Showed use of synthetic insulin (doctor's clinical judgment), patient denied use Insulin: insulin levels elevated Should be equivalent the c-peptide level Glucose Levels For abdominal pain, tenderness/firmness when abdomen palpated Upper endoscopy: No abnormal findings Lower endoscopy: Could not complete, bowel full of stool Patient refused to drink all prep Upper and Lower Endoscopies Upper and Lower Endoscopies Examine how large the blockage in the abdomen was Showed significant excess of stool in the bowel Doctor determined patient was constipated. Doctor called blockage a "petrified turd" Abdominal X-ray Abdominal X-ray Problems noticed Risk for uncontrollable blood glucose Constipation Objective Data Facial grimacing Abdomen firm High and low glucose levels Subjective Data Abdomen tenderness Pain ranging from 7-10 Patient reported severe nausea Assessment Assessment Medications Medications Dilaudid: control patients pain Patient on continuous oxygen saturation Zofran: help with nausea Benadryl: control itchy from zofran TPN: nutrition needed D10 continuous: to keep BS elevated D50 bolus: per protocol for critically low BS below 70 Senna-docusate: help with constipation Risk for uncontrollable blood glucose Monitor blood sugars Monitor for tremors or slurred speech Assess temperature, pulse, color of patient Constipation Encourage activity, walking halls, fluids Give patient options, i.e. enema, digital extraction, stool softeners Interventions Interventions Uncontrollable blood sugars Signs and symptoms of hypoglycemia Nutrition alternatives Importance of blood sugar checks Consequences of severe hypoglycemia Constipation Signs and symptoms of constipation Ambulating in the halls High fiber foods Drinking ample fluids Regular sleeping schedule Patient Education Patient Education Endocrinology GI Hospitalist Mental Health Ethics Social Work Interdisciplinary Involvement Interdisciplinary Involvement Patient refusing to confess past medical history or give consent to request medical records Determining cause of sudden blood sugar drops Determining cause of synthetic insulin in C-peptide test Patient would show no s/s of hypoglycemia Patient refused all treatments and procedures after day 3 at SMC 6000 decided to transfer patient to critical care due to blood sugar drops, but patient refused to be transferred Patient threatened to leave AMA multiple times Challenges Challenges Patient denied use of using synthetic insulin despite confirmation from lab tests Patient would not allow anyone go through belongings to verify that she was not using insulin Patient carried purse Discussion question: At what point in this person's care should patient safety breach patient privacy? How would you effectively communicate with a patient who is refusing medical

