Pediatric Concept Map

Pediatric Concept Map

Assessment

Admitting Diagnosis:

Respiratory distress

& Episode of Syncope

Vital Signs: BP: 93/67 P 119 RR 25 O2 sat 100% T 36.6

Cardiac: Within normal limits. S1 & S2 present, apical pulse regular and strong, in synchrony with radial pulse. Cap refill <3 seconds in all extremities.

Respiratory: Patient had increased respirations. Stridor is patient's "normal" due to cleft palate, but would become worse if patient cried.

GI/GU: Patient's urine output adequate based on intake. Patient had not had a bowel movement (BM) since the day of admission, but wasn't digesting food adequately while hospitalized (regurgitation). Bowel sounds present in all 4 quadrants, no distention, no grimacing or crying w/palpation. Site of G-tube insertion was clean and intact with no signs of infection.

Integumentary: Skin was warm to touch. Two incision scars present from 10/05/16 & 10/27/16; both completely healed. Site of G-tube was clean and intact and showed no signs of infection (redness, swelling, etc). IV site on right arm clean and intact, flushed well and showed no signs of infection.

Developmental: Baby interacted well when awake. Would react to sounds and touch. Followed pen easily with eyes and smiled often. Grips in both hands were equal and strong, Babinski sign present in both lower extremities. Able to use pacifier, sucking reflex present.

1. Respiratory distress is defined by having difficulty to breath or not having enough oxygen. Respiratory distress can cause increased heart rate, increased respiratory rate, a change in skin color, nasal flaring, retractions, wheezing, stridor, and change in alertness among others (University of Rochester Medical Center, 2017).

2. Syncope, also known as fainting, is a temporary loss of consciousness as a result of insufficient blood flow to the brain or decreased supply of oxygen to brain (American Heart Association, 2016)

References

Baby DJ

ED summary:

Patient was brought to the ED after fainting while having a bowel movement. Patient was "unconscious for 2 minutes, not moving, & turned blue". Patient then regained consciousness after someone blew on baby's face and took him outside. Parents mentioned baby's baseline included nasal flaring, intercostal retractions, noisy breathing, and had turned blue before when having a BM, but had never lost consciousness. Baby had increased WOB (not his usual) according to parents.

Alur, P., Liss, J., Ferrentino, F., & Super, D. M. (2012). Do bulb syringes conform to neonatal resuscitation

guidelines? Resuscitation, 83(6), 746-749. doi:10.1016/j.resuscitation.2011.11.023

American Heart Association. (2016). Syncope (Fainting). Retrieved from

http://www.heart.org/HEARTORG/Conditions/Arrhythmia/SymptomsDiagnosisMonitoringofArrhythmia/Syncope-Fainting_UCM_430006_Article.jsp#.WL9Kl45JmRs

Badiee Z, Eshghi A, Mohammadizadeh M. High flow nasal cannula as a method for rapid weaning from

nasal continuous positive airway pressure. Int J Prev Med 2015;6:33.

Boston Children's Hospital. (2017). Laryngeal clefts in children. Retrieved

from http://www.childrenshospital.org/conditions-and-treatments/conditions/laryngeal-cleft

Freitas, J. A., Garib, D. G., Oliveira, M., Lauris, R. D., Almeida, A. L., Neves, L. T., … Pinto, J. H. (2012). Rehabilitative

treatment of cleft lip and palate: Experience of the Hospital for Rehabilitation of Craniofacial Anomalies - USP (HRAC-USP) - Part 2: Pediatric dentistry and orthodontics. Journal of Applied Oral Science, 20(2), 268-281. doi:10.1590/s1678-77572012000200024

Griffith, C., & Liversedge, T. (2015). Laryngeal clefts. BJA Education, 15(5),

237-241. doi:10.1093/bjaceaccp/mku046

Jadcherla, S. R., Chan, C. Y., Moore, R., Malkar, M., Timan, C. J., & Valentine, C. J. (2012). Impact of feeding strategies on the

frequency and clearance of acid and nonacid gastroesophageal reflux events in dysphagic neonates. Journal of Parenteral and Enteral Nutrition, 36(4), 449-455. doi:10.1177/0148607111415980

