Pediatric Nursing Rounds Francesca Paragas

TRUE OR FALSE? Heat thermal burns are only caused by fire.

TRUE OR FALSE? Scald burns are cause by something wet, such as hot water or steam.

TRUE OR FALSE? Scald burns from hot liquids are the most common type of burns to children.

TRUE OR FALSE? Superficial partial thickness burn is different than a second degree burn.

TRUE OR FALSE? Nutrition is very important in order to recover from burns.

Objectives Introduction of the patient Family/Psychosocial History Cultural Considerations of client Hospitalization (reason for admission, diagnoses) Treatment plan Pathophysiology of admitting diagnosis

Objectives (con’t) Client’s developmental stage (applied to care) Physical Assessment Concept Map Nursing Care Teaching Needs Research related to client (interventions)

Focus of Presentation Discussion of client history, assessment, plan of care (concept map), and research Techniques: Powerpoint Quizzes Visualizations Video

Introduction of the Patient Philip W is a 15 year old African American male admitted to CHKD on 10/27/15 after being transferred from Sentara Norfolk Hospital. Philip was diagnosed with superficial partial thickness burns that affected 15-20% of his body. The client has no known allergies and currently weighs 41.7 kg.

Past Health Hx No Past Medical Hx shown

Birth Hx & Psychosocial Family Hx Birth Hx: none present Social Hx: Patient lives with mother, sister. Currently attends high school and is on two basketball teams. Family Hx: No pertinent Family Hx

Cultural Considerations African American Age group- 15 year old High school Basketball Player

Circumstances that led to Hospital Client’s chief reason for admission Grease Burn Frying fries at home Spilled over Address primary medical: Burn (15-20%) Partial thickness burns Chest/Abdomen Left and right hands Entire right arm Right leg and foot Left foot

Pathophysiology of Burns Understanding patho is necessary to provide care Edema Formation Increased capillary permeability Increased hydrostatic pressure Loss of water, protein, and electrolytes Increased in sodium and potassium shift- swelling Fluid Loss Capillary barriers are disrupted Severe depletion of plasma volume

Pathophys (Con’t) Cardiac Reduce blood flow in burned area (capillary stasis) Depressed cardiac output Superficial partial thickness burns ceases immediately after injury Can be restored within hours Renal Renal vasoconstriction Reduce plasma flow and depressed GFR BUN and CR increase

Pathophys (con’t) GI System Blood flow decreases to GI system Organ Dysfunction Ischemia results Ulcers can form Metabolism Hypermetabolism Protein and lipid catabolism Stress places many demands on body

Superficial Partial Thickness Burn

Treatment Plan Dressing change, wound debridement skin graft on 11/2 Scheduled to have another one 11/6 Foot drop boot Allows for better circulation Reduces skin and heel pressure Reduces risk of further skin shearing Monitor VS q4h Medications: Emollients (topical), polyethylene glycol (constipation), morphine (pain), acetaminophen (pain), Calorie Counting Diet

Burn Wound Debridement

Secondary Medical Diagnosis? None No other medical condition listed

Developmental Stage Piaget Formal operation 11 years and up Can think logically about abstract propositions, strategize, plan, and understand concepts Become concerned with the future and ideological problems Erikson Ego identity vs. Role Confusion 12 to 18 years Children become more independent, begin to look at the future “Fit in” Begin to form identity based upon outcome of their explorations

Developmental Stage Application to Care This patient did meet the norms Set goals for him to achieve independently Ex: Limb exercise to maximize functionality Performed exercises on his own throughout day Encourage that the pain is temporary and in the future he will be healed from burns Motivated to get better Pushed himself appropriately to get better Explained why certain procedures needed to be done Patient verbalized his understanding

Physical Assessment GI: Calorie diet. Patient ate <25% of breakfast (on both clinical days. Stated that he does not like the food at the hospital. Must drink Ensure after every meal. Skin: Skin discolorations due to burns. Superficial partial burns on right arm, left hand, right leg, right foot, chest, and abdomen. Pinkish color. Moist with emollient. Skin graft on right arm. Has dressings on right arm and right leg. MS: Unable to assess gait first day. Pt’s right foot was extremely stiff first day of clinical. 2 nd day, patient’s movement improved and was able to independently stretch right leg and walk.

Physical Assessment (Con’t) P/S: Patient expressed frustration when trying to stretch and exercise limbs. Began to cry stating that he is too overwhelmed and that the pain is too much. On 2 nd day of clinical, patient was more positive. Pain: First day of clinical, patient was in constant pain. Verbalized that pain is a 6 in right foot when resting. Stated that morphine helps reduce the pain. Cried when trying to move limbs with PT because of pain. Could not walk due or get out of bed due to too much pain. 2 nd day of clinical, pt’s pain improved tremendously. Pt reported no pain when resting and stated that with activity pain rises to a 5, which he said is tolerable.