Nursing Grand Rounds

Transcript: Treatment Plan Chief Reason for Admission: Abdominal Pain Primary Medical Diagnosis: Relapsed Stage IV Neuroblastoma Secondary Diagnoses: - Fever and Neutropenia r/t chemotherapy - Diarrhea r/t chemotherapy Circumstances Leading to Hospitalization Surgery Chemotherapy Radiation Stem Cell/Bone Marrow Transplantation Retinoid Therapy References ("Neuroblastoma", 2015) ("Neuroblastoma", 2015) Neuroblastoma Age: 9 Primary Medical Diagnosis: Relapsed Stage IV Neuroblastoma Secondary Medical Diagnoses: - Fever and Neutropenia - Diarrhea Chief Complaint: Abdominal Pain Amanda Porter ODU Senior Nursing Student Cultural Considerations "Evaluating the acceptability and efficacy of a psycho-educational intervention for coping and symptom management by children with cancer: a randomized controlled study" Journal of Advanced Nursing Psycho-educational intervention programme "Provide information about treatment management and to facilitate the identification and use of effective skills to manage physical symptoms, including cognitive and/or behavioral modifications" Conclusion: The intervention was acceptable for pediatric oncology patients and reduced GI problems and pain Hockenberry, M. & Wilson, D., (2010). Nursing care of infants and children, (9th ed.) . St.Louis, MO. Elsevier. Neuroblastoma. (2015). Retrieved October 5, 2015. Neuroblastoma - Childhood - Treatment Options. (2012, June 25). Retrieved October 5, 2015. Sposito, A. P., Silva-Rodrigues, F. M., Sparapani, V. C., Pfeifer, L. I., de Lima, R. G., & Nascimento, L. C. (2015). Coping strategies used by hospitalized children with cancer undergoing chemotherapy. Journal Of Nursing Scholarship, 47(2), 143-151. doi:10.1111/jnu.12126 Wu, L., Chiou, S., Sheen, J., Lin, P., Liao, Y. M., Chen, H., & Hsiao, C. (2014). Evaluating the acceptability and efficacy of a psycho-educational intervention for coping and symptom management by children with cancer: a randomized controlled study. Journal Of Advanced Nursing, 70(7), 1653-1662. doi:10.1111/jan.12328 "Coping strategies used by hospitalized children with cancer undergoing chemotherapy" Journal of Nursing Scholarship Children need to cope with hospitalizations, pain, medications, side effects, idle time and uncertainty regarding the success of treatment Conclusion: Children develop coping strategies which were effective while undergoing chemotherapy WP's Method: Conversation, watching his favorite shows, and video games Primary Focus: Reinforcement Hygiene habits Nutritional choices, eating frequently Understanding seizure precautions Self-Care and ADLs Holistic Nursing Care Teaching and Patient Outcomes Pertinent Health History Developmental Considerations What is a Relapsed Stage IV Neuroblastoma? Neuro: Nerves Blastoma: Cancer that affects immature/developing cells Starts in certain very early forms of nerve cells or neuroblasts in an embryo or fetus During maturation some neuroblasts may become cancerous and cause a neuroblastoma (a malignant tumor composed of neuroblasts that typically occurs on the adrenal gland) ("Neuroblastoma", 2015) Medical History and Physical Exam Blood and Urine Catecholamine Tests Routine Labs Imaging Tests (MRI, CT, PET, etc.) Biopsies Patient: W.P. Family/Psychosocial History Nursing Grand Rounds Missing the first day of school due to hospitalization Being the "sick" child in the family Feeling different than his peers (ie. travel, hospitalizations, taking medications) Most common cancer in infants (less than a year old) Accounts for 6% of all cancers in children Approximately 700 new cases each year in the US Rarely found in children over the age of 10 Nearly 90% of all cases are diagnosed by age 5 Cardiovascular - Double R IVAD - History of HTN Musculoskeletal - Weak, unsteady gait Genitourinary - Diarrhea associated incontinence - Decreased urine output WP is a rising 4th grader He lives with Mom, Dad and 2 younger brothers Has 2 dogs and 1 cat He is 9 years old and very interested in The Walking Dead and Pokemon Staging Physical Assessment (Li-Min et. al, 2014) Erik Erikson: "Crises" Theory "Industry (Competence) vs. Inferiority" - Age: 6 to 12 - Goal: Achieve a sense of interpersonal competence through technological and social skills Due to illness, WP faced several challenges to this stage - Stress of illness preventing him from meeting societal and social benchmarks - Feelings of inferiority Based upon the "5-year survival rate" Low-risk: >95% Intermediate: 90-95% High-risk: 40-50% Prognosis/Survival Traditional Complimentary/Alternative Collaborative Nursing Research Integrate knowledge from the sciences, developmental theory and physical assessment data for the plan of care of a pediatric client and family in the acute care setting Formulate a holistic plan of care for the patient and family Developmental Considerations Jean Piaget: Theory of Cognitive Development "Concrete Operational Phase" - Age: 7 to 11 - Children are able to use their thought processes to experience events

