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PEDIATRIC GRAND ROUNDS AND CONCEPT MAP PRESENTATION GRADING CRITERIA (Include with presentation)

Response to Hospitalization Data Form (Accuracy & completeness is key, typed responses required) Using the Response to Hospitalization Data Form, Map it out with Colleagues

Name _________________________ Section I NURSING PROCESSES & ASSESSMENT 33 points DATA Admission, Medical & History Data (HPI and Past Medical History; Medical Diagnosis & Definition; Childs presentation/description of the illness, signs & symptoms S&S, risk factors, previous treatments/therapies) Laboratory test results with reference ranges. Explanation of lab test(s) to include the normal reference range, the patients results, and the significance of results. Explanation of the diagnostic test(s), the patients results and the significance of results. Medications/Pharmacological: Medication name, dose, route, frequency, indication for use and why child is receiving the medication, nursing implications and considerations. Fluid/electrolyte balance Psychosocial data Developmental history Response to hospitalization section Medical treatments/therapies & other nursing considerations Planning Needs & Community/Other Resources PHYSICAL EXAM FINDINGS: Head to Toe Descriptive, accurate, concise interpretation of the pertinent Section ANALYSIS & CRITICAL REASONING II 12 points ANALYZE AND DESCRIBE YOUR INTERPRETATION OF THE ABOVE DATA (Narrative summary to include all data and assessment findings. What does all of this data mean?) Section PLAN OF CARE III NURSING DIAGNOSES, GOALS/OUTCOMES, 20 points PLANNING AND IMPLEMENTATION, EVALUATION

Date ___________ Maximum Student Points Points 4

2 5

2 2 3 3 2 2 5

12

Formulation of nursing diagnoses, goals and expected outcomes (measureable) Prioritization of diagnoses (one physical and one psycho-social) At least SIX Nursing Interventions per nursing diagnosis & Rationales for each intervention Evaluation of nursing interventions & goals Discharge planning (Teaching child and/or caregiver; must be different from teaching handout) Includes Rationale and expected outcomes Section IV 5 points

2 2

6 pts.

6 4

6 HEALTH PROMOTION & OTHER PLANNING NEEDS Anticipatory guidance instructions Provides at least three parental anticipatory guidance instructions with rationales (relevance for selecting/relate to child/family) Community & other resources (at least 2) Provides at least 2 resources with rationales (relevance for selecting/relate to child/family) MANAGEMENT OF THE GROUP PROCESS Established & leads discussion with ground rules Clear, articulate, & presented content in logical flow Maintained eye contact, audible & clear voice projection Explains why the nursing diagnoses and interventions were chosen for the development of the care plan Explains the teaching handout and the rationale for the content The Presentation contributed toward group learning Creative and kept group engaged Respectfully listened, & validated input from others Formulated questions to stimulate discussion Allowed time for questions & summarized effectively Section VI 20 Points

Section V 10 points

1 point each

CONCEPT MAP & TEACHING PROJECT Teaching Handout (Creative, relevant to the child/family)

15

Concept Map Development & Content Creativity TOTAL POINTS EARNED out of 100 _________ Faculty Comments:

3 2

RESPONSE TO HOSPITALIZATION DATA FORM Data collection sources should be from the student nurse interactions with the child and family, other members of the health care teamas well as other sources such as charts, etc. (This form must be turned into the faculty member and typed) Student Name___Dina Spencer______ ASSESSMENT DATA Date 4/19/12

ADMISSION DATA: Date of Admission: 4/11/12 Childs initials: SD Age: 14 Gender: Female Cultural/Religious Considerations: Algerian/Muslim. Patient and family speak English, mother is currently in Algeria, father is in the United States with patient. Religious considerations for Muslim patients include avoiding pork products. Some female patients are uncomfortable with male health care providers, so you should ask the patient about this beforehand. Also some muslims are forbidden from receiving blood, or blood products. This should be asked of the patient during admission. For the patient at hand, she is only strict about not eating pork. Admission V.S. Wt., Ht.., HC (if applies <3 years age), pulse oximetry, pain (Graph out Wt., Ht., & HC)
T(Oral) = 36.10C HR(apical) = 135bpm

RR = 20br/min BP = 116/64 SpO2 = 95% on room air SpO2 Site = Right hand Height = 159.9cm Weight = 38.8kg BMI = 15.18 BSA = 1.31 Growth Charts on separate sheets

