Trauma In Peds

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Specializes in Behavioral Health.

good morning, all. any advice on a third dx for a peds client with a l sub. hematoma, gcs 6, strep. pnem. infection, and sub. clav. line? so far i have, ineffective airway as first, hyperthermia as second, now i am torn between r/f impaired skin or r/f infection r/t sub. clav. line. which is priority? :bugeyes:thanks, i just love this site! :rolleyes:

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Specializes in med/surg, telemetry, IV therapy, mgmt.

what does "r/f" mean?

the only information you've given is the patient's medical diagnoses. that is of no help except in knowing the pathophysiology of what is going on. nursing diagnoses are based on the patient's responses to these diseases. what behavior did you observe in this patient? what symptoms did you see? if there was impaired skin, what does the incision (?) or other wounds you are talking about look like--those are the symptoms. incisions, by the way, are impaired tissue integrity and not impaired skin integrity.

to diagnose you need a nursing diagnosis reference. there are a number of ways to acquire this information.

please read the information on writing care plans on this thread:

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Specializes in Trauma ICU, MICU/SICU.

A patient with SDH is usually at high risk for falls secondary to confusion. Why is your patient so sick? Is your patient still intubated? If so, then they're also at risk for interrupting their treatment, for example, extubating self.

HTH.

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Specializes in Cardiac Care.
what does "r/f" mean?

the only information you've given is the patient's medical diagnoses. that is of no help except in knowing the pathophysiology of what is going on. nursing diagnoses are based on the patient's responses to these diseases. what behavior did you observe in this patient? what symptoms did you see? if there was impaired skin, what does the incision (?) or other wounds you are talking about look like--those are the symptoms. incisions, by the way, are impaired tissue integrity and not impaired skin integrity.

to diagnose you need a nursing diagnosis reference. there are a number of ways to acquire this information.

please read the information on writing care plans on this thread:

i think the op is intending "r/f" to mean "risk for", which seems odd with so many other real threats.

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Specializes in Behavioral Health.

Hello again. Sorry for the misuse of capital letters. :zzzzz No offense intended. I am just new to this and I am learning as I go.

In reference to responses to my thread, my client was in t-boned with an automobile on an atv and presented to the ed unresponsive and an artificial airway in place. This client was unresponsive verbally, to eye opening, and to external stimuli. The client remained unresponsive for around 14 days, and then began to wiggle his left toes, but has done no further progress for the las 7 days. This body has responded to the medical diagnosis of closed head injury by shutting down. This client stopped breathing and stopped responding to any stimuli. Then the client developed a strep infection from, I am thinking, the artificial airway being in for so long? The client also has a continuous tpn, and we were goaling toward bolus feeding. I am not sure where that stands, as I have not been in to see him this week, other than just scooting in on my shift in the evenings. I am on a diffferent floor.

Thanks for the help, and ya'll keep me straight. :wink2:

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Specializes in Education, FP, LNC, Forensics, ED, OB.

Hello, 425april

I merged your second thread with the first one to maintain continuity.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

425april. . .i started my hospital nursing career working on a neuro floor and took care of many patients with traumatic closed head injuries. these patients have many actual nursing problems. while ineffective airway (the actual nanda diagnostic label is ineffective airway clearance) and hyperthermia are probably appropriate here, what about

  • fluid and nutrition - you mention the patient is on tpn and he has a central line for this
  • mobility and circulation - the nursing staff, i hope, isn't just letting him lie there like a lump and a turning schedule at the very least has been initiated
  • self care - who baths him? does his mouth care? how is elimination of urine and feces being handled?

to care plan for these things you need to assess for them. assessment not only involves doing a physical assessment of the patient, but also collecting data from the medical record and assessing the patient's abilities to perform adl's.

there are also potential problems that will be the basis for your ideas for "risk for" diagnoses. however, potential problems are of a lower priority than actual problems.