Nursing Grand Rounds

Transcript: Nursing Grand Rounds by Shannon Loutzenhiser Shannon Loutzenhiser INTRODUCTION INTRODUCTION OLD DOMINION UNIVERSITY PATIENT Female Born at 25 weeks, now 5 months but developmentally 8 weeks IVH with shunt placement NGT HISTORY & ASSESSMENT CLIENT HISTORY & ASSESSMENT 1 HISTORY 48 weeks old born at 25 weeks Interventricular hemorrhage determined at 5 weeks old External Ventricular Drainage performed q.o.d Permanent CSF shunt put in place at 17 weeks old Bronchopulmonary Dyplasia as a result of intubation from 0 - 15 weeks old NGT placed at birth FAMILY HX Was A twin, brother passed at 5 weeks Mother is an immigrant from sicily, father in the Navy Mother and father very involved in cAre 2 Developmentally Gross motor skills Nutritional needs and Eating habits Assessment Vital Signs Spo2% Weight Heart Rate 3 Daily Weights I/O Nutritonal and NGT care 83mL/60mins every 3 hRs 23 kcal/oz Gel formula Nursing Specific Care PLAN OF CARE PLAN OF CARE Main Problems: Apirating when eating Not gaining adequate weight Interventions: Occupational therapy High calorie formula Intended Outcomes: Gain 30g a day Tolerate PO feedings NGT removal EDUCATION FAMILY EDUCATION IVH SHUNT EMERGENCY INTERVENTRICULAR HEMORRHAGE (IVH) Bleeding into the ventricles, usually in preterm babies due to immaturity of the cerebral vascular area and fragile capillaries Causes vary Graded from I (mild) to IV (severe) Dxed via CT and MRI Calls for follow up scans Causes for concern with Shunt Buldging Fontannelle Bradycardia High pitch cry Apnea Weak suck NGT CARE NG TUBE EDUCATION Measure from the tip of the nose to the earlobe, down to the xiphoid process- MARK LOCATION ON TUBE & TAPE TO CHEEK!! Placement can be confirmed via measuring pH of gastric secretions- pH <5 Patient should be placed in supine position with elevation of 30 degress of more during feedings STOP FEEDING if child begins to vomit during feeding and TURN CHILD ON SIDE or SIT CHILD UP Watch for signs of oxygen deprivation and choking as this may be due to NGT in the lungs How to set up pump RELATED RESEARCH RELATED RESEARCH Permanent CSF shunting after intraventricular hemorrhage in the CLEAR III trial OBJECTIVE & Methods OBJECTIVE To study the factors related to permanent CSF diversion and the relationship between shunting and the functional outcomes related to spontaneous interventricular hemmorrhage (IVH). METHODS A randomized, multicenter, double-blind, placebo-controlled trial was conducted to determine if employed external ventricular drainage (EVD) plus intraventricular alteplase improved outcomes versus EVD plus Saline. Outcome measures were predictors of shunting and blinded assessment of mortality and modified Rankin scale at 180 days. RESULTS & Conclusions RESULTS Among 500 patients with IVH, a CSF shunt was put in place in 90 (18%) of pateints. In the multivariate analysis, black race, duration of EVD, daily CSF drainage , and intracranial pressure greater than 30 mm Hg were all associated with higher odds of permanent CSF shunting. Patients with CSF shunts had similar odds of 180 day mortality, while survivors with shunts had increased odds of poor functional outcome compared to survivors without shunts. CONCLUSIONS Among the patients with spontaneous IVH requiring emergency CSF diversion, those with early intracranial pressure, high CSF output, and placement of more than one EVD, are at increased odds of permanent ventricular shunting. Administration of intraventricular alteplase, early radiographic findings, and CSF measures were not useful predictors of permanent CSF diversion. Carman, T.K. S. (2020). Lippincott CoursePoint Enhanced for Kyle & Carman's Essentials of Pediatric Nursing (4th Edition). Wolters Kluwer Health. P. 60-76, 377, 516. https://coursepoint.vitalsource.com/books/9781975156060 REFERENCES REFERENCES Murthy, Santosh B. at al. (July 25, 2017). Permanent CSF shunting after ventricular hemorrhage in the CLEAR III trial. American Association of Neurology. 89(4): 355-362