Allergies & Reactions: No known drug or food allergies. Cannot eat pork- no reaction documented though, strictly for religious purposes Other Significant admission/history data: Home Medications
Pulmicort BID Albuterol BID Pulmozyme daily Megase (250mg/day)

Immunization up to date MEDICAL DATA: History of Present Illness/Injury 14 y/o F Muslim pt from Algeria has history of primary ciliary dyskinesia (PCD) and a h/o pseudomonas in sputum culture s/p LLL lobectomy here with worsening cough and FTT for the past 2-3 weeks (stated by dad). She has frequent coughing that is worse in the morning with a productive yellow color sputum, non-bloody. Patient continues to have poor appetite and is prescribed megase. Patient is encouraged PO intake with high protein (ie meat) but still maintains poor appetite. Denies fever, vomiting, diarrhea, and constipation. Reports adherence to home medication regiment. Past Medical History PCD diagnosed 4 years ago at CNMC. H/o chronic otitis media and loss of hearing in that ear (left). Hx of mild pulmonary HTN and hx of enalapril (to treat HTN) at last admission. Past Surgical History LLL lobectomy Social Hx: Lives at home (Ashburn, VA) with mom, dad, sister (with Kartaegners and also currently admitted) and 3 brothers. Also lives with uncle. Mom is currently in Algeria for personal/family matters.

Medical Diagnoses (Include ALL):


1.

a) definition of the illness/problem/condition(s) (with APA reference) Primary ciliary dyskinesia Primary ciliary dyskinesia (PCD) is a rare genetic lung disorder, also known as Immotile Cilia Syndrome and is associated with Kartegener's Syndrome. In people with PCD, the tiny hair-like structures (cilia) that are supposed to move mucus out of airways are abnormal or do not move. The mucus accumulates, causing blockage and infections. There is no cure for PCD, but if the disease is monitored closely and treatment begins early, people can live productive lives. b) major symptoms with this condition (with reference) Major Symptoms include: Respiratory distress as a newborn Chronic cough Pneumonia, bronchitis and other recurring infections Excess mucus Difficulty clearing mucus Middle ear infections Hearing loss Severe sinus infections Recurring cold symptoms, such as coughing and sneezing Lack of response to common antibiotics like penicillin when you have infections c) Childs presentation/description of the illness, signs & symptoms, risk factors (history of the condition in this child) Child presents PCD with h/o pseudomonas, LLL lobectomy, worsening cough with yellow sputum, FTT (Poor weight gain-less than 3% on growth chart. H/o bronchitis, chronic sinusistis, chronic otitis media, kyphosis, hearing loss, FTT and bronchopneumonia. Risk factors: PCD is a autosomal recessive disease. Both parents were carriers, so the patient had chance of having PCD d) childs previous treatment and/or therapy Previous treatment include Pulmicort BID, Albuterol BID, Pulmozyme daily, Megase (250mg/day), respiratory consult, nutrition consult, antibiotics for past pneumonia, chest x-ray 1/22/11 for evaluation of pulmonary exacerbation, and enalapril (to treat HTN) at last admission.
2. a) definition of the illness/problem/condition(s) (with APA reference)

Chronic sinusitis Chronic sinusitis is a common condition in which the cavities around nasal passages (sinuses) become inflamed and swollen. Chronic sinusitis lasts 12 weeks or longer despite treatment attempts. b) major symptoms with this condition (with reference) At least two of the following signs and symptoms must be present for a diagnosis of chronic sinusitis: Drainage of a thick, yellow or greenish discharge from the nose or down the back of the throat Nasal obstruction or congestion, causing difficulty breathing through your nose Pain, tenderness and swelling around your eyes, cheeks, nose or forehead Reduced sense of smell and taste Other signs and symptoms can include: Ear pain Aching in your upper jaw and teeth Cough, which may be worse at night Sore throat Bad breath (halitosis) Fatigue or irritability Nausea c) Childs presentation/description of the illness, signs & symptoms, risk factors (history of the condition in this child) Cough with productive yellow sputum Reduced sense of smell (CN I not illicited) Ear pain Fatigue Risk factors: PCD d) childs previous treatment and/or therapy Antibiotics and corticosteroids
3.

a) definition of the illness/problem/condition(s) (with APA reference) Chronic otitis media resulting in hearing loss Chronic ear infection is fluid, swelling, or an infection behind the eardrum that does not go away or keeps coming back, and causes long-term or permanent damage to the ear. b) major symptoms with this condition (with reference) Major Symptoms:

