1. Pediatric Grand Rounds By Jamie Martin

2. Overview AA female infant AA female infant Born on 11/20/12 at 26 weeks gestation Born on 11/20/12 at 26 weeks gestation Chronological age: 16 weeks/ 4 months Chronological age: 16 weeks/ 4 months Adjusted age: 2 weeks Adjusted age: 2 weeks

3. Overview Client History and Assessment Client History and Assessment Identification of Nursing Problems and Plan of Care Identification of Nursing Problems and Plan of Care Clinical Teaching Clinical Teaching Research Research

4. Maternal History 37 yo G4P0030 mother 37 yo G4P0030 mother Fibroid uterus Fibroid uterus Cystic fibrosis Cystic fibrosis Elevated WBC count Elevated WBC count

5. Client History Extreme prematurity (26 weeks gestation), 920 g Extreme prematurity (26 weeks gestation), 920 g Retinopathy of prematurity Retinopathy of prematurity L and R sided MSSA neck abscesses L and R sided MSSA neck abscesses Respiratory distress syndrome Respiratory distress syndrome Large PDA Large PDA Anemia of prematurity Anemia of prematurity Left pnuemothorax Left pnuemothorax Hypotension Hypotension hyperbilirubinemia hyperbilirubinemia

6. Family/Psychosocial History Mother—student at TCC at time of birth Mother—student at TCC at time of birth Father—working in Richmond Father—working in Richmond Single parent household? Single parent household? Both parents currently living in Richmond Both parents currently living in Richmond Have “strong support network” Have “strong support network”

7. Cultural Considerations Physical separation Physical separation Emotional detachment Emotional detachment

8. Primary Medical Diagnosis Feeding Intolerance related to prematurity

9. Pathophysiology Feeding Intolerance measured by: Feeding Intolerance measured by: Soft abdomen Soft abdomen Absence of abdominal distention Absence of abdominal distention Minimum/no aspirated gastric residual Minimum/no aspirated gastric residual Presence of bowel sounds Presence of bowel sounds Minimum to no spitting up or vomiting Minimum to no spitting up or vomiting Infant’s continued interest in feeding Infant’s continued interest in feeding Consistent behavior pattern Consistent behavior pattern

10. Pathophysiology Feeding success is measured by the infant’s ability to: Feeding success is measured by the infant’s ability to: Participate in feeding with energy Participate in feeding with energy Coordinate sucking and swallowing with adequate pauses for breathing Coordinate sucking and swallowing with adequate pauses for breathing Maintain vital signs and oxygenation WNL Maintain vital signs and oxygenation WNL Maintain normal muscle tone in face and body Maintain normal muscle tone in face and body Complete feeding in about 20 to 25 minutes Complete feeding in about 20 to 25 minutes Manage a liquid fluid bolus with minimum or no loss of liquid from mouth Manage a liquid fluid bolus with minimum or no loss of liquid from mouth Sustain alertness for feeding Sustain alertness for feeding Maintain strength and endurance for entire feeding Maintain strength and endurance for entire feeding Measure appropriate for age on standard growth curve Measure appropriate for age on standard growth curve

11. Pathophysiology Anatomic/physiologic disabilities of the premature infant: Anatomic/physiologic disabilities of the premature infant: Coordination of suck and swallow at 32-34 wks Coordination of suck and swallow at 32-34 wks Poor muscle tone of the cardiac sphincter Poor muscle tone of the cardiac sphincter Carbs and fats are less tolerated Carbs and fats are less tolerated

12. Secondary Medical Diagnoses BPD BPD Aspiration Aspiration GERD GERD Thrush Thrush Very large umbilical hernia Very large umbilical hernia

13. Treatment Plan Thickened PO feeds as tolerated Thickened PO feeds as tolerated OT OT Rehab Rehab Medications Medications Nystatin Nystatin Prilosec Prilosec Lasix Lasix O2 O2

14. Treatment Plan OT/Rehab support OT/Rehab support Pattern Pattern Consistency Consistency Nipple type Nipple type Jaw and cheek support Jaw and cheek support Swaddle Swaddle Enteral feedings prn Enteral feedings prn

