JOSEPH CROSSMAN

Pectus Repair

INTRODUCTION

Patient: N.A., 13 y/o maleFocus:

1)To discuss history and assessment data2)To identify nursing diagnoses and outline an appropriate plan of care

HEALTHY HISTORY

Brief History:

Uncomplicated vaginal birth at term

Pectus Excavatum

Asymptomatic until adolescent

Chief complaint = SOB

Nuss procedure

PSYCHOSOCIAL AND FAMILY HISTORY

Grandmother has custodyMother and Father still togetherMother and Father still active in his lifeGrandmother not at hospitalCultural Considerations

Gamers, adolescent

CURRENT HOSPITALIZATION

Reason for AdmitScheduled Nuss procedurePrimary complaint: Shortness of breath

Diagnosis: Pectus ExcavatumPatho: congenital abnormal growth of the chest wall, characterized by an “inversion” of the chestTreatment Plan: Surgery, PT, recovery

EXPECTED DEVELOPMENTAL STAGE

Theories:Cognitive (Piaget): Formal Operations (Reasoning of abstract ideas)Psychosocial (Erikson): Identity vs. Role Confusion (Finding “self”)Psychosexual (Freud): Genital Stage (Strong interest in opposite sex)

IS THIS CHILD AGE APPROPRIATE?Yes!

PHYSICAL ASSESSMENT

NEURO: Awake and alert x3. Fatigued. Reports nausea. Pain 0 at lowest 7 at highest Respiratory: Crackles in lower quadrants, diminished sounds bilaterally. Saturation 88-94%. Weaning from 2L NC to RA (100% on 2L). RR 26. Cough on deep inspiration.CV: No Exceptions.GI: Hypoactive bowel sounds. Constipation – multiple urges with no movement.

PHYSICAL ASSESSMENT CON’T

GU: No exceptions. Voided at “last minute” of 1600

SKIN: PIV @ L AC. Dressings at mid axillary line bilaterally at nipple height.

MUSCULOSKELETAL: Limited ROM in upper extremities. Lifting and ROM restriction – arms not allowed above or across chest. Severe pain/soreness along chest wall.

PSYCHOSOCIAL: Parents at bedside, active in care.

FALL RISK: Medium. Family constantly at bedside. Morphine PCA. Post-op.

Pt Initials: NA

Age: 13

Medical Diagnoses:

Pectis excavatum

1. Risk for InfectionR/T: Surgery (Pectis repair)

 Temp: ↑39.2C

WBC: 5.4k“Burning” pain at right sided

surgical site. 

Meds: Cefazolin

3. Acute painR/T: Surgery

 Pt report of pain (4/10 resting) increasing during movement at surgical sites along chest wall.

 Meds: Morphine PCA

Toradol

2. Impaired Gas exchangeR/t: Anesthesia

 -O2 saturation falling to between 88-94% on RA

-100% o2 sat with 2L/min NC

-Dizziness with exercise-Morphine and valium ↓

respiratory effort   

4. Impaired mobilityR/t: dizziness, weakness, limitations of

surgery 

-Dizziness with activity-Unsteady gait

-Requires assistance with ambulation-Weakness with activity

-May not use arms for support-Morphine, toradol, valium, Zofran, and

dolcolax may all be contributing to dizziness

  

6 Psychosocial: Health seeking behaviors R/t: Increase in mobility with PT

 AEB: Patient states “I just want to move

again even though it hurts”Patient asking when next PT session isPatient requesting to be OOB to chair

5 ConstipationR/t: medication side effects

Patient’s urge, but inability to pass stools x4 during clinical day

Hypoactive bowel soundsPt report of nausea

Morphine PCA, valium Meds: Colace, dulcolax

EXPECTED OUTCOMES

1.Risk for Infection: Temperature will remain below 38.5C during hospital stay, surgical sites will remain free of infection.

2.Impaired Gas Exchange: 02 Saturation on room air will stay above 95% throughout stay.

3.Acute pain: Pain scores will be 2/10 or below while resting during hospitalization, and remain so after discharge.

4.Impaired mobility: Patient will steadily increase his mobility and distance walked with PT daily. Patient will not experience a fall during hospitalization.

EXPECTED OUTCOMES

5. Constipation: Patient will be able to have a bowel movement P.O.D. 2. Patient will have regular bowel movements throughout hospital stay.

HOLISTIC CARE GIVEN

NURSING:TRADITIONAL:

Incentive spirometerVS q4hAmbulation assistanceI&OO2 2L/min NC (PRN)D5 1/2NS with 20Meq KCLEncouraged to void (techniques)Pulse OximetryPatient/family teaching

COMPLIMENTARY/ALTERNATIVE:

Offer to perform healthcare activities for familyOffer refreshments or meals to family Other family comfort measures

COLLABORATIVE: Physical therapy BID, regular diet, antibiotics (Vanco)

DISCHARGE PLANNING

Review S&S of infection

S&S of proper healing

Wound care basics

Provide information on resources to reduce caregiver role strain

Incentive Spirometer

Activity restrictions. NO LOG ROLLING/SIDE LAYING

Pain management

Alternate techniques

Side effects

Narcotics

RESEARCH

Implemented a respiratory care bundle to all patients post-op

Incentive spirometer x10/hour

Frequent oral care

Early ambulation/raised HOB

6 Months before implementation, 33 patients were sent to ICU due to respiratory distress

6 Months in the intervention, 15 were sent

12 Months in the intervention, 6 were sentLamar, J. (2012). Relationship of respiratory care bundle with incentive spirometry to reduced pulmonary complications in a medical general practice

unit.MEDSURG Nursing, 21(1), 33-37. Retrieved from http://ehis.ebscohost.com.proxy.lib.odu.edu/eds/detail?vid=10&sid=b8631269-3dcd-414c-9818-

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