Ear pain or discomfort that is usually mild and feels like pressure in the ear Fever, usually low-grade Fussiness in young infants Pus-like drainage from the ear Hearing loss

c) Childs presentation/description of the illness, signs & symptoms, risk factors (history of the condition in this child) Current Hearing loss in left ear Multiple otitis media infections during childhood with low grade fever, pain, pus Risk factors: PCD, chronic sinusitis d) childs previous treatment and/or therapy Antibiotics, trying to treat underlying conditions
4.

a) definition of the illness/problem/condition(s) (with APA reference) Kyphosis deformity of spine Kyphosis is a condition of abnormal angulation of the spine. In kyphosis there is an excessive curvature (upper back) that often leads to a round back deformity b) major symptoms with this condition (with reference) Major Symptoms Hunch back appearance Back pain Muscle fatigue Stiffness in back Severe Cases of thoracic kyphosis can cause cardiac and pulmonary problems (limits space in chest) o Chest pain o Shortness of breath c) Childs presentation/description of the illness, signs & symptoms, risk factors (history of the condition in this child)
Child presents with mild kyphosis No c/o back pain, muscle fatigue, or stiffness Pt does have shortness of breath

Risk factors include poor posture d) childs previous treatment and/or therapy X-ray of spine, anti-inflammatory

5. a) definition of the illness/problem/condition(s) (with APA reference)

Bronchopenumonia Acute inflammation of the walls of the smaller bronchial tubes, with irregular areas of consolidation due to spread of the inflammation into the peribronchiolar alveoli and the alveolar ducts of the lungs. b) major symptoms with this condition (with reference) Major Symptoms Loss of appetite Cough Chest congestion Coughing up thick mucus: o Mucus may be green, brown, yellow or tan Hemoptysis: o Mucus may contain blood Chest pain: o Chest pain when taking a breath o Chest pain when coughing o Pain often described as sharp Fever Chills Sore throat Nausea Vomiting Hiccups Weakness or fatigue Headache Loss of appetite Rapid breathing rate Risk Factors: PCD c) Childs presentation/description of the illness, signs & symptoms, risk factors (history of the condition in this child) Loss of appetite, cough, chest congestion, thick yellow mucus, chest pain, fatigue, rapid breathing d) childs previous treatment and/or therapy Antibiotics, albuterol inhaler, respiratory therapy, oxygen therapy
6. a) definition of the illness/problem/condition(s) (with APA reference)

Bronchiectasis Bronchiectasis is destruction and widening of the large airways Often caused by recurrent inflammation or infection of the airways. It most often begins in childhood as a complication from infection or inhaling a foreign object. b) major symptoms with this condition (with reference)

Major Symptoms Bluish skin color Breath odor Chronic cough with large amounts of foul-smelling sputum Clubbing of fingers Coughing up blood Cough that gets worse when lying on one side Fatigue Paleness Shortness of breath that gets worse with exercise Weight loss Wheezing c) Childs presentation/description of the illness, signs & symptoms, risk factors (history of the condition in this child) Chronic cough, clubbing of the fingers, cough that gets worse when lying down, fatigue, paleness, dyspnea, weight loss, wheezing Risk Factors: Certain genetic conditions can also cause bronchiectasis, including primary ciliary dyskinesia and immunodeficiency syndromes. d) childs previous treatment and/or therapy Regular, daily drainage to remove bronchial secretions Respiratory therapist consult Coughing exercises Antibiotics, bronchodilators, and expectorants Surgery to resection the lung- LLL lobectomy

Laboratory Test Results: Lab Test Normal Values (per institution) Normal respiratory flora present only Patient results Why ordered (relate to this childs condition) Significance of result (Discussion and Analysis of All Values) Gram + cocci indicate bacterial infection in the lungs/respiratory system. PCD increases a patients susceptibility PAB is a blood component released in liver necessary for

Sputum smear and culture

Rare gram + cocci present Rare WBC present

Pt c/o cough with productive yellow sputum and h/o PCD

PAB (prealbumin(

24.246.6mg/dL

15.8mg/dL

Decreased PAB is seen in people with burns, inflammatory

disorders, poor nutrition, aspirin toxicity or liver disease. Pt came in with poor nutrition and pulmonary edema

Vit A

3075mcg/dL

28mcg/dL

Pt came in with FTT, weight loss and poor appetite.