15. Expected Developmental Age Newborn Norms: Newborn Norms: Can turn head side to side Can turn head side to side head lag head lag Strong grasp reflex Strong grasp reflex Clenches hand on contact w/ rattle Clenches hand on contact w/ rattle Follows light to midline Follows light to midline Quiets when hears a voice Quiets when hears a voice Cries to express displeasure Cries to express displeasure Watches parents’ faces intently Watches parents’ faces intently as they talk as they talk

16. Developmental Theory Trust vs. mistrust Trust vs. mistrust Sensorimotor Sensorimotor Oral Oral

17. Abnormal Physical Assessment Neuro: Fussy at times Respiratory: BPD, upper airway congestion GI: very large umbilical hernia Feeds: inconsistent, PO/enteral Thrush Altered Vision

19. Feeding Intolerance Difficulty Taking PO feeds Difficulty Taking PO feeds Aspiration on VSS Aspiration on VSS Treatments: Treatments: PO feeds: 6 per day if awake, Neosure 24 kcal PO feeds: 6 per day if awake, Neosure 24 kcal PO feeds thickened w/ rice cereal PO feeds thickened w/ rice cereal OT OT Rehab Rehab Meds: Nystatin, Prilosec Meds: Nystatin, Prilosec

20. Impaired Gas Exchange BPD BPD Upper airway congestion Upper airway congestion Hx PDA Hx PDA Inactive Inactive Treatments: Treatments: 1/8L NC 1/8L NC Suction prn Suction prn PT PT Meds: Lasix Meds: Lasix

21. Infection Candida Albicans (thrush) Candida Albicans (thrush) Hx MSSA abscess on R and L sides of neck Hx MSSA abscess on R and L sides of neck Long hospital stay Long hospital stay Treatments: Treatments: Change pacifier daily Change pacifier daily Clean/Sterile technique Clean/Sterile technique HANDWASHING! HANDWASHING! Meds: Nystatin Meds: Nystatin

22. Deficient Knowledge, Family Parents live in Richmond Parents live in Richmond Expressed being overwhelmed with information Expressed being overwhelmed with information Daughter hospitalized since birth (Nov. 20, 2012) Daughter hospitalized since birth (Nov. 20, 2012) Treatment: Treatment: Provide education/information via phone Provide education/information via phone Facilitate contact during visits Facilitate contact during visits

23. Risk for Imbalanced Nutrition Prematurity Prematurity Feeding intolerance Feeding intolerance VSS showed aspiration VSS showed aspiration Treatments: Treatments: Neosure 24kcal w/feeds 6 times per day Neosure 24kcal w/feeds 6 times per day PT PT OT OT Rehab Rehab

24. Holistic Nursing Care Traditional interventions Traditional interventions Assessments Assessments Medication administration Medication administration Feedings Feedings

25. Holistic Nursing Care Complimentary/Alternative Interventions Complimentary/Alternative Interventions Respectful approach Respectful approach Blanket swaddling and nesting Blanket swaddling and nesting Infant Massage Infant Massage

26. Holistic Nursing Care Collaborative Interventions Collaborative Interventions Feeding Feeding Nursing Nursing OT OT PT PT Rehab Rehab

27. Relationship between Nursing Dx

28. Discharge Planning Family Teaching Family Teaching Model appropriate feeding techniques Model appropriate feeding techniques Provide opportunity for feeding Provide opportunity for feeding Educate on infant cues and how to measure feeding success Educate on infant cues and how to measure feeding success Home oxygen administration Home oxygen administration Immunizations Immunizations Car seat safety Car seat safety Medications Medications Referrals Referrals Home Health Care Home Health Care Support groups Support groups Plan nursing follow-up Plan nursing follow-up

29. Clinical Teaching iPhone App iPhone App NICU Knowledge Parent Educator NICU Knowledge Parent Educator https://itunes.apple.com/us/app/nicu-knowledge-parent- educator/id508051096?mt=8

30. Clinical Teaching

31. Current Nursing Research

35. Reference Schlittenhart, J. M., Smart, D., Miller, K., & Severtson, B. (2011). Preparing Parents for NICU Discharge. Nursing For Women's Health, 15(6), 484-494. doi:10.1111/j.1751-486X.2011.01676.x

36. Questions?

37. The End