Johnston, D., Ferrari, L., Rahbar, R., & Watters, K. (2014). Laryngeal cleft:

Evaluation and management. International Journal of Pediatric Otohinolaryngology, 78, 905-911. doi:10.1002/lary.23498

Kids Health From Nemours. (2017). Blood test: Comprehensive metabolic

panel (CMP). Retrieved from http://kidshealth.org/en/parents/blood-test-cmp.html

Lechtzin, N. (2017). Chest imaging. Retrieved from http://

www.merckmanuals.com/home/lung-and-airway-disorders/diagnosis-of-lung-disorders/chest-imaging

London, M. L., Ladewig, P. W., Davidson, M. R., Ball, J. W., McGillis, R. C., &

Cowen, K. J. (2014). Maternal & child nursing care (5th ed.). NJ: Pearson Education Inc.

Mayo Clinic. (2016). Overview - complete blood count (CBC). Retrieved from

http://www.mayoclinic.org/tests-procedures/complete-blood-count/home/ovc-20257165

McNab, S. (2016). Intravenous maintenance fluid therapy in children. Journal of Paediatrics and Child Health, 52(2),

137-140. doi:10.1111/jpc.13076

University of Rochester Medical Center. (2017). Signs of

respiratory distress in children. Retrieved from https://www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=90&ContentID=P02960

Nursing Diagnosis 1

Ineffective breathing patterns related to congenital laryngeal cleft and increased oral secretions (drooling) as evidenced by nasal flaring, intercostal retractions, tachypnea, and noisy breathing (stridor).

Outcome 1: Patient's O2 saturation will remain above 93% during hospital stay. O2 saturation to be measured by continuous pulse ox.

Intervention 1: Student nurse will provide patient 3L of O2 with high flow nasal cannula as ordered and keep O2 probe sticker in place. Delivery of oxygen via high flow nasal cannula has been found to decrease airway cooling, thickened secretions, and nasal irritation (Badiee, Eshghi, Mohammadizadeh, 2015).

Evaluation 1: Goal in progress. Patient's oxygen saturation during shift remained between 98-100%. Nurse will continue to monitor O2 sat and make sure cannula is in place.

Outcome 2: Patient will have effective airway clearance by coughing secretions (saliva & mucus) out of oral cavity or by being suctioned as needed during shift. Clearance can be evaluated by hearing patient's breathing an O2 sat.

Intervention 2: Student nurse will use suction equipment and bulb syringe as needed to clear patient's airway. The American Academy of Pediatrics' Neonatal Resuscitation Program has established a guideline indicating that the use of bulb syringes and suction catheter systems are recommended for clearing the airway (Alur, Liss, Ferrentino, & Super, 2012).

Evaluation 2: Goal met. Patient was turned more to side by grandma or suctioned when needed if patient started coughing or breathing noises sounded different than normal.

Outcome 3: Patient will show effective breathing patterns such as normal respiratory rate and characteristics (No stridor, intercostal retractions, nasal flarings, etc) after cleft is repaired.

Intervention 3: Student nurse or nurse will assess respiratory status (rate and characteristics), will monitor vital signs as ordered, and will try to avoid crying or coughing by patient. Adequate post operative care is important as complications (loss of graft) rates are high and can be avoided with good care (Griffith & Liversedge, 2015).

Evaluation 3: Goal in progress. Patient's plan is to have cleft repaired within the first year of life as long as he is healthy and stable according to grandma.