Creatinine

0.51.1mg/dL

0.4mg/dL

Creatinine is an indicator of kidney function. Creatinine also indicates the amount of chemical waste that is generated from muscle metabolism. It is produced from creatinine, a major molecule important for energy production. For the patient with FTT, this can show the amount of muscle metabolism

protein use by body, the transport and use of thyroid hormones and vitamin A, normal fluid balance in body. Pts low PAB could contribute to her low vit. A level, and indicates bronchopneumonia and bronchiectasis Low Vit A level indicates that she is lacking adequate amount of vit A. Vitamin A is essential for vision (especially dark adaptation), immune response, bone growth, reproduction, the maintenance of the surface linings of the eyes, epithelial cell growth and repair, and the epithelial integrity of the respiratory, urinary, and intestinal tracts In people with malnutrition, severe weight loss, and long standing illnesses the muscle mass tends to diminish over time and, therefore, their creatinine level may be lower than expected for their age. This indicates the pt should increase her protein intake

Calcium

9.310.7mg/dL

8.6mg/dL

Patient has FTT and may lack adequate intake of calcium especially

Calcium is important for healthy bones, teeth, and normal muscle and nerve function. Symptoms to look out for with hypocalcemia include neuromuscular irritability, muscle spasms, bone weakness, numbness, tingling. Pt needs to increase calcium intake and possibly include vit D supplement to help absorption because some antibiotics make it difficult for body to absorb calcium.

Other Diagnostic Test Results (Chest X-ray, MRI, Cat Scan, Etc.): Test Reason for Results/Findings Significance of Nursing test results Interventions
(relate to this childs condition)

Echocardiogram Eval for pulm. Artery, HTN, RVp, Pap, TR, pulm veins

Moderate mitral valve prolapse, moderate mitral valve regurgitation Inadequate data to quantify pulmonary artery pressure

pHTN team felt that her pulmonary pressures are normal to mildly elevated and that she does not show signs of pHTN at this time, recommend regular cardiology follow up for mitral regurg and mitral valve prolapse

Have patient follow up with cardiology. Cardiology will determine next step and whether medication is needed. Watch for S/Sx of pulmonary hypertension: lightheadedness, SOB, tachycardia, ankle and leg swelling, cyanosis, chest pain pressure, dizziness, syncope, weakness.

Chest X-ray

Indicated for patient with PCD here with pulmonary exacerbation. Compare to CXR on 1/22/12 to show extent of exacerbation

Mediastinal clips are in place. Heart is normal in size. There is upper lobe bronchiectasis with diffuse interstitial lung disease. No new focal infiltrates or effusions. Situs is normal. No vascular congestion. The ribs are thin and gracile. The imaged portion of the bowl gas pattern is normal

No significant interval change in bronchiectasis and bronchial thickening. Condition not worsening.

Patients with MV prolapse have increased risk for infective endocarditis (infection of heart) Watch for Mitral Regurgitation complication symptoms: cough, fatigue, exhaustion, light-headedness, palpitation (a-fib), SOB, urination at night (excessive) Report and symptoms to doctor Continue with current plan of care Respiratory therapy treatments, nutrition consults, daily weights, medications continued, predinisose wean continues

Medications: Set up your medication chart with the following criteria Include the following for all medications ordered including prn medications: 1. Drug: generic and trade name 2. Drug Classification, pharmacologic and therapeutic categories 3. Mechanism of Action/Therapeutic Effect/Pharmacokinetics 4. Dosage, frequency & route ordered

5. Recommended safe dosage range/kg. body weight 6. Indication(s) for use/Purpose for use in relation to medical diagnosis and childs needs 7. Nursing Considerations & implications including side effects, adverse reactions, interactions 8. Administration technique considerations

Fluid and Electrolyte Balance: Weight: _(current): 42.7kg. Med Calc Weight (Admission Weight): 38.8kg IV Therapy: N/A Type of Fluid Vit.) Rate Additives: (KCL,

Enteral Therapy: N/A Type of Enteral Formula Rate Route

Other: Nutritional History: PO intake with increased protein foods, supplement diet with Boost Plus, use of appetite stimulant (Megestrol 250mg/day), nutritional consult, f/u nutrition labs, daily weights. Daily calorie count sheet (includes time, food time, amount served, amount eaten, CHO, PRO, FAT, calories). Pt appears to be gaining weight appropriately

