Pediatric Nursing Rounds
MARIAN GEMENDER
Introduction and Overview
 Client:
 21-year-old male with cerebral palsy, mental retardation, and
developmental delay
 Admitted for spinal fusion to treat scoliosis
 Focus of presentation:
 Client history and assessment
 Nursing plan of care
 Applicable research
 Techniques to obtain audience interest:
 Handout
 Discussion
Client History
 Birth history
 Full-term birth
 C-section with Pitocin secondary to non-reassuring heart tones
 Suffered intracranial hemorrhage at this time
 Heath history
 Quadriplegic with thoracolumbar curve 95 degrees to the right
 Scoliosis diagnosed 2-3 years ago
 Allergies: Chloral hydrate
 Past surgical history:
 G-tube
 Appendectomy for ruptured appendix
Cultural Considerations
 Special needs child
 Mother’s relationship
with patient
Hospitalization
 Chief reason for admission:
 Spinal fusion
 Primary medical diagnosis:
 Idiopathic scoliosis
 Relationship of secondary
medical diagnoses:

Children with cerebral palsy (CP)
are at increased risk for developing
scoliosis (Persson-Bunke, Hägglund,
Lauge-Pedersen, Ma, & Westbom, 2012)
Pathophysiology of Scoliosis
 Curvature of the spine; “S” or “C” shaped
 Three types: congenital, neuromuscular, idiopathic
 Soft tissues shorten along concave side of curve
 One-sided compression of vertebrae
(McCance, Huether,
Brashers, & Rote,
2010; Scoliosis in
Children / Escoliosis,
2014)
Treatment Plan
 Posterior spinal fusion and Ponte osteotomies
Developmental Stage
 Expected developmental stage- Piaget
 Formal operational stage- does not meet norm
 Expected developmental stage- Erikson
 Intimacy vs. Isolation stage- does not meet norm
Physical Assessment Data
 Neuro


Nonverbal, unable to assess
orientation; alert
Unable to follow commands at
time of assessment
 Skin


 Respiratory

Tachypnic; respirations 24
 GI


Bowel sounds present but no
bowel movement for three
days
Abdomen firm and distended


 Musculoskeletal

 GU

Incontinent; voids in diaper
 Fall Risk

High
Scar on abdomen from prior
G-tube insertion
Scar along spine from spinal
fusion; bandage dry and intact
with scant serosanguineous
drainage
Peripheral IV left wrist; right
radial arterial line
Wound vac right side of back
Contractures all four
extremities; unable to
straighten completely
 Pain