  • respiratory infection (patient already has pneumonia)
  • pneumothorax secondary to mechanical ventilation
  • seizures (this is a common complication in brain injured patients)
  • uncontrolled glucose levels/fluid imbalances secondary to tpn
    (there is a nursing diagnosis for erratic glucose levels: risk for unstable blood glucose)
  • central iv catheter related sepsis

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Specializes in Behavioral Health.

Thanks for all that information. Sounds as if you are a wonderful source for information.:D

My client had all the issues you mentioned , such as bowel and bladder, turning, and bathing taken care of by the dedicated nurses on staff. His dad comes in and does rom with him on some days. Otherwise, the nurses and PT comes in to do that.

He has an automatic rotating bed to continually move him, since manual turning may increase his ICP.

Also, he has a cooling blanket that circulates cool water when he has a fever, and warm water when he has temp below 97.7. I understand that it is not uncommon to see an irratic temp. fluctuation in closed head injury patients.

The glucose levels were high, the anion gap was 14, which is high, the pH was 7.47 (alkalotic), the hco3 was 27.6 (high), the po2 105, the pco2 38, and the co2 29 (high).

The foley was replaced within 7 days of admission due to sediment build up from all the sodium they put on board to decrease his ICP. I suspect that he may also end up with a uti.

The platelets were hight (40.9) and the neutrophils were high ( 86.4).

The rbc was low( 3.80) and the wbc was high (20).

I am trying to use the skills I have been taught to see the "roadmap" to what is happening in his body due to the head injury. I think all the electrical impulses that are usually so well maintained by the cerebrum and the medulla oblongata are just haywire because of all the pressure built up in the brain. It is almost like a circuit board all messed up and there are some impulses getting sent, and some are not. He does have some "bucking" when the oral cavity is being suctioned . It is like his muscles jump but he cannot control them.

His teeth are cleaned twice a day with a special solution and sponge, then he is suctioned. He seems to have a lot of secrestions.

He also has already had a pnuemothorax, resolved.

This is very a interesting , but heartbreaking case. This is my first trauma.

Thanks for all the help. :mad:

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Specializes in med/surg, telemetry, IV therapy, mgmt.

425april. . .you are posting all kinds of information. But, I don't think any of us reading your posts know what it is that you are in need of here. What is it that you are looking for from us? What kind of help do you need?

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Specializes in Behavioral Health.

I really am just unsure about my priority diagnosis, and which ones to use because there is so much. It is a little overwhelming, this being my first trauma case. I can just use what advice I have gotten so far. I am just so excited to have people to talk with about my ideas, and how things work to create a story of how the body adjusts to this type of situation. Thank you for all your help. It it truely appreciated. :wink2:

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Specializes in med/surg, telemetry, IV therapy, mgmt.

In priority order:

  1. Ineffective Airway Clearance
  2. Hyperthermia
  3. Risk for Impaired Skin
  4. Risk for Infection (IV and foley catheter sepsis)

I believe, however that you should also have diagnoses for

  • Ineffective Tissue Perfusion, cerebral
  • Impaired Spontaneous Ventilation
  • Impaired Physical Mobility
  • Risk for Imbalanced Nutrition: less than body requirements
  • Risk for Unstable Glucose
  • Bathing/Hygiene Self-Care Deficit
  • Risk for Injury (seizures)

I strongly suggest that you find a good textbook of pathophysiology such as Pathophysiology: The Biologic Basis for Disease in Adults and Children by Kathryn L. McCance and Sue E. Heuther and read about what is going on in the brain during an injury like this. If this little guy ever regains consciousness he will most likely have a lot of neuro deficits and a long road of rehabilitation in front of him. If he is unable to breathe on his own a trach will be done since ET tubes can only remain in place for 3 or 4 weeks. The TPN will be replaced by a gastric tube and tube feedings. When these things are done, he will be discharged to a rehab facility. Trach, lung, foley and bladder infections that could go septic, potential for pressure ulcers, and seizures will be risks for this patient.

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Specializes in Behavioral Health.

Thanks,Daytonite. That is just what i needed to hear. :lol2:

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