Intake & Output (Today & for previous 24 hours): 1186mL previous 24 hours. Patient does not measure output but went urinated twice during my shift and reported that it was light yellow, clear, no particles, or odor present. Pt did not have BM during my shift. Intake is recorded on daily calorie counter (separate sheet). CALCULATE MAINTENANCE FLUIDS FOR THIS CHILD: >20 kg = 1500mL + (20ml/kg above 20kg) Med Calc Rate: 38.8kg 38.8-20 = 18.8kg 1500mL + (20mL/18.8kg) = 1500mL + 376mL = 1876mL

IS HE/SHE MEETING HIS NEED? yes no. Support with rationale. It is hard to determine because she does not I&Os It appears that she is essentially meeting these needs if her previous 24hours intake was 1186mL. PSYCHO-SOCIAL DATA: Social and Environmental History (describe patients living conditions, exposure to pets, well water, recent travel, school performance, hobbies, general behavior, sleep pattern, who child lives with/household composition): Patient lives with mom, dad, uncle, and 4 siblings (1 sister, 3 brothers). Her mother and brothers are currently in Algeria attending to personal family matters. Her sister and she are both admitted at CNMH and are next door to each other. They often travel back and forth to Algeria. They do not own any pets. They have well water system. Pt is in 9th grade at local public high school and reports average school performance. She interacts with sister most of the day, they have been seen watching movies together, reading magazines, painting their nails, and going to bingo at the hospital together. The pt is soft spoken, cooperative, and pleasant. She tends to sleep in as much as she can until woke up for medications. During my shift she woke up around 9:30am because I was giving her medication. Neonatal/Birth History (if appropriate): N/A Ethnicity: Algerian, Religion= Muslim Language Spoken: English and Arabic. No interpreter needed for pt of family Educational Level of Child: 9th grade high school. Appropriate for age

DEVELOPMENTAL HISTORY: (Discuss the age appropriate developmental stages according to Piaget and Erikson and describe childs ability to meet the developmental stages or not meet the stages. Be sure to provide examples/descriptions): Ericksons Developmental Stage: Adolescence (12-18yrs); patients is 14 y/o The adolescent stage is based on identity verses role confusion. Social interactions predominate this developmental stage. Patient exhibits this behavior by interacting with her sister most of the time. During this stage, life becomes more complex as the adolescent attempts to find her own identity, struggles with social interactions, and forms her own basis for moral issues. Due to the patients prolonged and recurrent admission to the hospital, she misses out on a lot of social interactions that take place in school and after school. Her PCD makes it difficult to play sports and she must devote time to respiratory therapy and nutritional therapy. Being in the hospital and having this condition, the patient is often taken care of so it may be hard for her to develop independence and identity. Piagets Stage of Development: Formal Operational (11+years). The key features of this stage are the childs ability to now manipulate ideas in their head (abstract thinking). This means the child can think logically and test hypotheses systematically. During this stage, the person is concerned with the hypothetical, the future and ideological problems. The patient is able to understand her diagnosis, treatments and tests. Therefore the doctor, nurse and other health care providers should be open and honest about what is going on and give an explanation of things. The patient in this stage might question how her future will be affected by her disease. When interacting with the patient she was very quiet, but seemed to understand what was going on. She did not express concerns for the future or show ideological problems/thinking. She was more involved in watching tv with her sister then socializing with the staff.

RESPONSE TO HOSPITALIZATION:
a) List common stressors that affect the hospitalized child (age specific) Separation from friends rather than parents more important o Adolescents unsure if they want their parents there or not (some enjoy freedom) o Ideally peer group will support ill friend Fear of Injury and Pain o Fear of altered appearance o Will act as though theyre not afraid when they really are Loss of Control o Give them some control and avoid power struggle

Stressors common to all children


Fear of unknown

Separation anxiety Fear of Pain or mutilation Loss of Control Anger Guilt Regression

b) Discuss stages of separation anxiety (age specific). Stages of Separation


Protest: child is agitated, resists caregivers, cries, and is inconsolable Despair: child experiences hopelessness and becomes quiet, withdrawn, and apathetic Detachment: child becomes interested in the environment, plays and seems to form relationships with caregivers and other children. If parents reappear, the child may ignore them.

