I. Days of Care Summary:
Student name: Barbara Shreibman
Patient initials: SF
Admit date: 9/18/08
Estimated discharge date: 9/29/08
Admit Wt (kg): 33 kg
Allergies: NKDA, allergic to Tegaderm
Developmental Stage: A normal 7 yo
would be in the Industry vs. Inferiority
stage: child compares her self-worth to
others, and can recognize major
disparities in personal abilities relative to
other children. However, this child is
developmentally delayed and exhibited
behaviors that were more like a 4 or 5
year old in the Intitiative vs. Guilt stage.
She is able to dress herself and perform
self-care such as brush her teeth and
comb her hair. She is proud of her
accomplishments. However, as I
observed in the playroom, she is
unaware of how others see her and
does not display the self-consciousness
that would indicate she recognizes
differences between herself and other
children.
Admitting diagnosis: 7 yo female with
Apert Syndrome and history of
hydrocephalus requiring a Ventricle
Peritoneal shunt (last revised age 6 mo),
who presented with 3 days of abdominal
pain. Was noted to have reddening skin
tracking along skin at shunt site. Surgery
on 9/19 for externalization of shunt. On
9/22 underwent EVD revision and on
9/26 underwent VPS internalization.
Clinical date: 9/28/08
Room#: 764
Gender: female
RN: Faryat Ali
Age: 7
Code status: Full
Current Wt (kg): 32.6 kg
Play needs: Activity is ad lib with fall risk precautions.
On this day the client was eager to go to the hospital
playroom.
Other active diagnoses: Postural Ataxia,
Developmental Delay
Primary Physician/Service: Manish Aghi
Consultations: Neuro
Current immunization status (note source of info): Mother states the child is current on all
immunizations.
Medications/ dose:
Indications:
Singulair 5 mg PO q24 (0.15 mg/kg)
asthma or allergic rhinitis.
Ceftrioxone 1650 mg IV q12 (50mg/kg)
Antibiotic for infection, active against gram negative
bacteria
Temp > 38.3 or for mild to moderate pain
Acetaminophen 500mg PO q4 PRN
(15 mg/kg dose, max 2475/24hr)
Zofran 3 mg IV q8 PRN
(0.1 mg/kg/dose)
Reglan 3.3 mg IV q8 PRN
(0.1 mg/dose)
Nausea
Nausea not responsive to Zofran
Miralax 17 g PO q24 PRN
constipation
(0.5 g/kg)
Morphine 1-2 mg IV q3 PRN
Severe pain
(0.03-0.06 mg/kg)
Brief pathophysiology summary of the primary and admitting diagnoses: The client’s
primary diagnosis is Apert Syndrome and Ventricle Peritoneal shunt revision for infection.
*Apert Syndrome is a condition involving distortions of the head and face and webbing of the
hands and feet. It is a genetic disease in which the seams of the cranial bones close earlier than
normal (craniosynostosis). It is caused by mutations in a gene called fibroblast growth factor
receptor 2. My client showed characteristic abnormalities of the syndrome: her skull is short from
back to front, wide on the sides, and overly tall. Her eyes are slightly side-spaced, bulging, and
the eyelids tilt downward abnormally at the sides. My client’s mid-face has a sunken-in
appearance, her upper jaw slopes backward, and the lower teeth project in front of the upper
teeth, all characteristics of the syndrome. Individuals may have full-length webbing or fusion
between the 2nd, 3rd, and 4th fingers, as well as the toes. As the child grows, the bones in the
hands and feet become progressively fused, which reduces flexibility and function. Even though
my client showed the physical manifestations of this disease, she seems to have found ways to
compensate for her limitations. Other signs of Apert Syndrome are cognitive delay or slowing of
intellectual development, vision loss from imbalanced eye muscles, and hearing loss from
recurrent ear infections. My client did not show signs of hearing or vision loss. She did show signs
of developmental delay, which was evident in the way she related to children in the playroom and
also by her verbal communication. This may improve as she grows older. Treatment for Apert
Syndrome consists of surgery to correct abnormal bone growth of the skull, mid-face, and jaw
area.
**This client also has a history of hydrocephalus, a sequelae of Apert Syndrome, requiring a
ventricle peritoneal shunt, which was last revised at age six months. Hydrocephalus results from
(1) obstruction of cerebrospinal fluid (CSF) flow, (2) interference with absorption of CSF, and (3)
overproduction of CSF. When the movement or flow of CSF is restricted, intracranial pressure
(ICP) rises, the ventricular system dilates proximal to the obstruction of the flow, resulting in
hydrocephalus. Complications of hydrocephalus include increased ICP, infection, shunt
malfunction, delays in cognitive, psychosocial, and physical development, and decreased IQ.
