Nursing Rounds on G.H Annie Kownack ODUSON, 00937493

Introduction 16 month old male, baby born at 37 weeks on 6/23/14 Chief complaint: Respiratory distress related to Tracheitis Focus: Pertinent family and medical history as well as history of present illness and reason for current hospitalization

Client History and Assessment

Pertinent Medical History History of multiple health issues including: Respiratory insufficiency Tracheostomy tube dependency secondary to hypoxic ischemic encephalopathy G-tube dependence status post Nissen Hearing loss so he wears hearing aids GERD Delayed development Hospitalized from birth, 6/23/14, to 1/27/15 for fetal distress and discharged from TCU with home health care to father. Mom deceased during childbirth from a stroke. NKDA, allergic to milk products

What its like to be G.H https://www.youtube.com/watch?v=HAEQw8iFpz4 Small segment, just first 20 seconds, have people put cups over their ears and breathe through straw to see what it was like for him to come into the ER

Medications Albuterol 1.25-1.5 ml, inhalant, q4h Budesonide 0.25 mg, nebulizer, b.i.d Keppra 150mg, G tube, b.i.d Glycopyrolate 300mcg, G tube, t.i.d Atrovent 0.5mg, nebulizer, q8h Ocular lubricant solution, both eyes, q.i.d

Cultural Considerations Caucasion 16-month-old only child who lives at home with father and home nursing. No pertinent cultural considerations except possible increased sensitivity in care Delayed development considerations Increased sensitivity needed for recent loss of wife and stresses of illness. Make sure G.H is comfortable and shows no signs of pain as to not scare him any more since he has delayed development

Reason for Admission G.H presented to the ED with a 1 day history of increased secretions and increased work of breathing. He was given PRN treatments of Albuterol at home that did not help and he continued to have desaturations 70-80 so he was brought to the ED. Respiratory distress related to Tracheitis Admitted for observation and treatment of Tracheitis

Pathophysiology: Tracheitis Inflammation of the trachea related to a nose or throat infection Most often caused by the bacteria Staphylococcus aureus Commonly found in young children because of smaller tracheas that are more easily blocked by swelling Tracheostomy in patient causes increased swelling

Pathophysiology: Respiratory distress and Tracheitis Respiratory distress related to bacteria in the trachea causing difficulty breathing and deprivation of oxygen Defining characteristics: Elevated white blood cell count (24,000) from sputum culture, CBC, chest x-ray (revealed bilateral bronchial thickening related to airway disease) Treatment: IV antibiotics started with Zosyn and Bactrim, humidified trach collar with oxygen therapy as needed. Albuterol and chest PT q4h, Atrovent q8h, continue home medications and care

Secondary Medical Diagnosis Tracheostomy tube dependency Delayed development Trach tube puts him at risk for infections Delayed development – he cannot state when he is starting to feel sick

Developmental Stage Late sensorimotor and trust vs. mistrust - not met Patient cannot perform basic social, language, fine motor, or gross motor skills for his age level Patient cannot speak, sit up without assistance, walk, or follow simple commands I had to rely on the father for care and communication needs as well as facial expressions and body language of the patient

Physical Assessment Neuro - Delayed Respiratory: - Coarse lung sounds bilaterally - Clear secretions from nose and tracheostomy - No retractions or increased work of breathing currently - Tracheostomy dependent. 35 RR Gastrointestinal: - G-tube in LLQ All other systems within normal limits

Identification of Nursing Problems and Plan of Care

Ineffective Breathing Pattern - Respiratory virus panel revealing increased WBC on sputum culture - Tracheostomy 3.5 uncuffed - Coarse breath sounds - RR 35 - Increased secretions, thick sputum - Albuterol, Budesonide, atrovent, oxygen PRN - Keep extra trach at bedside in case of dislodge - Ensure meds are on hand in case of emergency - Monitor RR and ease of respirations - Evaluate ability to withstand activity - Administer O2 when desats occur Patient will be able to maintain respirations between 20-30 and show no signs of increased work of breathing. - Monitor vital signs and observes RR, O2 sats, and patient for signs of increased work of breathing

Ineffective Airway Clearance - Coarse with transmitted upper airway - Substernal retractions seen on admission - Suctioned x2 during shift with thick clear secretions -Encourage client to cough and deep breathe - Encourage intake of fluids to loosen secretions - Suction secretions by deep suction in trach - Turn patient on side so they don’t choke on secretions - Chest PT to loosen secretions -Patient will sound clear to auscultation and be able to cough up secretions. - Auscultate lung sounds for adventitious breath sounds and stimulate coughing for airway clearance.

Risk for Inadequate Nutrition - Feeding difficulties - Dysphagia - Dependent on G-tube - Pediasure sidekick 225 mL/hr, 8 am, 12 pm, 4 pm - Increased energy used for increased work of breathing requires more nutrients -Obtain calorie and intake count daily with each meal - Weigh patient daily - Prevent constipation with medications - Offer food shake high in protein and calories - Assess for signs of malnutrition -Patient will maintain adequate weight throughout hospitalization. - Weight patient daily and record intake and output to observe changes in status and monitor nutritional intake.

Holistic Nursing Care Traditional: Respiratory treatments, antibiotics, and oxygen PRN Alternative: touch, visualization, and music Collaborative: Dietary recommendations, chest PT and other respiratory therapist treatments, and child life The music calms him, touch lets him know that someone is there for him, and the visualization distracts him from stresses of the hospital

Teaching Needs Early signs of respiratory illness Serious signs in respiratory illness How to prevent illness in child Hand washing techniques Father said child had been exposed to 2 sick people in the past week so do not expose him to them

Research “Tracheal Suctioning: An Exploration of Nurses’ Knowledge and Competence in Acute and High Dependency Ward Areas” Study of 28 nurses competency in caring for tracheostomies For interventions of patient to be met, nurses must be adequately trained to take care of patients with tracheostomies Study revealed that many nurses need more education regarding tracheostomies, suctioning, how to care for, clean, and changed out tracheostomies

Resources Day, T. Farnell, S., Haynes, S., Wainwright, S. and Wilson-Barnett, J. (2002), Tracheal Suctioning: An Exploration of Nurses’ Knowledge and Competence in Acute and High Dependency Ward Areas. Journal of Advanced Nursing, 39: 35-45. doi:10.1046/j.1365-2648.2002.02240.x