Nursing Grand Rounds

Transcript: 23 September 2018 Understanding A Patient's Journey STROKE CARE IN QRI Introduction Department of Nursing & Midwifery Education & Research is accredited as a provider of Continuing Nursing Education by the American Nurses Credentialing Center's Commission on Accreditation This activity is accredited activity under Category 1 as defined by the Qatar Council for Healthcare Practitioners - Accreditation Department and is approved for a maximum of hour(s): All individuals in a position to control content (Nurse Planer, content expert, presenters, faculty, authors, and content reviewers) disclosed no relevant relationships with any commercial organization to influence the content of this activity To successfully complete the activity Learners must attend the entire activity complete the participant feedback tool. actively participate in the discussion Disclosure All information disclosed within this case study is confidential and permission was granted by the patient depicted in this presentation for said information to be used as a teaching tool. Confidentiality Introduction Videos QRI Facilities utilized by Stroke Patients STROKE WHY STROKE? COMMUNITY Every Minute Counts What is your Role? Recognize someone is having a STROKE HOW? Every Minute Counts Importance of Nurses in Stroke Rehabilitation Video Incidence Rate Incidence Rate Video 2nd Leading Cause of DEATH worldwide 1st Leading cause of DISABILITY in the United States Total: 4823 cases WHY? low income workers high smoking rates Medical Professionals Issues / Risk Factors Treatment Options Undiagnosed Professor Ashfaq Shuaib Director, Neurosciences Institute of Hamad Medical Corporation Risk Factors Video Stroke pathway 06 February 2018 2329H Mr. K arrived at the HGH Emergency Department via stretcher accompanied by EMS staff.. Complained of Right Sided body weakness for 3 hours Slurred speech Mild Headache Mouth slightly deviated to the right Appears to be irritated Upon Assessment, Mr. K is a known case of Hypertension and DM Type II. BP= 201/113 mmhg HR= 103bpm RR=18 br/min Temp = 37.1*C SPo2 = 100% RBS= 20mmol/L weight = 50kg height = 160cm Right Upper limb 2/5, Right Lower limb 3/5 Decreased pinprick on right upper arm Left upper and llower 5/5 Labetalol 200mg IV Bolus given Head CT Scan was done Management Left Thalamic Bleed Intracranial Hemorrhage Labetalol 20mg IV Given Foley's Catheter Fr14 Inserted ADMIT TO WARD Seen by the Medical Stroke Team 08 February 2018 Case was discussed with Rehab Doctor; according to him, it was a good case for rehabilitation,(QRI Consultant for Rehabilitation) was informed and agreed to transfer patient to QRI NIHSS = 7 ST recommends continuing on MSD with Thin liquids, start trial for Regular diet Bladder= on diaper, needs 2 person during changing due to cognitive impairment OT: Fluctuating alertness and orientation and limitation in short term memory. 2 person’s assistance during transfer ADMIT To QRI Admission Criteria Is hemodynamically stable Is able to understand and cooperate with the plan of the rehabilitation program. National Institutes of Health stroke Scale (NIHSS) score is between 6-13. A clear diagnosis and co-morbidities have been established. All abnormal laboratory values have been acknowledged and addressed as needed There is no substance abuse or psychiatric issues limiting the patient’s ability to participate in the program Needs two or more Therapy services and intensive rehabilitation care that cannot be provided in an Outpatient Stroke Rehabilitation Program Upon arrival to QRI Initial contact with the patient, performs Nursing Assessment, Received hand over from the Handing Over Nurse PMR Physician sends referral to (multdisciplinary team)OT,PT,ST,DIetitian,Social Worker, Case Manager, CBR *initial assessment done within 24 Hours upon admission Risk factors for stroke recurrence Medical co morbidities Level of consciousness and cognitive status Swallowing assessment Skin assessment and risk for pressure ulcers Bowel and bladder function Nutritional and Hydration assessment Mobility, with respect to the patient’s needs for assistance in movement  Risk of Deep Vein Thrombosis (DVT) History of previous antiplatelet or anticoagulation use, especially at the time of stroke Need for emotional support for the family and caregiver 12 February 2018 1st Case Conference Plan is for 6 weeks stay Rehabilitation Program Company will support patient's financial needs To continue Bladder Training To Continue rehabilitation program by gradually increasing intensity of exercise To Control Blood pressure and Blood sugar level Patient is already continent to both bladder and bowel on Regular Diabetic Diet Can walk with minimal assistance for DISCHARGE at the end of the week (local discharge then repatriation) Company is cooperative 2nd Case Conference 26 February 2018 Profile 08 Feb Day 01 Arrival in Stroke Unit Right Sided Body Weakness (RUE 2/5 RLE 3/5 LUE 5/5 LLE 5/5) SLURRED SPEECH Known case of DM II and 09