Clinical manifestations in older children include vital sign changes (decreased HR, decreased RR,
increased BP, increased T), frontal headache, nausea and vomiting, anorexia and/or abdominal
pain, ataxia, lower extremity spasticity, visual changes, change in mental status, behavioral
changes, deterioration in cognitive ability, and seizures. When this client was admitted on 9/18
she presented with reddening along the skin shunt and abdominal pain that had persisted for
three days, perhaps signs of increased ICP and infection. On 9/19 the shunt was removed, and
her CSF was tested for the presence of bacteria. On 9/26 she underwent externalization of the
shunt with a R occipital ventricular drain draining to the abdomen. She was treated with
Vancomycin for infection.
The client has a secondary active diagnosis of postural ataxia. The word ataxia means without
coordination. People with ataxia have problems with coordination because parts of the nervous
system that control movement and balance are affected. Postural ataxia affects my client’s ability
to balance when walking. She walks with feet placed further apart to compensate for poor
balance.
*Mosby’s Pediatric Nursing Reference, 2004
**http://www.nlm.nih.gov/medlineplus/ency/article/001581.htm
Diagnostic procedures/ tests recently done or ordered and indications/ findings: The client
was evaluated for an abdominal pseudocyst or free air. On 9/19 CSF was evaluated for the
presence of gram negative bacteria. There were two subsequent draws from CSF for the
evaluation of presence of gram negative bacteria. The client was put on Vancomycin. The Vanco
trough on 9/21 was 8. Following a dose change the trough was 12. Physicians were unable to
obtain CSF in the OR on 9/26 during internalization of the VP shunt,
Lab data relevant to care (be specific) and interpretation:
*Abnormal lab values (CBC with Platelet Count, collected 9/27/08)
RBC Count: 3.82 Low (range: 4-5). Interpretation: A decreased value could indicate anemia, but
this client is borderline low at 3.82. This client may have had a slightly diluted blood concentration
owing to being on IV fluids (which were discontinued on 9/28) when she was also drinking
normal amounts on her own.
Hemoglobin: 10.9 Low (range: 11.4-15.5). Interpretation: A decreased value could indicate
anemia. However, antibiotics could cause decreased levels of hemoglobin, and this client was on
both vancomycin for infection followed by Ceftrioxone (Cefoperazone).
Hematocrit: 32.2 Low (range: 35-45). Interpretation: A decreased value could indicate anemia.
However, a decreased hematocrit level could also be caused by antibiotics.
*Mosby’s Manual of Diagnostic and Laboratory Tests, Third Edition, 2006
Current immunization status (per chart or parent report): Mother states her daughter is current on
all immunizations.
***First focused AM assessment (optimally done by 8AM):
Vital Signs Day 1 *
Pain scale used: Faces Pain Rating Scale
0800
T: 36.7
P: 87
R: 22
1200
T: 36.8
P: 99
R: 22
1600
T:
P:
R:
Vital Signs Day 2:
0800
T:
P:
R:
1200
T:
P:
R:
1600
T:
P:
R:
Frequency ordered: q4 hr
BP: 113/67
BP: 113/72
BP:
Frequency ordered:
BP:
BP:
BP:
Intake & Output
Previous 24 hr total intake:
Dietary orders/ restrictions: no food
restrictions
Day 1
Oral
IV
Previous 24 hr total output:
0800
1200
1600
Totals
75%
breakfast
75% lunch
135 ml
D51/2
IV stopped,
but access
maintained
NG
UOP/Stool
200 ml urine
500 ml urine
200 ml urine
Pain: 0
Pain: 0
Pain:
Pain:
Pain:
Pain:
Suction /drains
Shift Totals
900 ml
*A neuro assessment was also ordered q4 hrs. I assessed pupillary response at 0800 and 1200.
Both assessments showed pupil size 3 and a brisk response to light (++).
Body system assessments:
Skin: Surgical scar on R occiput at VP shunt site. No reddening or signs of infection. Webbing
between fingers has been removed on both hands. Skin between toes is dry. Skin in general is
pink, warm, and dry, with good capillary refill.
Head & neck: Head shows cranial changes consistent with Apert Syndrome. The client’s vision
and hearing were not impaired and she was able to compensate for the side-spaced position of
her eyes by bringing objects into view.
