Pediatric Nursing Rounds
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Presented By: Bobbi Bowman
Old Dominion University – Nursing Program
Pertinent Past Medical History
Born – 09/08/94
 Normal delivery / birth history
 Vaccinations – up to date
 No prior surgeries / hospitalizations
 Minor lacerations
 NKDA

Psychosocial History
Education
 Future career
 Family
 Cultural consideration

Admitting Diagnoses

Primary

Intraparenchymal hemorrhages & diffuse axonal
injury (Traumatic Brain Injury)

Secondary
s/p post PEG placement for oropharyngeal
dysphagia
 Global aphasia
 History of seizures
 Cognitive deficits

Pathophysiology
Traumatic brain injury (TBI) is defined by the
Brain Injury Association of America as a
traumatic insult to the brain capable of
producing physical, intellectual, emotional,
social, and vocational Changes”
(McCance, K. & Huether, S. ,2010,p.583)
Treatment Plan
Expected Developmental Stage

Expected

Current

Communication
Physical Assessment
Neuro
 Skin
 Cardiovascular
 Respiratory
 GI
 GU
 Musculosketal

CLINICAL CONCEPT MAP
2. Self-care Deficit
1. Impaired Physical
Mobility
PT
OT
Speech therapy
Colace
Miralax
PT
OT
Pt Initials: BW
Age: 18 y/o female
Medical Diagnoses:
(Include secondary diagnoses)
TBI (intraparenchymal
hemorrhages / diffuse axonal
injury)
3. Altered Thought
Process
Oropharyngeal dysphagia, global
aphasia, hx of seizures, and cognitive
deficits
5. Risk for Altered
Nutrition
Colace
Diflucan
Zantac
Miralax
Ativan
4. Family Process Altered
Ativan
Speech therapy
PEG tube
Swallow study
Diagnosis – Expected Outcome

Impaired Physical Mobility - pt will maintain efforts in achieving
optimal independence through therapy (PT/OT) during each session while
admitted to rehab unit as evidence by increased gait stability

Self-care Deficit- pt will perform ADLs @ optimal level of functioning
during the entire 12 hour shift as evidence by increased independence.

Altered Thought Process - pt will be oriented to person, place, and
time with each interaction with staff during 12 hour shift as evidence by
appropriate responses when asked.

Family Process Altered - pt will verbalize a reduction / relief of
anxiety and stress during clinical experience as evidence by verbal
confirmation when asked

Risk for Altered Nutrition - pt will consume adequate calories to
maintain health status during each 24 hour period as evidence by I&O flow
sheet in chart displaying acceptable calculations
Nursing Diagnosis
Actual verse potential
Holistic Nursing Care

Traditional

Complimentary

Alternative

Collaborative
Teaching/ Discharge Planning
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Prep time
Research Review
Garcia, J., Chambers, E., Clark, M., Helverson, J., &
Matta, Z. (2010). Quality of care issues for
dysphagia: modifications involving oral
fluids. Journal of Clinical Nursing, 19(11-12),
1618-1624. doi:10.1111/j.13652702.2009.03009.x
Intervention
References

Garcia, J., Chambers, E., Clark, M., Helverson, J., & Matta, Z.
(2010). Quality of care issues for dysphagia: modifications
involving oral fluids. Journal of Clinical Nursing, 19(11-12), 16181624. doi:10.1111/j.1365-2702.2009.03009.x

McCance, K. & Huether, S. (2010). Pathophysiology: The biologic basis
for disease in adults and children. (5th ed.). Philadelphia: Mosby.

Hockenberry, M. & Wilson, D., (2010). Nursing care of infants and
children, (9th ed.) . St.Louis, MO. Elsevier.

All images were obtained through the Google Image search
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