Pediatric Nursing

Grand Rounds
Margaret Clough, Student Nurse

Objectives
• To apply physical assessment data to the care
of a pediatric client and family in the acute care
setting
• Utilize critical thinking and independent
judgments
• Understand a holistic plan of care for a pediatric
patient with Bowel Obstruction
• Review applicable research to the patient

Patient Introduction
• 1o month old
• Female
• Presented with






emesis,
personality change
intolerance to feedings
decreased activity
Dehydration
mild acidosis
hyperkalemia

Client Birth History
• DOB: 10/31/14 0304
• G1P0
• GA wk 35
• “some prenatal care”
• Cesarean Section d/t
fetal bradycardia
• Respiratory distress
• Congenital
Diaphragmatic hernia
diagnosed

Bowel Obstruction
Pathophysiology
When the passage of
nutrients and secretions
is impeded by a
constricted or occluded
lumen, or when these is
impaired motility.
Characterized by:
abdominal pain, nausea,
vomiting, abdominal
distention, and change in
stool patterns

Patient Introduction
• Post op day 9
and 10
• Primary
Medical Dx:
Bowel
Obstruction
• Secondary
Medical Dx:
Congenital
diaphragmati
c hernia

Cultural
Considerations
• Single mom
• Low
socioeconomic
status
• Frequent
Hospitalizations

Assessment
• Single parent

• Several female
influences

• Patient tolerated PO
feedings post-op day
10
• Fed herself with
bottle

• Regular BMs
• Appropriate I&O
• VS w/in normal limits
• Alert and Oriented

• Sucking, swallowing,
giggling
• Abdomen soft and
non-distended
• Incision on abdomen
clean, symmetrical,
and dressing intact
• Positive family
bonding, several
visitors
• Developmental age
appropriate

Development
• Erikson’s :
Trust Vs.
Mistrust
• Understand
behavioral
cues

• Piaget’s
Cognitive
Development
Sensorimotor
Phase

Nursing Diagnoses
1. Readiness for Enhanced Nutrition
2. Interrupted family processes
3. Risk for Infection
4. Risk for imbalanced nutrition: less than
body requirements related to risk for
altered body composition
5. Risk for Acute Pain related to extensive
exploratory laparoscopic surgery

Readiness for
Enhanced Nutrition
Supporting Data:
• Successful bowel movement
• absence of vomiting after PO intake
• expresses willingness to enhance nutrition
by reaching for bottle
Labs:
• TPN panel, metabolic panel, glucose check

Readiness For
Enhanced Nutrition
Nursing Interventions:
• Educate mother on proper nutrition for
patient
• monitor bowel movements and bowel
sounds
• assess tolerance of PO intake
• determine patterns of hunger
• Wean from TPN

Readiness For
Enhanced Nutrition
• Expected Outcome: Patient engages
in feeding herself with a bottle and
tolerates PO feeding.
• Evaluation: The patient was able to
appropriately reach for the bottle and
tolerate PO feeding on the day of
discharge as evidence by the absence
of emesis. Last bowel movement was
recorded 9/29.

Risk For Nutritional Imbalance: less than body
requirements related to Risk for Altered Body
Composition
Supporting Data:
• TPN dextrose 14% 32mL/hr, 768 mL per day
continuous
• Fat emulsion 20% 250mL bag 2.5mg/kg
4.11mL/hr,
•  prolonged NPO
• altered GI tract function
• increased metabolic rate

Risk For Nutritional Imbalance: less than body
requirements related to Risk for Altered Body
Composition

Nursing Interventions:
• maintain potassium <3.89
mEq/kg/day
• Maintain calcium <1.94
mEq/kg/day
• consult a dietician regarding TPN
order
• assess for the signs and
symptoms of electrolyte
imbalance
• monitor triglycerides
• assess hyper/hypoglycemia,

Risk For Nutritional Imbalance: less than body
requirements related to Risk for Altered Body
Composition
• Expected Outcome: The patient will
maintain normal serum electrolytes
and serum glucose while hospitalized.
Mother will be educated on signs and
symptoms of hypoglycemia before
discharge.
• Evaluation: The patient showed no
signs of hypoglycemia before
discharge. The mother was educated
and given discharge orders while I was
leaving for the day.

Interrupted Family
Processes

Supporting Data:

• multiple hospitalizations within first year of life
• history of surgery
• history of birth complications
• vocalization of stress
• unpredictable illness course
• discharge needs
• low socioeconomic status

Interrupted Family
Processes
Nursing Interventions:
• Assess caregiver-care
recipient relationship

• teach stress-reducing
techniques

• assess familial
communication patterns

• provide ample time to
discuss concerns

• assess family resources

• provide illness
information,
management strategies

• determine knowledge and
ability to provide care
• encourage identification
of resources whether
family or community

• signs and symptoms to
look for management
(Gulanick & Myers,
2013).