Past Medical History

3 months-old

FULL CODE

No Allergies

Admitted 1/25 to PICU

Day of Care: 1/28

Wt: 6.04 kg

Ht: 62 cm

BMI: 15.7

Diet: NPO; Neosure Infant Formula via g-tube once tolerated

O2: High Flow Nasal Cannula (3L), continuous pulse ox

• Esophageal atresia/Distal Esophageal Fistula (Repaired): With esophageal atresia, the esophagus does not lengthen and separate into two different tubes, and the esophagus and trachea are not formed correctly. This malformation can result with the esophagus being connected to the trachea by a fistula. Fistula is corrected once the esophagus is at the desired length, and can be reconnected to appropriate spot (London & Ladewig, 2014).

• Congenital Laryngeal Cleft (Type III): Malformation in which a child is born with an abnormal opening between the esophagus and the larynx (voice box). Having this opening present puts the child at risk for aspiration of food and breathing problems. Type 3 signifies that the opening extends beyond the larynx into the trachea (Boston Children's Hospital, 2017).

• Gastric tube insertion: Inserted for the purpose of nutritional support if a child cannot take food orally to maintain adequate nutritional intake (London & Ladewig, 2014).

Nursing Diagnosis 3

Altered Nutrition: Less than body requirements r/t inability to digest nutrients as evidenced by episodes of regurgitation.

Outcome 1: Patient will remain hydrated throughout hospital stay. Hydration determined by presence of moist mucous membranes and normal (not depressed) anterior fontanelle.

Intervention 1: Student nurse will provide continuous IV fluids as ordered at 25 ml/hr. Patients with reduced oral intake commonly receive IV fluids to maintain adequate hydration and prevent further deterioration of health (McNab, 2016).

Evaluation 1: Goal in progress. Patient's mucous membranes moist and anterior fontanelle normal (flat) during shift. Will continue to monitor.

Outcome 2: Patient will restart feeds slowly to prevent regurgitation and allow for digestion at 10 ml/hr. Bolus feed of 38 ml over 2 hours if well tolerated.

Intervention 2: Student nurse will start bolus at 10 ml/hr at 14:00 and assess for regurgitation. Longer feeding times and a slow rate are associated with decreased incidence of gastroesophageal reflux (Jadcherla, et. al., 2012)

Evaluation 2: Goal met/ in progress. First hour tolerated well. Was not present for second hour, but would be monitored for episodes of regurgitation by nurse.

Outcome 3: Patient will be back at 83 ml/hr bolus feeds as it was back home before discharge.

Intervention 3: Student nurse will increase feeds as ordered and tolerated. Period of good health, adequate nutritional intake, and good symptom control should be attained before corrective surgery (Griffith & Liversedge, 2015).

Evaluation 3: Goal in progress. First hour tolerated well. Nurse would try to aim for the first bolus feed to be at 38 ml over 2 hours. Bolus rate would be increased to goal (83ml/2hrs) slowly (about 10 ml/ increase every bolus) if tolerated.

Nursing Diagnosis 2

Risk for aspiration related to congenital laryngeal cleft as evidenced by respiratory distress, increased work of breathing, stridor, increased oral secretions (drooling), and episodes of regurgitation.

Last Set of Vitals (Ordered q2-4) hrs

• Temp: 36.2 C
• Blood Pressure: 104/63
• Heart Rate: 129 bpm
• Respiratory Rate: 36
• O2 sat: 100%

Outcome 1: Patient will have no episodes of aspiration during shift by coughing up secretions effectively or with assistance of suction.

Intervention 1: Student nurse will make sure suction equipment and bulb syringe is at bedside at all times. Having equipment ready is essential to remove large amount of secretions in a timely manner (Alur, Liss, Ferrentino, & Super, 2012).

Evaluation 1: Goal met. Patient did not have any episodes of aspiration during shift. Patient was suctioned with bulb syringe when necessary by family and student nurse.

Outcome 2: Patient will tolerate & digest feeds appropriately without regurgitation during the first hour after restarting (preventing risk of aspiration).

