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USF College of Nursing NUR 4467L

PICU
Worksheet
Student: Shawn Hekkanen_ Date: 2/2/16 Instructor: Danielle
Beasley__
M/F__M_ Age__11___Current Wt._84.3kg_____Date of
Admission__1/26/16___
Vital Signs: T__98.5F___ HR__70____ RR_24______
BP__136/74____ O2 Sat%_100____ Capnography__EtCO2
27mmHg_____
Oxygen/Type___mechanical ventilator /45%
O2__________________________________
Procedures___Left side craniotomy, _intracranial pressure
monitor with Licox bolt, OG tube, switched Dobhoff NG tube to
duodenum, attempted spinal fusion of C1/C2 delayed due to
complications associated with pneumonia, foley catheter
insertion, right chest tube for pneumothorax now removed,
endotracheal intubation, right arterial line
1. Indicate the diagnosis/reason the patient was admitted to
the PICU and define treatments for the diagnosis:
11 year old African American male, 84.3kg, admitted to TGH as
transfer from Lee Memorial Hospital, after MVA from rock truck that
rolled onto patients vehicle. Patient was trapped inside vehicle 30-40
minutes and freed by emergency responders. Patient was unresponsive
at the scene of accident. He is diagnosed with Left subdural hematoma
with shift, mild mass on left cerebrum, large liver laceration (grade 5),
right rib fractures 1-7, left rib fracture 1, pulmonary contusions, right
pneumothorax, spleen laceration (grade 2), mesenteric hematoma.
Patient was originally intubated by first responders. He currently an
endotracheal tube with PEEP 7, O2 45%, RR 24, 24cm at the mouth
center.
Left side craniotomy for frontoparietal subdural hematoma was
performed for relief of brain shift. Monitoring ICP via bolt. Direct
monitoring of brain oxygenation via Licox bolt, maintaining
pO2>15mm Hg by adjusting mechanical vent above 45% O2, as
needed to promote brain oxygenation. Spinal precautions with C1/C2
fusion pending, C7-T4 compression fractures, and ligamentous injuries.
Right chest tube had been placed d/t
pneumothorax/hemothorax(doctors reported that it was combination),
with serosanguinous output. Chest tube has been removed and there is
bilateral equal chest expansion. Hourly neural exam and assessment.
Coarse breath sounds. Localizes to pain except right upper extremity,
only withdrawals. Continous titration with PRN bolus for pain and
sedation, with fentanyl and versed, respectively. Treatment for

USF College of Nursing NUR 4467L


PICU
Worksheet
pneumonia with antibiotics. Management of mild fever with cooling
blanket and ice packs placed under armpits, groin. Skin precautions
with pressure relieved off bony prominences of extremities, and
stretching extremities hourly under spinal precautions. Monitoring foley
output for color, consistency, amount. Attempting to raise hemoglobin
by administering PRBCs. Monitor edema, and CMP, CBC lab values.
Patient has pneumonia and is being given cefipime antibiotic. He has
coarse breath sounds. Monitor for seizure activity. Seizure precautions.

2. Review the medications pertaining to the child you are


caring for.
Nursing
Medication/
Specific
Usual rangeMajor Side
Considera
Dose
use
WNL?
effects
tions
Fentanyl
Pain
(0.5 to
Apnea,
Monitor
relief
2mcg/kg/hr)
laryngospa RR for
actual:
sm,
depressio
150mcg/hr=3 confusion,
n & BP for
mL/hr
drowsiness hypotensi
WNL, not on
, muscle
on, pulse.
weight based rigidity,
Assess
dosage
bradycardi vital signs
though
a
and
physical
reactions
for signs
of pain
for bolus.
Versed
sedation
(25-50mcg/kg Apnea,
Monitor
Actual:
laryngospa BP, pulse,
2mL/hr=2mg/ sm,
and
hr continuous respiratory respiratio
approximatle depression n
y WNL-dose
, cardiac
continuou
less than
arrest,
sly.
25mcg/kg
arrythmias Resuscita
tive
equipmen
t should
be
available.

USF College of Nursing NUR 4467L


PICU
Worksheet

famotidine

Prevent
aspiration
,
antiulcer

(0.25mg/kg)
Actual: 20mg
BID WNL dose
less than
0.25mg/kg

Arrhythmia
,
agranulocy
tosis,
anemia

Cefepime

antibiotic

(50mg/kg q12
hr for 10
days)
actual1g in
5%
dextrose=50
mL/hr TID
Lower than
normal
dosage

Seizures,
diarrhea,
c.diff,
anaphylaxi
s

(10mg/kg/BID
)
actual:

StevensJohnson
rash, toxic

Keppra

anticonvu
lsant

Maintain
patient
airway if
overdose,
reversed
with
romazicon
.
Monitor
Hgb.
Assess for
occult
blood in
stool,
emesis,
gastric
aspirate..
Monitor
CBC.
False
positives
for urine
protein,
can raise
ALT, AST,
crt.
Monitor
for S/S of
anaphylax
is due to
allergy.
Keep
epinephri
ne
nearby.
Monitor
bowel
function
and lung
sounds.
Assess for
rash, life