For the adolescent: separation from peers more important than parents

c) Describe and discuss this child's response(s) to illness/hospitalization and stages of separation anxiety. This patient appeared to be in the detachment stage of separation anxiety. She was interested in her environment and stayed in her sisters room for most of the day. She didnt seem to mind that her parents werent there. d) Describe appropriate age-specific play therapy techniques/strategies. Books, computers, television, board games, newspaper, magazines e) Discuss the psychological responses of the family to the illness of the child in the family. This was hard to determine because no family member visited during my shift. I know the dad comes most often and the mother is in Algeria. They seem to have a complex family dynamic traveling back and forth from Algeria. The parents seem to understand the illness and they also rely on the patients uncle for support. Although the mother is in Algeria, she is easily reached on the phone.

NURSING PHYSICAL ASSESSMENT FINDINGS (The description of what you found when you examined your patient). Time_0800___________ Vital signs: T 36.9 (AX) HR: 92(Apical) RR: 28 BP:90/54 Pox 100% Pain0/10 Description: N/A_Scale used: Numerical_Intervention: N/A Re-evaluation: 0/10

General Appearance and Behavior Pt appears to be in no acute distress, she is slightly pale, underweight/malnourished (cachetic), she is cooperative, with appropriate behavior, slightly shy and soft spoken. She has good hygiene and interacts with sister for entertainment. Skin and Lymph Skin is intact, moist, no rash. Slightly pale, warm to touch, clubbing of the fingers, cap refill less than 2 seconds, no lesions, obvious scars or lymph nodes noted upon inspection and palpation HEENT Oral mucosa is moist, and pink. No swelling, erythema, pus or drainage. Normal conjunctiva Respiratory Slightly tachypneic but appears to be breathing comfortably at that rate. Coarse breath sounds noted with diffuse crackles and rhonchi heard at base of lungs. Productive yellow cough, persistent, worse in morning. Cardiovascular Regular rate, normal rhythm, normal S1 and S2. Mitral Valve prolapse and MV regurgitation (seen on Echocardiogram) Gastrointestinal Soft, non-tender, non-distended, normal bowel sounds noted Genitourinary No pain or discomfort with urination, no discharge, no problems with incontience, urgency. No sexual history, no menarche. Appropriate personal hygiene r/t toileting Musculoskeletal Normal ROM, normal strength (5/5) in all extremities, no swelling, kyphosis of spine, clubbing noted on fingers. Neurologic A&O x3, PERRLA intact, CN II-XII grossly intact Psycho-social: Algerian, muslim patient that is 1 of 5 children. Family frequently travels back and forth to Algeria. Patient states she is in 9th grade at local high school and has a good group of friends there but is not able to participate in a lot of physical activities due to condition. She and her sister are both at the hospital and very supportive of each other, often spending most of the day together watching tv, playing games, etc. Patient is shy and doesnt interact with staff unless prompted. She is highly engaged in television and playing with her sister. The patients family is on food stamps and WIC program. The father is out of work for several years and relies on his family for further financial support. They currently live with the uncle at his house in Ashburn, VA. Other Findings Patient stated that part of her decreased appetite is due to her dislike of familys cultural food.

MEDICAL TREATMENTS: (nebs, dressing changes, chest PT, etc.) Describe the treatment and/or therapy Include frequency (Provide rationale for treatment and/or therapy) Airway management/clearance Positioning TCDB, controlled coughing Chest PT and postural drainage Hydration Mucolytics

People with CPD may be prescribed antibiotics regularly because bacteria live and thrive in retained mucus. Other medications prescribed may include steroids, bronchodilators, and mucolytics (mucus thinners).

Chest Physiotherapy is the removal of excess secretions from inside the lungs, by physical means. Purpose: Aid in bronchial hygiene- prevent accumulation of pulmonary secretions, mobilization of secretions, and improve cough mechanisms Improve efficiency and distribution of ventilation Sputum volumes or consistency that requires external manipulation of the thorax Postural Drainage- uses gravity and correct positioning to bring secretions to the throat where it is easier to clear them. Assisted coughing is a very important adjunct to chest physiotherapy and when done well is effective and comfortable. It assists the work of the diaphragm to increase the cough pressure and try and force the secretions out. Chest Percussion- Another technique is percussion. This involves a form of 'patting' of the chest to vibrate the lungs and help the secretions move. It is not hitting! Active Cycle of Breathing- involves taking deep breaths and trying to Huff the air out.

OTHER NURSING CONSIDERATIONS: (play therapy, teaching, etc.) Adolescent- Identity vs. Role Confusion Assess knowledge. Encourage questioning regarding fears, or risks.

