Pediatric Grand

RoundsBy Jamie Martin

Overview

AA female infant Born on 11/20/12 at 26 weeks gestation Chronological age: 16 weeks/ 4 months Adjusted age: 2 weeks

Overview

Client History and Assessment Identification of Nursing Problems and Plan

of Care Clinical Teaching Research

Maternal History

37 yo G4P0030 mother Fibroid uterus Cystic fibrosis Elevated WBC count

Client History Extreme prematurity (26 weeks gestation), 920 g

Retinopathy of prematurity

L and R sided MSSA neck abscesses

Respiratory distress syndrome

Large PDA

Anemia of prematurity

Left pnuemothorax

Hypotension

hyperbilirubinemia

Family/Psychosocial History

Mother—student at TCC at time of birth Father—working in Richmond Single parent household? Both parents currently living in Richmond Have “strong support network”

Cultural Considerations

Physical separation Emotional detachment

Primary Medical Diagnosis

Feeding Intolerance related to prematurity

Pathophysiology

Feeding Intolerance measured by: Soft abdomen Absence of abdominal distention Minimum/no aspirated gastric residual Presence of bowel sounds Minimum to no spitting up or vomiting Infant’s continued interest in feeding Consistent behavior pattern

Pathophysiology

Feeding success is measured by the infant’s ability to: Participate in feeding with energy Coordinate sucking and swallowing with adequate pauses

for breathing Maintain vital signs and oxygenation WNL Maintain normal muscle tone in face and body Complete feeding in about 20 to 25 minutes Manage a liquid fluid bolus with minimum or no loss of

liquid from mouth Sustain alertness for feeding Maintain strength and endurance for entire feeding Measure appropriate for age on standard growth curve

Pathophysiology

Anatomic/physiologic disabilities of the premature infant:

Coordination of suck and swallow at 32-34 wks

Poor muscle tone of the cardiac sphincter

Carbs and fats are less tolerated

Secondary Medical Diagnoses

BPD Aspiration GERD Thrush Very large umbilical hernia

Treatment Plan

Thickened PO feeds as tolerated OT Rehab Medications

Nystatin Prilosec Lasix O2

Treatment Plan

OT/Rehab support Pattern Consistency Nipple type Jaw and cheek support Swaddle Enteral feedings prn

Expected Developmental Age

Newborn Norms: Can turn head side to side head lag Strong grasp reflex Clenches hand on contact w/ rattle Follows light to midline Quiets when hears a voice Cries to express displeasure Watches parents’ faces intently as they talk

Developmental Theory

Trust vs. mistrust Sensorimotor Oral

Abnormal Physical Assessment

Neuro: Fussy at times

Respiratory: BPD, upper airway congestion

GI: very large umbilical hernia

Feeds: inconsistent, PO/enteral

Thrush

Altered Vision

Feeding Intolerance

Difficulty Taking PO feeds Aspiration on VSS Treatments:

PO feeds: 6 per day if awake, Neosure 24 kcal PO feeds thickened w/ rice cereal OT Rehab Meds: Nystatin, Prilosec

Impaired Gas Exchange

BPD Upper airway congestion Hx PDA Inactive Treatments:

1/8L NC Suction prn PT Meds: Lasix

Infection

Candida Albicans (thrush) Hx MSSA abscess on R and L sides of neck Long hospital stay Treatments:

Change pacifier daily Clean/Sterile technique HANDWASHING! Meds: Nystatin

Deficient Knowledge, Family

Parents live in Richmond Expressed being overwhelmed with

information Daughter hospitalized since birth (Nov. 20,

2012) Treatment:

Provide education/information via phone Facilitate contact during visits

Risk for Imbalanced Nutrition

Prematurity Feeding intolerance VSS showed aspiration Treatments:

Neosure 24kcal w/feeds 6 times per day PT OT Rehab

Holistic Nursing Care

Traditional interventions Assessments Medication administration Feedings

Holistic Nursing Care

Complimentary/Alternative Interventions Respectful approach Blanket swaddling and nesting Infant Massage

Holistic Nursing Care

Collaborative Interventions Feeding

Nursing OT PT Rehab

Relationship between Nursing Dx

Discharge Planning Family Teaching

Model appropriate feeding techniques Provide opportunity for feeding Educate on infant cues and how to measure feeding success Home oxygen administration Immunizations Car seat safety Medications

Referrals Home Health Care Support groups Plan nursing follow-up

Clinical Teaching

iPhone AppNICU Knowledge Parent

Educatorhttps://itunes.apple.com/us/app/nicu-knowledge-parent-educator/id508051096?mt=8

Clinical Teaching

Current Nursing Research

Current Nursing Research

Current Nursing Research

Current Nursing Research

Current Nursing Research

ReferenceSchlittenhart, J. M., Smart, D., Miller, K., &

Severtson, B. (2011). Preparing Parents for NICU Discharge. Nursing For Women's Health, 15(6), 484-494. doi:10.1111/j.1751-486X.2011.01676.x

Questions?

The End