Pediatric Grand

Rounds
KYRSTIE PIERSON
OLD DOMINION
UNIVERSITY
N. 421

Presentation Purpose:
To provide the student an opportunity to
integrate knowledge from the sciences,
developmental theory and physical assessment
data to the care of a pediatric client and family
in the acute care setting. The student will
utilize critical thinking and independent
judgments in presenting a holistic plan of care
in a formal oral presentation.

Objectives:
Present information related to a chosen

patient
Pertinent health history
Admission diagnosis and patho.
Culture
Assessment/Developmental stage
Identify nursing problems and care
Concept map, Interventions,
Expected outcomes
Integrate nursing research into patient
care

Patient History
Born April 5, 2013
Birth History:
GBS+

pregnancy
Born 39 weeks
Birth weight 6 lbs. 7 oz.
Cyanosis and apnea one week
post birth
Allergies:
Vancomycin (red man
syndrome)
Latex
Co-Band tape
Oxacillin

Family History
Mothers

Family has
a history of
Leukemia.

Surgical History
2013:

2014:

2015:

2016:

6/14:
Genetic
Tests
7/11: Failure
to Thrive
8/14: Nissen
8/25: G tube
complete

1/16 G tube
changed

8/14:
Failure to
Thrive
Aspiration

319: G tube
change

Culture
The main culture is the family.
Family

is very involved
In and out of hospital, only three
Admitted on His, his brothers, and her
birthday
Mother does most of his care in hospital, all at
home.
Mother also has one year old son
Contact precautions

Admitting Diagnosis:
April 5, 2016
Admission History:

Three year old Caucasian

Male
Presented to the ED with:
Fever for 1 day of 39 C
Nose bleed
Stomach pain
Hx. of multiple line
infections:
Staph Epidermidis
Klebsiella Oxytoca
Enterobacter Cloacae

Central Venous
Line

Pathophysiology
Infection and obstruction:

most common
complications
ABX to treat

Infection: suspected or

proven infection caused by

any pathogen; or a clinical
syndrome associated with
a high probability of
infection; and evidence
includes positive findings
on clinical exam, imaging,
and laboratory tests .

Plan of Care
Medications:
Antibiotics:
Meropenem
Vancomycin
Acetaminophen
Benadryl
Erythromycin
Keppra
VS Q4h
Daily head to toe assessment
Daily blood cultures
Continuous Pulse Ox
NPO, G tube feedings
(30 kcal/oz, Neocate Jr.)

Secondary Diagnoses:
Abdominal

distention
Dysphagia
Epilepsy
Failure to Thrive
Gastroesophageal
Reflux
Mendelian Disorder
Oral Aversion
Short Stature
Iris Cysts

Sleep Apnea
Growth Hormone

Deficiency
Frequent Aspiration
Anemic
2q13 Chromosomal
deletion
Short bowel
syndrome
Sucrase-isomaltase
deficiency

Development Stage

Speech

Complete 3-4 word

sentences

Asks many questions

Ability to follow directional

command- limited

Egocentric thought

Speech

Personal:

Ability to follow directional

command

Egocentric thought

Actual
Personal:

Expected

Complete 1-2 word

sentences- chooses to sign

Asks many questions

Fine Motor/Adaptive

Fine Motor/Adaptive

Gross Motor

Gross Motor

Builds 9-10 cube tower

Broad Jumps

Builds bridge with 3 cubes

Stands on one foot for

seconds

Builds 9-10 cube tower

Stands on one foot for seconds

Developmental Theory:
Piaget
Preoperational

stage
Preconceptual phase 2-4 years
Egocentrism
Erikson
Autonomy vs. shame and doubt
Negativism No

Assessment Data
Neurological:
Not

Talking like he should, uses sign

language.
Respiratory:
No 02, 100% Saturation
Cardiovascular/Neurovascular:
Facial Edema
Cold Sweats (normal for him)
BP 115/76 (high)
HR 148 (High)
Psychosocial:
Family and friends visited
Mother at bedside
Child wants to go home, states car
Pain:
Child fussy
FLACC 0
Fall Risk:
18/23: HIGH