Involve in decision-making. Ask if patient wants parent there. Make as few of restrictions as possible. Suggest ways of maintaining control. Accept regression to more childish ways of coping. Give positive reinforcement. Provide privacy for care Encourage to wear street clothes and perform normal grooming Allow favorite food to be brought in if not on a special diet

Nursing Care to Help Families Cope Orient to hospital Assess what parent/child know of illness and treatment Assess teaching needs - keep updated on condition of child Reinforce and encourage questions Discuss ways the parents can participate in the care Assess & discuss family support, make referrals

PLANNING NEEDS: Discharge planning (Developmentally appropriate) Chest PT teaching for home exercise program Outpatient f/u for kyphosis/scoliosis F/u with cardiology every year Oral instructions/written instructions, review, ask questions for understanding. Communicate understanding with discussion and demonstration of skills. Medication adherence Reduce Risk of Respiratory Infection (avoid exposure)

OTHER PLANNING NEEDS Nutritional Needs- Keep Diary of foods and continue to count calories

COMMUNITY & OTHER AVAILABLE RESOURCES: Family on food stamps, and WIC program. Support Groups (Found 8 resources) Groups providing a wide range of services, supportive resources, and information

Disease-Specific Organizations

Primary Ciliary Dyskinesia Family Support Group Web site: www.pcdsupport.org.uk o Primary Ciliary Dyskinesia (PCD) Foundation 10137 Portland Avenue South Minneapolis, Minnesota 55420 E-mail: info@pcdfoundation.org Web site: www.pcdfoundation.org Parent Resources

The Parent Technical Assistance Center Network provides a list of the Parent Training and Information Centers in each state. These centers are funded by the United States Department of Education to provide early intervention and special education information and training to parents of children with disabilities from birth to age 26. Click on the link to find the Parent Center in your state.

ANTICIPATORY GUIDANCE INSTRUCTIONS: (Helpful resources: the pediatric text and the Bright Futures website) Define anticipatory guidance -----Anticipatory Guidance: a nursing intervention from the Nursing Interventions Classification (NIC) defined as preparation of a patient for an anticipated developmental and/or situational crisis Anticipatory guidance is the key to achieving two of the primary goals of pediatric care: (1) promoting health and (2) preventing disease. Providing anticipatory guidance in primary care is challenging because of the range and complexity of appropriate issues, the enormous individual differences among normal children and their families, and the limited time in health supervision visits. Despite the time constraints, these challenges can be the greatest source of interesting variety and rewarding physician-patient interactions in the practice of primary pediatric care. Anticipatory guidance involves three types of tasks: (1) gathering information, (2) establishing a therapeutic alliance, and (3) providing education and guidance. Many discussions of anticipatory guidance focus only on the third task. Without the first two, however, education and guidance are often misguided or ineffective.

*You Must Cite All Sources APA citation style is required. This information may be typed within the text or attach a reference page.

NURSING DIAGNOSES APPLICABLE TO THIS PATIENT (Please list ALL)


** These should include nursing diagnosis related to physical, social, psychological, family, and developmental needs. List your plans for care for the two (2) highest priorities. Choose one physical & one psychosocial to work through completely.

1) Ineffective airway clearance related to excessive mucus accumulation secondary to abnormal or non-mobile cilia

2) Imbalanced nutrition: less than body requirements r/t decreased appetite

3) Risk for infection r/t loss of ciliary infection (bronchiectasis, ear infections, sinus infection)

4) Interrupted family processes r/t chronic illness

5) Impaired gas exchange r/t increased mucous production

6) Activity intolerance r/t metabolic demands

7) Fatigue r/t inadequate tissue oxygenation

8) Risk for irreversible hearing loss r/t chronic otitis media

9) Risk for infective endocarditis r/t mitral valve prolapse

10) Risk for CHF r/t mitral regurgitation, pulmonary hypertension secondary to lung disease (PCD)

THE CONCEPT MAP


Following the Grand Round Presentation, students will take the results of the group work and complete the Map at home. The FINAL Concept Map should include the medical diagnosis/diagnoses, 1 physical & 1 psychosocial nursing diagnoses, nursing goals, outcomes, all nursing interventions with rationales, evaluation of interventions/goals, and discharge planning related to the nursing diagnoses and the child/family needs. The Map should be two (8 x11 in.) pages total, in pictorial/schematic fashion. Do NOT write a narrative summary.