Measured with FLACC scale- 4
Nursing Problems/Plan of Care
Nursing Diagnosis 1
 Pain related to postoperative pain, musculoskeletal
pain, and abdominal pain as evidenced by FLACC
scale of 5, moaning, crying, and a facial mask of pain.
 Expected Outcome:
 The patient shows signs of pain relief by a FLACC of <4, not
moaning, crying, or looking distraught 30-60 minutes after
administration of pain medication.
Nursing Diagnosis 1
 Nursing Interventions:
 Observe or monitor signs and symptoms associated with pain
such as BP, heart rate, temperature, color and moisture of
skin, and restlessness q4h.
 Assess for probable cause of pain.
 Evaluate patient's response to pain using FLACC with
medications or therapeutics aimed at abolishing or relieving
pain 30 to 60 minutes after administration and q4h. Evaluate
for decreased moaning and crying.
 Monitor for changes in general condition that may herald need
for change in pain relief method if current medications are not
working within 30 to 60 minutes of administration.
 Anticipate the need for pain relief.
Nursing Diagnosis 2
 Constipation related to impaired mobility and use of
narcotic analgesics as evidenced by abdominal
distention/firmness and no passage of stool for three
days.
 Expected Outcome:
 The patient will pass stool after administration of fleet enema.
Nursing Diagnosis 2
 Nursing Interventions:
 Evaluate laxative use, type, frequency, and effectiveness at
every shift.
 Evaluate reliance on enemas for elimination.
 Evaluate usual dietary habits, eating habits, eating schedule,
and liquid intake. Maintenance fluids should be
1,698ml/24hrs.
 Monitor stooling pattern and abdominal distension q4h.
 Assess fluid balance by measuring and comparing I&O q4h.
Nursing Diagnosis 3
 Risk for infection related to an invasive procedure.
 Expected Outcome:
 Patient remains free of infection throughout hospitalization, as
evidenced by temperature between 36.4 and 37.4 degrees
Celsius and absence of purulent drainage from wounds,
incisions, and tubes
Nursing Diagnosis 3
 Nursing Interventions:
 Monitor for signs of infection q4h, including redness, swelling,
increased pain, or purulent drainage at surgical site located
along his spine. Also monitor temperature to see if it goes
above 37.4 degrees Celsius q4h.
 Maintain asepsis for dressing changes and wound care.
 Provide maintenance fluids 70.75ml/hr.
 Teach caregiver importance of washing hands often and how to
use aseptic technique when caring for surgical site.
Nursing Diagnosis 4
 Risk for impaired skin integrity related to impaired
mobility, incontinence, and healing surgical wound
located along spine.
 Expected Outcome:
 The patient’s skin remains intact as evidenced by no redness
over bony prominences and capillary refill <2 seconds
throughout hospitalization.
Nursing Diagnosis 4
 Nursing Interventions:
 Assess general condition of skin at the beginning of the shift to
use as baseline.
 Specifically assess skin over bony prominences (sacrum,
trochanters, scapulae, elbows, heels, inner and outer
malleolus, inner and outer knees, back of head).
 Assess patient's nutritional status, including weight, weight
loss, and fluid maintenance. Maintenance fluids should be
70.75ml/hr
 Encourage implementation of a turning schedule, restricting
time in one position to 2 hours or less.
Nursing Diagnosis 5
 Parent knowledge deficit related to new procedure as
evidenced by questioning members of the health care
team.
 Expected Outcome:
 Mother will verbalize that she feels comfortable caring for her
child’s needs, including caring for the surgical site and
monitoring his daily needs by discharge.
Nursing Diagnosis 5
 Nursing Interventions:
 Assess ability of mother to learn or perform post-operative
care, paying attention to physical and psychological
limitations.
 Question the mother regarding previous experience and health
teaching to determine what she already knows.
 Provide clear instruction for specific topics such as using
aseptic technique.
 Evaluate how much the mother knows after providing her with
new information.
Holistic Nursing Care
 Traditional Care




Nursing assessment
Medication administration
Turning in bed
Communication with family
 Collaborative Care


Surgical procedure (spinal fusion)
Physical therapy
 Complimentary/Alternative Care



Massage therapy
Acupuncture
Music therapy
Relationship of Nursing Problems
Constipation
Pain
Risk for impaired skin integrity
Risk for infection
Parent knowledge deficit
Discharge Planning
 Follow up care- medications for pain and




constipation
Schedule home health nurse as necessary
Schedule follow up visit
Fluids and nutrition
Teaching directed towards family



How to safely transfer patient
Teaching for infection prevention around surgical site
Teach signs of infection
Nursing Research
 Individualized Numeric Rating Scale (INRS) is geared




toward nonverbal children with intellectual disability
Aim: at assessing pain in nonverbal children with
intellectual disabilities
Population: parents of 50 children with intellectual
disabilities going in for surgery
Results: Pain assessment of both bedside nurse and
research nurse agreed with parent’s assessment
(Solodiuk et al., 2010)
Correlation: may provide a much more accurate pain
assessment and could result in better pain
management for patient if used
Summary
 Introduction of patient
 History and assessment
 Developmental Stage
 Nursing plan of care
 Applicable nursing research
References
McCance, K.L., Huether, S.E., Brashers, V.L., Rote N.S., (2010). Pathophysiology: The biologic basis for
disease in adults and children. Maryland Heights: Mosby Elsevier
Persson-Bunke, M., Hägglund, G., Lauge-Pedersen, H., Ma, P., & Westbom, L. (2012). Scoliosis in a total
population of children with cerebral palsy. Spine, 37(12), E708-13. doi:10.1097/BRS.
0b013e318246a962
Scoliosis in Children / Escoliosis. (2014). Retrieved December 1, 2014, from http://
www.chkd.org/Patients-and-Families/Health-Library/Content.aspx?
contentTypeId=90&contentId=P02281
Solodiuk, J., Scott-Sutherland, J., Meyers, M., Myette, B., Shusterman, C., Karian, V., & ... Curley, M.
(2010). Validation of the Individualized Numeric Rating Scale (INRS): a pain assessment tool
for nonverbal children with intellectual disability. Pain (03043959), 150(2), 231-236. doi:
10.1016/j.pain.2010.03.016