Intervention 2: Student nurse will restart feedings slowly at 10 ml/hr as ordered instead of the usual 83 ml/hr given at home. Presence of GER puts the child at greater risk for aspiration (Johnston, Ferrari, Rahbar, Watters, 2014).

Evaluation 2: Goal met. Patient tolerated feeds well the first hour and did not have any episodes of regurgitation.

Outcome 3: Patient will maintain patent airway throughout hospital stay.

Intervention 3: Student nurse will position baby correctly using sling and rolled up blankets to keep patient at 30-45 degree angle and to one side. Infants should be placed in vertical position (approx. 45 degree angle), especially when feeding, to reduce risk of reflux (Freitas, et.al., 2012).

Evaluation 3: Goal in progress. Patient's position was checked frequently to make sure baby's head was higher than body. Sling and rolled up blankets repositioned by both grandma and student nurse. Grandma was educated about positioning, but was already aware and practicing at home.

Medication List

Lines

• Basilic vein (medial side of right arm) over the needle catheter system. 22 g

Intake & Output (1/27-1/28)

1. Cholecalciferol (Vit D3) oral drops: 200 units daily. Administer via G-tube.

• Used as a dietary supplement to avoid Vit D deficiencies and to enhance absorption of calcium.

2. Dextrose 0.5% & 0.9% NaCl with 20 mEq/L KCL infusion at 25 ml/hr IV continuous infusion.

• Maintenance fluids to keep child hydrated and electrolytes balanced.

3. Famotidine 8 mg/ml oral suspension: give 2.4 mg via feeding tube 2 x daily.

• Antacid used to prevent excess stomach acid and gastroesophageal reflux (GER); prevents incidence of aspiration of stomach contents.

4. Glycopyrrolate (Robinul) injection, 0.024 mg

Dose: 4 mcg/kg x 5.95 kg, IV q 6 hrs

• Anticholinergic given to reduce the secretions of the mouth and throat; therefore preventing incidence of aspiration.

5. Dexamethasone (decadron) injection, 2.96 mg

Dose: 0.5 mg/kg

Admin dose: 2.96 mg IV q 12 hrs

• Steroid given to treat inflammation such as inflammation of the respiratory tract.

6. Tube feeds bolus 150 ml 6 x daily. STOPPED 1/26

Tube feeds bolus 86 ml 6x daily. STOPPED 1/26

• Infant formula stopped due to baby having episodes of vomiting the day before. Feeds started on 1/27 at 14:00 again starting at 10ml/hr to check if patient would tolerate.

Labs

IV: 665.1

IVPB 1.8

Feeding 13

Total: 679.9 ml

Rrine: 576

Other: 46

Total Output: 622

Plan:

Patient will be transferred to Peds floor once high flow nasal cannula is not needed.

X- Ray: Chest images can show serious disorders in the lungs such as pneumonia, tumors, pneumothorax, and pleural effusion (Lechtzin, 2017).

• Lungs expanded adequately in DJ. Redomonstration of focal airspace disease in right lower lobe with additional scattered air space opacities within the remainder of the lungs were seen. Presence of focal airspace disease can indicate airspace is swollen and may contain fluid due to infection or aspiration (Gaillard, 2017).

Complete blood count: Test used to assess for different disorders anemias and infections. This test measures the components & features of blood including red blood cells, white blood cells, hemoglobin, hematocrit, and platelets (Mayo Clinic, 2016).

• All labs within normal limits on 1/25 and not reassessed by 1/27.

Comprehensive Metabolic Panel: Blood test used to evaluate kidney function, liver function, sugar and protein levels in the blood , and fluid & electrolyte balance in the body (Kids Health From Nemours, 2017).

• All labs within normal limits on 1/25 and not reassessed by 1/27

Nasopharyngeal swab culture taken to rule out Reflex Flu (A & B)/RSV. Rule out culture also done for Bordetella pertussis and B parapertussis. ALL CULTURES NEGATIVE.

By: Brianda Ramirez