USF College of Nursing NUR 4467L


PICU
Worksheet
400mL/hr=50
0mg q 12hr
less than
normal
dosage

epidermal
necrolysis
monitoring
of skin,
agranulocy
stosis lab
monitoring

threateni
ng.
Monitor
skin and
oral
lesions

a. View the individualized code sheet on your patient-why is


this so important?
This is a weight-based drug listing on the front of each door for often
used medications, including medication s for emergency and strict
therapeutic ranges, such as epinephrine, atropine, romazicon(benzo
reveral emergency), cerebryx, Medications are often weight-based in
PICU, as the best determinant of therapeutic range and preventing
toxicity.
3. Think about the childs perspective and identify the
environmental stressors in the PICU?
In the PICU, there are many medications and machines. Patients are
assessed often. Some procedures and administrations are
uncomfortable. Some procedures are performed in different areas, but
and ICU nurse must accompany ICU patient during transfer and
perform a proper handoff. Different staff come on different shifts on
different days. Sometimes different doctors or teams might be
handling aspects of a childs care. There is an attempt to keep nurses
assigned to the same patients, which helps staff and patient.

a. What are the childs responses to the stressors? Is there


evidence of coping mechanisms and support, if so, what
are they?
The child is not alert or oriented. He responds to
command to squeeze fingers placed in his left hand and
localizes to pain in bottom extremities. His family uses
religion as a coping skill. Both his mom and dad are
present for big procedures.
4. What is family/social situation? Indicate strategies and
support services utilized.

USF College of Nursing NUR 4467L


PICU
Worksheet
Mother and father are currently divorced but have been trying to
reconcile. They have been living together before the accident. After
reconciliation began, patient moved in with grandmother. Patient was
living with grandmother at the time of the accident. Grandmother was
not the driver of the car involved in MVA. Mother and father are only
present at bedside for large medical events, such as when the C1/C2
fusion was attempted. The procedure was deferred due to
complications related to pneumonia. The physicians did not thought
the patients pressures would be uncontrollable being prone for
surgery. Mom and dad are both employed. Father began process to
gain FMLA and is now referred to the PICU social worker. Mother is
religious and is active in her church. Pastor intends to visit hospital and
church is attended every Sunday and Wednesday. The church is
praying for patient. Mother reads bible passages to son and to herself
while at bedside. It is unknown when patient will be discharged. A
tracheostomy is likely. Family teaching of trach care or acquiring
professional care would be needed.

a. Are family members permitted to be present during


procedures including resuscitation?
Family members have the right to be present for PICU procedures,
though it is not always encouraged, such as when the Dobhoff tube
was placed. A staff member may be assigned to care and questions
from family during procedures.
5. Describe examples of specialized nursing care delivered in
the PICU.
Medications are titrated often. Assessments are at least every two
hours, unless a patient is about to get discharged. Continuous
monitoring. Arterial lines for monitoring and blood gases. Special
monitoring devices for ICP, etc. All rooms are near to nursing station.
Cardiac monitors are summarized at nurses station. ICU doctors.
Respiratory therapist assigned to ICU. Nurse primary coordinator of all
bedside care. Intensive titrations sometimes. Special certifications.
Nurse coordinates with caregiver for treatment consent.

a. How do the nurses promote a sense of security and control,


provide education, and facilitate use of play?

USF College of Nursing NUR 4467L


PICU
Worksheet
Child life specialists are available. These professionals are trained to
cater to a childs developmental level for coping with hospitalization.
They also work with the patients family members. Ronald McDonald
regularly appears on the unit to talk with the children. Professional
athletes also do outreach at the hospital. There are also sometimes
volunteers, such as a guitar player. The rooms have internet, movies,
and television shows on-demand. Patients have a goal for the day that
is written on the dry-erase board. The nurse, doctor, and managers
name is written on the board, as well. Family wishing to spend the
night is accommodated in the room. Books and other personal items
are allowed in the room. Snacks and food in between mealtimes can
be accommodated. Specialty care is taught to family and encouraged.

6. What are the priority nursing diagnoses and goals for


today?
Ineffective airway clearance related to altered level of consciousness
and diminished protective reflexes.
Regularly suction patients ETT and suction patients mouth. Monitor
lung sounds. Monitor pressures and ventilator for increased suctioning.
Patient is ordered assessment at least every hour.
Bowel incontinence related to impairment in neurologic sensing and
control and also related to changes in nutritional delivery methods.
Monitor foley output with color, consistency, and amount. Monitor for
infection and ensure does not become plugged.
Risk for impaired skin integrity related to immobility.
Log roll patient with spinal precautions to check posterior. Cushion
bony prominences. Regular movement of limbs to prevent breakdown.
P500 bed. When increase angle of bed to help lower ICP then increase
angle of entire bed, keeping it straight for spinal precautions.
Impaired oral mucous membrane related to mouth-breathing, absence
of pharyngeal reflex, and altered fluid intake.
Provide oral care and lip care at least 5 times over shift. Assess
breakdown and dryness of membranes. Suction excess mouth
secretions and ETT suction.
Risk for infection related to ICP monitoring system

USF College of Nursing NUR 4467L


PICU
Worksheet
Wash hands, use hand sanitizer, wear gloves, keep bolt covered and
undamaged. Monitor dressing.
7. What is the anticipated length of stay? Identify actual or
potential discharge planning needs.
His anticipated length of stay is unknown but will be longer than 1
week. This patients length of stay is currently complicated by
pneumonia infection preventing pending surgeries. Multiple spinal
surgeries are planned. The piece of skull removed for left craniotomy is
not expected to be replaced for several months. He sometimes
responds to command to squeeze fingers in his left hand, but he is not
alert and oriented. A CT scan that morning was pending results. The
results may be indicative of brain damage and deficits. Depending on
how oriented this patient can get, he will require therapy for bodily
functions, including movement, bladder and bowel function, weaning
off the ventilator, etc. Currently his breathing is less than 30% under
his control.