Concept Map- Nursing Problems Acute Pain Impaired Skin Integrity Impaired Physical Mobility Imbalanced Nutrition- Less than Body Requirements Fear

Acute Pain 11/3 Pt verbalized constant pain Rated pain a 5 on Right foot Received morphine and pt stated pain decreased to 3 Pt had PT, cried and stated pain was a 10 Blood pressure increased to 144/80 11/4 Pt stated pain was a 0 in the morning After walking pt reported pain a 5 After receiving morphine, rated pain back to 0 Meds: acetaminophen- hydrocodone & morphine

Impaired Skin Integrity Warm, moist skin Burns present on right arm, right leg, right and left foot, chest, abdomen, and left hand Bright Pink burns Left hand shows peeling Meds: Emollients- Eucerin topical cream

Impaired Physical Mobility 11/3 Pt has not got up from bed Pt states that the pain is unbearable on his right foot Has limited range of motion in right foot, right elbow, and left hand- evident in PT Asks mother for objects that are out of reach (urinal, cell phone) 11/4 Was able to walk around hospital floor. Got out of bed with assistance Applied moisturizer on self independently

Imbalanced Nutrition Less than Body Requirements 11/3 Pt ate <25% of breakfast States that he does not like breakfast food States the he hardly ever has an appetite Only drinks juice Drinks 50% of Ensure 11/4 Pt ate <25% of breakfast again Stated that he will try to eat more for lunch

Fear 11/3 Pt expresses fear stating that he is scared to move because of the pain Blood pressure rose slightly from 127/80 to 136/84 right before exercises with PT Pt attempts to stall exercises by being on his phone 11/4 Pt fear reduces on exercises since pain diminished Has a brighter outlook towards the future

Expected Outcomes Acute Pain Pt should report satisfactory pain control level of 3 or below as evidenced by baseline blood pressure, verbalization of comfort, and effectiveness of medication by end of the day Impaired Skin Integrity Pt’s tissue should exhibit skin healing as evidenced by moisturization of burns, absence of pain to touch, and dead skin peeling by end of the day.

Expected Outcomes Con’t Impaired Physical Mobility Pt should be able to perform physical activity within limits of burn as evidenced by independently stretching limbs, walking with assistance, and reporting activity as being tolerable by end of day. Imbalanced Nutrition Less than Body Requirements Pt should demonstrate need for eating appropriate amount of food as evidenced by eating at least 75% of meal and verbalizing importance of eating for recovery by end of teaching.

Expected Outcomes (con’t) Fear Pt should exhibit reduced feelings of fear as evidenced by verbalization of reduction in fear, hopefulness to the future, and verbalizing positive outcomes.

Nursing Care Pt participated in PT and OT once daily in the morning Encouraged and motivated pt to get better Provided a calm environment Assessed patient q4h (focused on skin and pain) Calorie Count- Promote healing Administered medications and assessed need for PRN meds Alternative intervention: Music therapy

Interrelatedness Impaired skin integrity from the burns can cause Acute Pain towards the patient. Philip’s main complaint during clinical was constant pain. The pain interfered with the patients ability to move. This caused him to have impaired physical mobility. The pain became so intolerable that the patient developed fear from moving. This fear also interfered with the patient’s mobility. The patient expressed that he did not eat because he never had an appetite. This fear of pain distracts him throughout the day from eating, which leads to Imbalanced Nutrition: Less than Body Requirements.

Teaching/Discharge Importance of moisturizing burn wounds Must eat foods high in calories and protein Continue physical therapy at home Change dressing as directed Avoid sun exposure Sunscreen if neccessary

Teaching/Discharge (con’t) Call for any signs or symptoms of infection Fever, excessive pain, redness, swelling, new drainage Do not pick wounds Avoid strenuous activity, heavy lifting, and contact sports until cleared by doctor Do not wear tight fitting clothes that may rub against burn areas and cause friction blisters and skin damage

Research Title: Functional Independence in Teenage Patients with Burns Purpose of Study: To see if FIM instrument can effectively assess the functional independence of teenagers undergoing a process of rehabilitation

Research Methods: Cross-sectional study 63 burn patient teenagers (12-20 years old) Going through a process of rehabilitation Functional Independence Measurement instrument Motor Self-care, sphincter control, transfers, and locomotion Cognitive Communication & social cognition O (full dependence) to 7 (completely independent) All data interpreted by researchers

Research Findings Results: Most teenagers scored % of them scored 6 Still needing family FIM exhibited internal consistency and reliability as observed by Cronbach’s reliability test FIM can appraise extent of handicap, dysfunction, and social limitations of teenagers during rehabilitation process.

Correlation Research Findings with Interventions for Client Nursing Diagnosis: Impaired Physical Mobility Interventions include promoting physical mobility Performing passive or active assistive ROM exercises to all extremities Encourage early ambulation when possible Provide pain medications as necessary Utilize a physical activity tool to evaluate mobility Utilizing a physical activity tool can help provide baselines of performance. This tool (such as the FIM) will allow nurses and other healthcare members develop a routine care plan with realistic goals that will enhance and maximize the patient’s mobility and functionality.

Quiz! Are you still awake?

Quiz! Which layers of the skin are affected with superficial partial thickness burns?

Quiz! What should a burn patient include in their diet?

Quiz! Name a discharge teaching that a burn patient should have.

Quiz! Based on the Pathophysiology given, name a nursing diagnosis that can apply to a burn patient other than the ones I used. (Acute pain, impaired skin integrity, impaired physical mobility, Imbalanced nutrition, fear)

Summary Understanding of Burns Cultural Considerations for the patient Expected developmental stage of the patient Care Map for patient with Superficial Partial Thickness Burns Research related to patient and interventions

References tm tm Nicolosi, J. T., de Carvalho, V. F., Sabatés, A. L., & Paggiaro, A. O. (2014). Functional independence in teenage patients with burns. British Journal Of Nursing, 23S20-6 1p. Wong, Donna L., Marilyn J. Hockenberry, and David Wilson. Wong's Nursing Care of Infants and Children. 9th ed. St. Louis, MO: Mosby/Elsevier, Print