Gastrointestinal:
Soft

abd.
Parenteral Nutrition- fat emulsion 20%, 30
kcal/oz
NPO
G tube (Mickey Button, LUQ)
Genitourinary:
Mom states he gets some bottom rashes at
times, currently none.
Musculoskeletal:
No ambulation noted, tried to get out of crib.
Signs using hands to communicate
Skin:
Has fever blister on chin, covered with band
aid.
Red birthmark on forehead between eyebrows
CVL dressing clean, no drainage noted, Right
upper chest
IV Type/Site:
CVL Right upper chest
Redness, dressing intact, dry and no drainage
noted

1. Infection/Risk for Infection

CVL, Abdominal Mickey
Button, Cold sore on chin that
commonly opens, patient
presented with fever of 38.7,
stomach pain, and nose
bleed, patient on contact
precautions, HX of multiple
line infections, getting 21%
dextrose which creates a
favorable environment for
bacterial growth. Daily blood
cultures.
Cultures were positive for
Gram positive clusters and
Enterobacter and
Staphylococcus
Meropenem, Vancomycin,
Acetaminophen

4. Risk for ineffective breathing pattern

Patient diagnosis of asthma, frequent aspiration,
sleep apnea, multiple allergies to Vancomycin,
and HX of seizures. Latex, coband tape, and
oxacillin, child was coughing some in the crib.
Singulair, Benadryl, Beclomethasone, Keppra,
Albuterol
Pt Initials: N.H.
Age: 3 y.o.
Medical Diagnoses: CVL infection, Short Bowel
Syndrome
(Include secondary diagnoses)
Iris Cysts, Epilepsy, Sleep Apnea, Growth hormone
deficiency, Gastric Enzyme deficiency, Frequent Aspiration,
FTT, GERD, Dysphagia, Mendelian Disorder, Short
Stature, 2q13 chromosome deletion, Anemic, Asthma

3. Dysfunctional GI Motility
Short bowel syndrome that often times results in
diarrhea, abdominal distention on admission,
patient complaint of abdominal pain on admission,
multiple antibiotics that can cause GI problems,
patient somewhat confined to crib and mothers
arms, not moving around much, on contact for
diarrhea and all diapers were combined for the
days totals.
Lactulose PRN for constipation

2. Altered Nutrition: less than body

requirements
Short bowel syndrome, FTT,
GERD, Oral aversion, sucroseisomaltase deficiency, child sort of
choking and gagging, NPO,
Growth chart weight 1.8% and
height in the 0.00%.
HCT 29.9 HGB 9.9, Albumin WNL
Fat emulsion, Parenteral Nutrition
through CVL, Omeprazole, Zofran,
Erythromycin, Ferrous Sulfate

5. Altered Family Coping

Mother really wanted someone
to talk to, the child was admitted
on his birthday and the mother
was talking about having to
move the birthday, she spoke of
how he is constantly in the
hospital at least twice a month
for some reason, child has
Mendelian disorder and 2q13
chromosome deletion that leads
to developmental delays and
cardiac defects, mother stated
the child has been admitted on
every birthday of someone in the
family, she also stated her father
has trouble coming to visit
because of his job and he stated
it is very hard on him each time
the child is admitted. She also
seemed to have trouble with him
being there because this CVL is
the last site they have and she is
worried about what will happen
next.
I did talk to her, and so did
infection control and they let her
air some of her worries, but she
could benefit from having a
professional to talk to about her
childs condition and the way she
feels.

Intervention: 1 and 2
Nursing Interventions:
Infection:

The nurse should observe and report signs of infection at the Mickey button and CVL,
such as redness, warmth, discharge and increased body temperature at site every 4
hours.
Monitor patient vital signs every 4 hours per hospital protocol.
Assess skin for color, moisture, texture and turgor with daily assessment.
Educate on hand hygiene for all visitors of child and the proper use of PPEs.
Maintain abx as ordered for patient.
2. Nursing Interventions:
Altered nutrition
Make sure the child is getting all of the TPN continuous infusion via CVL.
Weigh and the child daily and monitor for any weight loss. Height should be charted
monthly. Mucous membranes should be checked daily with assessment.
Make sure the child is getting the correct infusion of Neocate Jr. 30 kcal/oz via G-tube.
Check hemoglobin, HCT, BUN and serum albumin daily
Take GERD medications as prescribed.

Intervention: 3,4&5
3. Nursing Interventions:
Dysfunctional GI motility

Assess for diarrhea and pain in abdomen every 4 hours.