Nursing grand rounds

Transcript: PMH: Trisomy 21 35wk / 4lbs 11oz / twin "b" Hearing loss bilaterally Poor PO feeding, GERD Congenital heart disease Hyperopia Family: Married parents, twin brother, younger sister, nanny Collaborative Care Admitted: 3-31-2015 Dx: Oral Aversion (1) and failure to thrive (2) Patho-physiology: Down Syndrome Hypotonia Hx of GERD and VSD Tx: Safely support nutrition & hydration Determine optimal feeding techniques Provide meals in most normal setting Prevent future feeding problems with education Focus on parental stress Attentive to parents perceptions Encourage open communication Help decrease added stressors Find additional support Positive appraise for child & family Follow-up with families Nursing Problems Cont. Nursing care of the infant with oral aversion Objectives Neuro: Hearing loss, fussy GI: Oral aversion Skin: Healed scar midline on chest from previous VSD repair, flaky skin Musc/Skel: Hypotonic, not walking Psy/Soc: Parents have not visited or called for 4 days Fall Risk: 21 (Humpty Dumpty Scale) Feeding disorders in Down syndrome Parental stress reaction Education, support, & resources (Hall, et. al., 2012) Comrie, J. (n.d.). Feeding difficulties in children with down syndrome. Hall, H., Neely-Barnes, S., Graff, J., Krcek, T., Roberts, R., & Hankins, J. (2012). Parental stress in families of children with a genetic disorder/disability and the resiliency model of family stress, adjustment, and adaptation. Issues in Comprehensive Pediatric Nursing, 35, 24-44. Hockenberry, M., & Wong, D. (2013). Wong's nursing care of infants and children (9th ed., pp. 920-921). St. Louis, Mo.: Elsevier Mosby. Developmentally delayed toddler Special needs child Distant/absent parents Repeatedly admitted for poor feeding Twin brother Developmental Age Purpose: Determine how stress impacts parent-child relationship for children with disabilities Methods: Sequential mixed-methods (qual. & quant.) 25 mothers of children with ASD, DS, CP, and SCD Results: 10 clinically stressed 12 non-stressed profile Physical Assessment (Hockenberry & Wong, 2013) references Problems Cont. Introduce patient Discuss medical diagnosis and hospitalization Discuss development and assessment data Apply appropriate nursing diagnoses including interventions and expected outcomes Michelle Estep Reason for Hospitalization Patient: (Comrie) Summary Research Implications Spring 2015 Observation of feeding by OT Teaching of feeding skills Supplemental additive calories (carnation breakfast) Yogurt with whole milk Liquids first Water offered x2 daily Singing when fussy Scheduled feedings Normal development of infant with trisomy 21 Cultural Considerations Expected Stage: Autonomy vs. Shame & Doubt Sensorimotor / preoperational Does not meet norms - 10mo developmentally Trust vs. Mistrust Sensorimotor Application to Care: Held and rocked patient Carried around Eye level interactions Sang and blew on his face to calm "Blake" 32mo old OT PT ST Nutrition Pet therapy Family & Discharge Teaching

