Pediatric Nursing Grand Rounds Robyn Lutzkanin

Focus  Client history  Client assessment  Identification of Nursing problems  Plan of care  Applicable Research

Client  R.S.  Male  Age: 6 years old  High functioning Autism  ATV accident with a crushing injury  Compartment Syndrome in right lower leg

Client History and Assessment

Past Pertinent Health History  R.S. has a history of and is currently diagnosed with:  High Functioning Autism  Oppositional Defiant Disorder (ODD)  Attention Deficit Hyperactivity Disorder (ADHD)  Sleep Disorder with mild sleep apnea

Cultural Considerations  The culture of a little boy:  Forming a therapeutic relationship

Admitting Diagnosis  R.S. had an ATV accident  Trapped under ATV  Crushing Injury  Compartment Syndrome of Right lower leg

Pathophysiology  Acute compartment syndrome is a medical emergency usually caused by a severe injury  Compartment syndrome develops when swelling or bleeding occurs within a compartment (the muscle fascia)  Swelling will cause damage to tissues  Signs and symptoms

Treatment plan  Immediate surgery: Fasciotomy  Leave wound open until swelling decreases  Negative pressure wound therapy & skin graft

Secondary Diagnosis  Autism  ODD  ADHD  These could have led to the initial injury and also impacts healing  Not following instructions  Resistance to dressing changes

Development  For six year olds such as R.S. expected development includes:  Social and Cognition  Speech and Language  Fine Motor / Adaptive  Gross Motor

Development  R.S. is diagnosed with Global Developmental Delay  Not reaching two or more developmental milestones in each developmental domain.  Speech and Language  Social and Cognition

Physical Assessment  Cardiovascular : +2 Edema in rt. foot  Musculoskeletal : altered gait r/t fasciotomy  Integument : 5” x 2” surgical incision on right lower leg, bruising on right knee and right ankle  Psychosocial : High Functioning Autism  Extreme pain in right lower leg

Nursing Problems and Plan of Care

Concept Map: Acute Pain  Assessment : Related to crush injury  R.S. crying and screaming when right leg is handled  R.S. unwilling to move right leg  Multiple surgeries on right leg

Acute Pain  Nursing Interventions :  R.S. is non-verbal  Pain assessment  Pain management:  IV morphine  Video games  Toys

Acute Pain  Expected outcomes:  Short-term: R.S. no longer crying by fifteen minutes  Long-term: R.S. no longer shows signs of pain by the end of shift  Outcomes : Met!

Concept Map: Risk for Fall  Assessment : Related to injury and pain medications  Young age  Injury of lower right leg (pain)  Morphine administered IV  New environment

Risk for Fall  Nursing Interventions:  Keep bed in low position  Assign sitter to room when his parents weren’t present (R.S. likes to get out of bed!)  Keep wanted items within reach  Encourage R.S. to ask for help to move  Do not rush R.S. to move or walk faster than he is able / willing to do

Risk for Fall  Expected outcome:  R.S. will not experience any falls during his hospitalization  Outcome : Met!

Concept Map: Risk for Infection  Assessment : Related to large surgical incision and IV access  Multiple surgeries  Hospitals are inherently germy

Risk for Infection  Nursing Interventions:  Assess for fever, elevated HR/RR, chills, lethargy, and increased WBC count  Hand hygiene!!  Encourage R.S. to drink fluids  Avoid unnecessary manipulation of open wound and IV sites  Cefazolin (Preventative antibiotic)

Risk for Infection  Expected outcome:  R.S. will not develop an infection as a result of his fasciotomy  Outcome : Met!

Concept Map: Impaired Verbal Communication  Assessment : Related to autism and global developmental delay  R.S. will not speak to health care workers  R.S. is unable to use any pain rating scales  R.S. is unable to verbalize that something is wrong in a way other than screaming and crying

Impaired Verbal Communication  Nursing Interventions:  Anticipate R.S.’s needs through non-verbal cues such as squirming, frowning, fetal positioning  Be patient with R.S.  Give ample time for and be concrete with directions that R.S. is capable of doing  Form a therapeutic relationship with R.S. and his parents  Clonidine for ADHD

Impaired Verbal Communication  Expected Outcome:  Short-term: R.S. will be able to point to where he is experiencing pain by the end of shift on Wednesday  Long-term: R.S. will be willing to vocalize if and where he is having pain in more than one word by the end of shift on Thursday  Outcome : Met!

Concept Map: Impaired Physical Mobility  Assessment : Related to crush injury of right lower leg  Reluctance to attempt movement  Limited range of motion of ankle  Pain from injury and surgery  Fear of pain from movement

Impaired Physical Mobility  Nursing Interventions:  Assess what R.S. was able to do prior to injury from parents  Assess what R.S. is willing to do currently  Assess elimination status: give Miralax  Encourage and facilitate movement  Positive reinforcement!  Work with physical therapy (Collaborative)

Impaired Physical Mobility  Expected Outcomes:  Short-term: R.S. will partially put weight on his right leg to pivot into sitting chair by end of shift Thursday  Long-term: R.S. will be able to move with crutches independently by one week after last surgery  Outcome : Partially met

Connecting the Dots Acute Pain Risk for Infection Impaired Physical Mobility Risk for Fall Impaired Verbal Communication

Discharge Teaching & Planning  Pain management  Wound management, healing and nutrition  Exercises and movement

Research  Therapeutic play intervention on children's perioperative anxiety, negative emotional manifestation and postoperative pain: a randomized controlled trial.  Objective: To see if therapeutic play intervention could reduce preoperative anxiety, postoperative pain, and negative emotional manifestation in general

Research  Design: Randomized controlled trial  Methods:  47 children received routine care (control group)  48 children received 1-hour therapeutic play along with routine care (experimental group)  The state of anxiety, pain, and emotional manifestations were measured 24 hours before and 24 hours after surgery

Research  Results: Children in the experimental group had significantly lower scores of negative emotion prior to surgery and less postoperative pain  Conclusion: Therapeutic play is effective in reducing negative emotions and postoperative pain.

Research and R.S.  R.S. was able to have therapeutic play pre and postoperatively  Collaborative care with Child Life at CHKD provided R.S. with many distractions from the clinical reality of his injury  A difference in negative emotions was seen with and without play therapy in R.S.

Conclusion and Questions  Nursing care of R.S.  Crushing Injury & Compartment Syndrome  Developmental Delays  Nursing Diagnosis  Effectiveness of Therapeutic Play

References  He H.-G., Zhu L., Chan W.-C.S., Liam J.L.W., Li H.C.W., Ko S.S., Klainin-Yobas P. & Wang W. (2015) Therapeutic play intervention on children's perioperative anxiety, negative emotional manifestation and postoperative pain: a randomized controlled trial. Journal of Advanced Nursing 71(5), 1032–1043. doi: /jan.12608

References  Wong, D. (2011). Virtual clinical excursions- -pediatrics: For Wong's Nursing care of infants and children, 9th ed. (9th ed.). Maryland Heights, Mo.: Elsevier/Mosby.