1. Nursing Rounds on G.H
Annie Kownack
ODUSON,

2. 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

3. Client History and Assessment

4. 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

5. 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

6. 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

7. 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

8. 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 so he was brought to the ED.
Respiratory distress related to Tracheitis
Admitted for observation and treatment of Tracheitis

9. 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

10. 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

11. 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

12. 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

13. 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

14. Identification of Nursing Problems and Plan of Care

15. 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 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

16. 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.

17. 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.

18. 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

19. 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

20. 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

21. 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: doi: /j x