Interrupted Family
Processes
• Expected Outcome: Before discharge, the caregiver will
express satisfaction with caregiving role, demonstrate
confidence in post discharge care, recognize available
resources, and demonstrate flexibility and understanding
towards health issues.
• Evaluation: The patient’s primary caregiver demonstrated
satisfaction after feeding the patient on the day of discharge
by smiling and interacting with the patient positively. She
expressed excitement to get home, as well as, appropriate
understanding of signs and symptoms that would indicate
return to the hospital. The caregiver addressed day care as
an available resource in the community. She discussed
helpful sources within her family as her mother,
grandmother, and brother.

Risk For Infection
• Supporting Data: abdominal
incisions and presence of tubes, PICC
line, TPN
• Labs: CBC, glucose, any cultures if
necessary
• Meds: Prophylactic antibiotics post op

Risk For Infection
Nursing Interventions:
• monitor incision for redness, drainage, swelling,
and increased pain
• monitor PICC line
• wash hands and maintain aseptic technique during
dressing changes
• monitor TPN dextrose levels and influence on
patients glucose
• Assess patient temperature and other vital signs

Risk for Infection
• Expected Outcome: Patient remains free of
infection, as evidence by healing of the incision and
normal vital signs during hospitalization.
• Evaluation: Patient was free of infection
throughout stay in the hospital as evidence by a
temperature of 37.1 and a heart rate of 116..
Mother was educated on cleaning the incision and
dressing the incision for prevention of infection at
home. The mother was also educated to not bathe
the child in a full tub, rather have the child sit in a
few inches of water to prevent the water from
infecting the incision site.

Risk for Acute Pain
• Post op day 10 from extensive
exploratory surgery
• Incision
• Bowel inflammation
• FLACC score 0

Risk for Acute Pain
Nursing Interventions
• Assess signs and symptoms associated with
pain
• monitor vitals
• Assess



activity
Personality
fatigue
comfort level

Risk for Acute Pain
Expected Outcome: Patient exhibits
comfort demonstrated by a return to
baseline personality and activity.
Evaluation: The patient showed no
signs of pain, had normal vital signs as
indicated earlier, and a positive overall
demeanor as evidence by no crying and
return to personality.

Collaborative and Holistic
Care
• How was care provided for the entire
patient?
• What types of cooperation was
utilized?
• Why is this type of care important?

Reviewing Patient ProblemDiagnosis Relationships

Interrupte
d Family
Processes

Readiness
for
enhanced
nutrition

Risk For
Infection

Bowel
Obstruction
secondary to
intraperitoneal
adhesions and
intestinal
malrotation

Risk for
imbalance
d nutrition

Risk for
acute pain

Discharge Planning
• Parent Teaching
• How to clean incision
• How to maintain appropriate I/O
• s/s of emergent complications
(including hyperglycemia)
• 3 week check back

Research
“Predictors of parent post-traumatic stress symptoms after child
hospitalization on general pediatric wards: A prospective cohort
study”
Objective: The aim of this study was to identify predictors of parental
post-traumatic stress symptoms following child hospitalization
Conclusions:
• one quarter of parents of children hospitalized on pediatric (non-intensive
care) wards experienced significant post-traumatic stress symptoms
after their child’s discharge.
• Parents’ hospital-related anxiety, uncertainty and use of negative
coping strategies are potentially modifiable factors
• Ruther research is urgently needed to test the effectiveness of different
methods to provide psychological, emotional and instrumental support for
parents, focusing on increasing parent coping resources and reducing
distress during hospitalization.

Research

Comments?
Thank you!

References
• Franck, L. S., Wray, J., Gay, C., Dearmun, A. K., Lee, K., & Cooper,
B. A. (2015). Predictors of parent post-traumatic stress symptoms
after child hospitalization on general pediatric wards: A
prospective cohort study. International Journal Of Nursing Studies,
5210-21. doi:10.1016/j.ijnurstu.2014.06.011
• Gulanick, Meg; Myers, Judith L. (2013-02-05). Nursing Care Plans:
Nursing Diagnosis and Intervention (Kindle Location 1329).
Elsevier Health Sciences. Kindle Edition.
• Mosby (2012-11-29). Mosby's Dictionary of Medicine, Nursing &
Health Professions (Kindle Locations 61798-61805, 78160).
Elsevier Health Sciences. Kindle Edition.
• Wong, D. L., Hockenberry, M. J., & Wilson, D. (2011). Wong's
nursing care of infants and children. St. Louis, Mo: Mosby/Elsevier.