Neuro: Eyes: PERL. Pupillary response 3 ++. A&O x 3. Appropriate speech and pleasant
demeanor. Client reported no discomfort or pain.
Musculoskeletal: Gross motor: Some weakness in legs when asked to push against hands.
Postural ataxia with unsteady gait with hx of falls. Toes on both feet are fused. The L great toe
has been surgically separated. Fine motor: client able to manipulate objects and perform ADLs
such as tooth brushing and feeding self. However, she has reduced manual dexterity. There was
stiffness in the wrist and ankle joints. No muscle atrophy or asymmetry noted.
Cardiovascular: Apical pulse strong and regular. Pedal pulses strong bilaterally.
Respiratory: Lungs clear. Client was taking Singulair PO for asthma but no signs of respiratory
difficulty.
GI: I did not see a bowel movement but heard in report that the last BM was normal. Abdomen
soft without distention; bowel sounds 4 quads.
GU: Voided normal amounts. Client’s IV fluids were dc’d at 12 pm as she was eating and drinking
sufficiently. Urine was clear, yellow, and odorless.
IV lines assessment: IV site on L hand clean and dry, without reddening or reported pain.
Isolation issues aside from universal precautions (Contact/ airborne): none
Special precautions (neutropenia/ thrombocytopenia): High risk for altered LOC r/t shunt
revision and changes in ICP
*Psycho-Social needs/ family issues: Risk for caregiver role strain r/t competing role
commitments. Mom and Dad visited daily and did not have much time for each other. They also
have three other children at home to care for. I was able to spend enough time with the client to
allow the parents to go for a walk and have lunch together. Mom also stated she was a Medical
Assistant and hoped to go to nursing school, but thought it would be difficult to do that as well as
balance being a wife, mother, and caregiver.
Resources utilized or potentially utilized outside the hospital: The following web links
provide resources for support for families affected by Apert Syndrome:
http://www.aboutfaceusa.org, and http://www.ccakids.org In addition, families can contact the
Apert Support and information Network, Don and Cathie Sears, PO Box 2571, Columbia, SC
29202 or check their web site, http://www.apert.org/
II. HEALTH PATTERNS ASSESSMENT (O: objective S: subjective)
Self-Perception-Self-concept:
Nutrition Metabolic:
O: Client on IVF D51/2
NS 35mL/h. This was
dc’d at 12 noon on
9/28/08. Client was
eating 75% of regular
diet meals and
drinking adequate
amounts. Lab values
for electrolytes on
9/27/08 were wnl, lab
values for CBC
showed borderline low
values for RBCs,
hematocrit, and
hemoglobin, probably
owing to course of
antibiotics. At time of
discharge client had
lost 0.4 kg of weight.
ND: Effective feeding
pattern.
Sleep Rest:
Client has normal and
regular sleeping
patterns.
ND: Effective sleep
rest patterns
Coping Stress:
Medical Diagnosis:
O: Client is a 7 yo female with Apert Syndrome and history of
hydrocephalus requiring a Ventricle Peritoneal shunt and
treatment for infection. Secondary active dx: postural ataxia and
developmental delay.
Activity Exercise:
S: Client stated she was ready and eager to go to the playroom.
O: She had been using a bedside commode with supervision as
she had fallen previously. When her IV was disconnected I
supervised her walking to the bathroom, which she
accomplished without difficulty. I then went with her to the
playroom, where she was able to walk and even climb stairs
(again, with careful supervision on my part in case she lost her
balance).
ND: Risk for Injury RT postural ataxia, fused toes, and stiff
ankle joints secondary to Apert Syndrome AEB unsteady gait.
when walking and previous falls.
Role Relationship:
O: This client is developmentally
delayed and presently does not
appear to have a negative selfconcept or self-perception.
S: Mother states she is currently
enrolled in a “regular” school and is
teased by a boy there, but when I
asked the client if anyone bothers
her, she stated “no.” Mother also
stated her daughter underwent
separation of the great toe on L foot
so she could wear flip flops and be
“like the other kids.”
ND: Risk for ineffective selfperception-self-concept RT social
issues at school AEB mother states
child is teased by classmate.
Value-Belief: Did not determine
family’s value-belief patterns.
O: Mother and Father were at bedside and visited daily.
S: Both parents stated they did not have much time to spend with each
other, as both were working and caring for three other children at home.
Mom and Dad both seemed to understand Apert Syndrome and Mom in
particular was tuned in to her daughter’s needs.
ND: Risk for Caregiver Role Strain RT multiple competing roles
ND
AEB mother stating she is having difficulty balancing
responsibilities of wife, mother, and work.