Administer Lactulose if needed for constipation with child.
Listen to all bowel sounds q4h for diminished sounds and measure abdomen for increased girth daily.
Record BM frequency, color, consistency and odor
4. Nursing Interventions:
Risk for ineffective breathing pattern
Listen to breath sounds of all lung quadrants q4h.
Listen for child wheezing or straining to breathe upon entering room.
Monitor 02 saturation continuously, as noted in orders.
Educate mother on medications and effects.
5. Nursing Interventions:
Altered family coping
Call in a social worker to evaluate the family and see if there is anything that can be done to make it easier on
the mom
Research a support group the mother can talk to about her feelings of dealing with a child that has a chronic
illness.
Encourage family to express their feelings in a healthy manner
Monitor patient and family interactions.

Outcome: Childs temperature will decrease to within normal limits of 36.2-37.8 Celsius before discharge

Eval: Patients temperature stayed within normal limits while on floor. Full evaluation to discharge could
not be done.

Outcome: Child will have healthy pink moisturized oral mucous membranes before discharge, and Neocate
Jr. tubing will be changed daily while hospitalized.
Eval: The Childs assessment revealed pink oral mucous membranes and his tubing is changed every night
by the nursing staff.

Outcome: Patient will continue to have stool, output (unless it is loose then balance of TPN and Neocate will
be evaluated) and will continue to have decreased abdominal distention.
Eval: During my time, the patient only has combined diapers, so constipation is not a problem, but loose
stools seemed to be becoming a problem.

Outcome: Childs breath sounds anterior and posterior will remain free from adventitious sounds while I
am on the unit.
Eval: I did hear him coughing but when I listened to his lungs I did not hear any wheezing or other
adventitious sounds, so it seemed he was just clearing his throat.

Outcome: The mother will verbalize ways she is adapting to changes in lifestyle and roles before discharge
of the child.
Eval: The mother did say her husband does not do the dishes at home and that her child is in and out of the
hospital a lot and she is always the one with him. She does keep the family involved through texts and
updates, but I could not fully evaluate this one due to leaving the unit.

Holistic Care
Traditional Care:
Medication
Isolation
Machines

to
monitor vital
signs
G tube feedings

Complimentary/Al

ternative
Movie distraction
Play distraction

Teach and Discharge

CVL care

Hand hygiene, emergency kit

Know signs of infection

Call Doctor if infection suspected

Skin care

Keep skin warm, dry and keep open sores covered and clean
Scent and alcohol free wipes

Nutritional support

Watch for diarrhea

Peer Support groups

Research
Goal:

Determine impact of CVL care bundle to decrease infections

Abstract:

Quasi-experimental unmatched pre/post-intervention design

6 inpatient care units
Riley Hospital
187 full-time nurses, educated over 2 months

Findings:

Increased compliance with bundle use after education

Decreased infections:

80,000 CLABSIs occur in critical care areas yearly

4 months before: 6 infections
4-months after inventory: 4 infections

Research and My
Patient:
NUR SE DISCUSSES LI NES WITH

DO CTOR
HAND HYGI ENE
TUBI NG CHANGES
DR ESSI NG CHANGES A ND CH ECKS

Closing Remarks:
Present information related to a chosen

patient
Pertinent health history
Admission diagnosis and patho.
Culture
Assessment/Developmental stage
Identify nursing problems and care
Concept map, Interventions, Expected
outcomes
Integrate nursing research into patient care

Questions??

References:
Application Frame | Children's Hospitals and Clinics of Minnesota. (2016). Children's Hospitals and Clinics of
Minnesota. Retrieved from
https://www.childrensmn.org/educationmaterials/childrensmn/article/15539/central-venous-catheter-careat-home/
Hockenberry, M. & Wilson, D., (2015). Nursing care of infants and children, (10th ed.). St.Louis, MO. Elsevier
McCaskey, M. S. (2013). Transferring central line care evidence into practice on pediatric acute care units. Journal
of Pediatric Nursing, 28(6), e57-63 1p. doi:10.1016/j.pedn.2013.02.027
Steiner, P. C. (2015). Empowering patients with central venous catheters: Utilizing evidence-based video-assisted
education to reduce central line-Associated bloodstream infections.
Kizior, R. J., Hodgson, B. B., Hodgson, K. J., & Witmer, J. B. (2015). Saunders Nursing Drug Handbook 2015.
Elsevier.