Nursing Grand Rounds

Transcript: Cognitive deficits Memory Speech/Language Processing Functional and motor impairments Mobility concerns Swallowing Strength Interdisciplinary Concept Map Please go to: kahoot.it Amanda Porter Capabilities Self sufficient with meals Verbalize thoughts and needs Morning self-care Patient: D.E. References https://play.kahoot.it/#/k/e7b06282-dcfd-428c-be55-24fb5dea3873 Lives in a 2 story home with her husband Has a daughter that lives in the area Retired Former pianist, interior decorator, & missionary Baptist Rehabilitation Progress Purpose Revisioning, reconnecting and revisiting: the psychosocial transition of returning home from hospital following a stroke Aim: Investigate and improve understanding of the experiences of patients and their carers during the first month at home following discharge from the hospital Method: Interviews and self-report diaries Participants: 12 patient/carer dyad Results: 1st month home is a dynamic time Conclusion: In the first month home after a stroke, the cliet and caregiver both experience drastic psychosocial changes and challenges. (Pringle, Drummond & McLafferty, 2013) 67yo, African American female Diagnosis: Hemorrhagic CVA with Right-sided Weakness Warm Up Client Capabilities and Areas of Dependence Osteoarthritis Intradural extramedullary meningioma of T6-T7 Laminectomy & removal of meningioma HTN Health History Chief Reason for Rehabilitation Carpenito, L. (2013). Handbook of nursing diagnosis (14th ed.). Philadelphia, Pennsylvania: Wolters Kluwer/Lippincott Williams & Wilkins Health. Pringle, J., Drummond, J. S., & McLafferty, E. (2013). Revisioning, reconnecting and revisiting: the psychosocial transition of returning home from hospital following a stroke. Disability & Rehabilitation, 35(23), 1991-1999 9p. doi:10.3109/09638288.2013.770081 Psychosocial History To provide the student an opportunity to: Integrate knowledge from the sciences to the care of a client with a physical disability Demonstrate critical thinking and independent judgments in managing care of a client with a physical disability Areas of Dependence Walking Transfers Mobilizing wheelchair Orientation to time Sequencing Language expression Homemaking Walking (Min Assist) Transfers balanced and safe Move wheelchair with arms & legs Improved cognitive processing Orientation and memory deficits Easily confused Nursing Grand Rounds Rehabilitation Transitions

Nursing Grand Rounds

Transcript: Prematurity is the most common risk factor Questions? Over 3 hours after B.G. was brought to the NICU I walked Dad to see Mom in her room Mom had not received any information about her baby The doctor arrived and talked to parents My role as communicator and teacher Acrocyanosis Normotensive: blood pressure 55/28 mmHg Thank You! Gentamicin 4 mg/kg IV every 24 hours Nasal flaring, grunting, retractions observed B.G. is a newborn girl delivered via C-section at 36 weeks Presentation at Birth Deterioration of lung function CPAP was inadequate to maintain oxygenation Intubated and ventilated Surfactant was administered Bloody fluid is discharged from pulmonary vasculature and collects in alveoli Impaired gas exchange r/t blood secretions and alveolar-capillary membrane changes AEB abnormal breathing rate and rhythm; nasal flaring; retractions; grunting Mother is a healthy 32 year old, G2P1 Blood cultures Blood glucose: 24 mg/dl Nursing Grand Rounds Neo-puff used for 1 minute at 1 minute old Ampicillin 50 mg/kg IV every 6 hours APGAR: 8 at one minute and 9 at five minutes Respiratory distress present at birth Surfactant 2.5 ml/kg, repeat dose as needed CBC with differential WBC: 26,500 Hemoglobin: 19 mg/dl RBC: 5.3 million/cu Hematocrit: 20% Further Complications Following intubation orange/red aspirate was noted Diagnosis of pulmonary hemorrhage was made Priority Nursing Diagnosis D10W 5 ml/kg IV The decision to transfer B.G. to a level IV NICU was made and at 6 hours of age she was transported via critical care transport ambulance. She was admitted to the NICU for respiratory distress and rule out sepsis Assessment NICU Case presentation: Pulmonary Hemorrhage Dopamine Hydrochloride 7 micrograms/kg/minute IV Chest X-ray bilateral infiltrates small pneumothorax present Length: 18 inches Background Pathophysiology: Pulmonary Hemorrhage C-reactive Protein 2.4 mg/dl Normal: less than 0.6 mg/dl indication of inflammation process or infection Falling blood pressure Albumin infusion started Dopamine was administered Usually a massive catastrophic event Situation Pharmacology Diagnostic Tests Tachycardia: heart rate of 180 beats per minute Inhaled nitric oxide Tachypnea: 80 breaths/minute Following Admission to the NICU Communication with parents Weight: 5 lbs. 2 oz. Routine uncomplicated C-section B.G. was promptly brought to the NICU 62 ECG bpm

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