ND
S: Mom and Dad were in
good spirits but stated were
ready for their daughter to
come home so they could
all get back to their regular ND
routine. The client was
feeling better and had a lot
of energy and was eager to
ND
go back to school.
ND: Effective coping-stress
pattern.
ND
Elimination:
ND
O: Client has no elimination
problems. Bowel sounds
present 4 quadrants.
ND: Effective elimination
patterns.
Cognitive Perceptual:
Health Maintenance-Perception:
O: Client has a hx of hydrocephalus and a VP shunt
draining to her abdomen. On 9/28 the client was A&O x 3
and pupillary reaction was 3++. No signs of hearing or
vision loss were observed, and client was able to
compensate for structural differences related to Apert’s
syndrome. Client is developmentally delayed, which affects
her ability to communicate and interact with other people.
O: Client has Apert Syndrome.
Client has a VP shunt draining
CSF to her abdomen. Client is
developmentally delayed and
has postural ataxia. Client was
treated for infection and
underwent shunt revision.
Incision site is clean, dry, intact,
and free of infection. No changes
in LOC on
9/28. Parents
ND
understand Apert Syndrome and
S&S of ICP. Both are involved in
child’s care at home.
ND: Developmental delay RT hx of hydrocephalus
secondary to Apert syndrome AEB interactions with other
children in the playroom.
ND: Effective Health
Maintenance-Perception.
ND
III.
Nursing diagnoses/ problems identified and prioritized (2-3 per clinical day)
and rational for identifying each of these problems on today's list:
*Nursing Diagnosis 1: Risk for Injury RT postural ataxia, fused toes, and stiff ankle joints
secondary to Apert Syndrome AEB unsteady gait when walking and previous falls.
Assessment/ functional pattern: Client has postural ataxia, which affects coordination and
balance. She also has fused toes on both feet, which creates difficulty planting her feet while
walking. She compensates by placing her feet farther apart for balance but her gait is unsteady.
Client is able to ambulate well but has fallen while hospitalized and needed to be supervised at all
times.
Nursing goals/ expected outcome: Client will not fall and injure self.
Nursing interventions: 'The nursing student will..........'
1. Keep siderails up on bed
2. Have bedside commode available so client doesn’t have
to walk to the bathroom
3. Monitor ambulation at all times
4. Keep floor free of clutter
Rationale/ Patho
Siderails up on the bed will
prevent client from falling out
Minimize need for walking any
distance that might increase risk
for falling
Close supervision provides the
opportunity to prevent a fall, while
still supporting independence
Clutter is an added risk for falling
5. Make sure the client is wearing hospital socks with rubber
Hospital socks provide greater
tread
traction while walking
Evaluation (can be current and/or prospective): On 9/28 the client was eager to go to the
playroom. I supervised her ambulating to the bathroom instead of using the bedside commode to
assess her readiness to walk in the playroom. She was able to ambulate to the toilet without
losing her balance, so I accompanied her to the playroom. She successfully walked and even
climbed a short stairway without losing her balance or falling.
*Nursing Diagnosis 2: Risk for Caregiver Role Strain RT multiple competing roles AEB mother
stating she is having difficulty balancing responsibilities of wife, mother, and work.
Assessment/ functional pattern: Mother stated she is a Medical Assisstant and hopes to go to
nursing school someday. She is currently taking care of four children at home, including the client.
She stated it has been difficult to find time to go out with her husband and get everything done
around the house, especially since she is also working part time.
Nursing goals/ expected outcome: Caregiver reports that formal and informal support systems are
adequate and helpful.
Nursing interventions: 'The nursing student will..........'
1. Encourage caregiver to identify available family and
friends who can assist with caregiving.
Rationale/ Patho
Successful caregiving should not
be the sole responsibility of one
person. In some situations there
may be no readily available
resources; however, often family
members hesitate to notify other
family members or significant
others because of unresolved
conflicts in the past.
2. Encourage caregiver to set aside time for self.
This could be as simple as a
relaxing bath, a time to read a
book, or going out with friends
3. Acknowledge to caregiver the role he or she is carrying
Caregivers have identified how
out and its value.
important it is to feel appreciated
for their efforts
4. Provide time for caregiver to discuss problems, concerns,
As a caregiver, the nurse is in an
and feelings. Ask caregiver how he or she is managing.
excellent position to provide
emotional support.
5. Encourage caregiver in support group participation.
Groups that come together for
mutual support can be quite
beneficial in providing education
and anticipatory guidance. Groups
can meet in the home, social
setting, by telephone, or even
through computer access.
Evaluation (can be current and/or prospective): Mom appears to have some information regarding
Apert Syndrome and has the support of her husband, but has not participated in support groups or
used her family much as a resource. Hopefully she will see her family and others as an option for
relief of caregiving, will find balance in her responsibilities as mother and wife, and will feel she is
able to one day go to nursing school.
*Wong’s Nursing Care of Infants and Children, Eighth Edition, 2007
* *Mosby’s Pediatric Nursing Reference, 2004
IV.
Medication Administration Worksheet
Show all calculations for at least 4 medications per 2 clinical days (at least 2 IV meds!): dose
range and maximum dose for weight, dose to be given, concentration of mixture and volume to
draw up, final dilution and rate to infuse)
1. Medication: Ceftrioxon (Cefoperazone)
50mg/kg dose
Pt’s current weight (kg): 32.6 kg*
What is the safe dosage
range** per day & dose:
50-200 mg/kg/day
What is the maximum
dose for this patient?
Dose ordered: 1650 mg IV
*(calculated for 33 kg, weight on admission.
Calculated using current weight of 32.6 kg, dose
should be 1630 mg)
Frequency: q12
50 x 33kg =1650 mg/day
200 x 33kg= 6600 mg/day
safe dose range = 1650mg-6600mg/day
6520 mg/day
Is the ordered
dose safe?
Yes: 2x1650=3300 mg/day
How is it reconstituted?
Intermittent: Dilute each 1 g with 5 mL sterile water. Shake
vigorously to dissolve, then dilute in 50–100 mL of D5W or
NS. Continuous: Further dilute in 500–1000 mL of the
selected IV solution.
How is it administered? (i.e. solutions, volumes and rate)
Intermittent: Give 50-100 mL over 15–30 min. Continuous: Give 500–1000 mL over 6–24 h.
Client’s IV of D51/2 NS was set at a continuous rate of 35 mL/h on 9/28/08. 1650mg/12h=137.5 mg/h. 137.5 mg/35
mL/h= 3.9 mg/h. Client received 3.9 mg/mL/h of ceftrioxone
2. Medication: Zofran (0.1 mg/kg/dose)
Dose ordered: 3 mg IV
Pt’s current weight (kg): 32.6 kg
Frequency: q8h PRN
What is the safe dosage
range** per day & dose:
Child: IV 1 mo–12 y, <40 kg, 0.1 mg/kg I did not find a specific reference for max dose
per day.
What is the maximum
dose for this patient?
32.6 kg x 0.1mg = 3.26
mg/dose
Is the ordered
dose safe?
yes
How is it diluted?
IV Infusion: Dilute a single does in 50 mL of D5W or NS.
May be further diluted in selected IV solution.
How is it reconstituted?
How is it administered? (i.e. solutions, volumes and rate)
IV Infusion: Give over 15 min. When three separate doses are administered, infuse each over 15 min.
50 mL/15 min = 3.3 mL/min 3 mg/15 min = 0.2 mg/min
3. Medication: Singulair
Dose ordered: 5 mg PO (0.15 mg/kg)
Pt’s current weight (kg): 32.6 kg
Frequency: q24
What is the safe dosage
range** per day & dose:
Child: PO 6–14 y, 5 mg chewable tablet q.d. in evening
What is the maximum
dose for this patient?
5mg
How is it reconstituted?
Is the ordered
dose safe?
yes
How is it diluted?
How is it administered? (i.e. solutions, volumes and rate)
4. Medication: Acetaminophen
(15 mg/kg dose, max)
Dose ordered: 500mg PO
Or 2000mg/day
Pt’s current weight (kg): 32.6 kg
Frequency: q4 PRN
What is the safe dosage
range** per day & dose:
10x32.6=326mg/dose
15x32.6=489mg/dose
What is the maximum
dose for this patient?
How is it reconstituted?
For children under 12 years of age, the recommended dose of acetaminophen is 10 to
15 mg/kg every 4 to 6 hours, not to exceed five doses (50-75 mg/kg) in 24 hours
4 x 326 = 1304 mg/day 50 x 32.6 = 1630 mg
4 x 489 = 1956 mg/day 75 x 32.6 = 2445 mg
15 mg x 32.6 kg = 489
mg x 4 = 1956 mg/day
Is the ordered
dose safe?
How is it diluted?
How is it administered? (i.e. solutions, volumes and rate)
*Nurse’s Drug Guide, 2008. Wilson, Shannon, Shields and Strang.
yes