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Nursing Case Studies: Thomas and

Care plan

Nursing problem 1: Marys pain must be contained so she does not injure herself.

Because children cannot always express their sensations of pain, their pain may go unnoticed until it becomes severe and frightening.

Nursing problem 2: Vomiting and the possibility of choking.

Anxiety and pain can cause children to vomit, making treatment of pain and administering proper nutrition difficult.

Nursing problem 3: Mary is attempting to remove her oxygen mask.

A lack of knowledge on the part of the child as to why certain treatments are administered can result in noncompliance.

Nursing problem 4: The need for social support when Marys mother is not present.

The unfamiliarity of the hospital environment is exacerbated by Marys lack of parental care.

Expected outcomes

Diagnosis 1: Pain management

Outcome: The FLACC: a behavioural scale for scoring postoperative pain in young children that can be helpful in determining how to treat a childs pain. Marys reactions of grimacing and squirming suggest a 2 rating for pain on the FLACC.

Diagnosis 2: Vomiting

Outcome: Treating Marys pain should reduce her anxiety and therefore her reaction of vomiting: however, if it does not, anti-nausea medication may be required as well as an IV. Pain medication can also cause nausea as a side effect.

Diagnosis 3: Discomfort and lack of knowledge

Outcome: Mary must be instructed, in an age-appropriate manner, about the need to leave on her oxygen mask: pain reduction techniques may reduce her discomfort. However, Mary may need to be observed and restrained if she continues to interfere with the equipment.

Diagnosis 4: Lack of parental support/knowledge of the severity of the childs condition.

Outcome: If Marys mother or a family member cannot be present, a member of the hospital staff (such as a volunteer) should be assigned to watch Mary. Mary and her caregiver will determine a way to communicate to indicate when Mary is experiencing discomfort.

Nursing intervention

Mary was treated with pain medication and an IV drip was used to administer nutrition. Pain stabilization reduced Marys nausea and a member of the hospital staff was assigned to watch Mary until Marys mother returned to the hospital. Marys mother briefed as to her daughters condition.

In conforming to RUMBA, the observational use of the FLACC scale provides a realistic, unambiguous, measurable, and observable, behavioural and achievable means to reduce Marys pain within the hospital environment and afterward.

Scientific rationale

While over-dosing of pain medications in children is always of acute concern, the anxiety provoked by pain is also of concern: observing a child post-operatively is essential, as well as developing a language for the child through which they can communicate their distress (Metzer 2007).

Evaluation of care (DAP)

Data: According to the FLACC scale, Marys grimacing, discomfort, and expressed distress rated a 2, indicating more pain medication was required.

Assessment: Marys physical distress was exacerbated by the emotional distress of confusion and abandonment. The fact that her mother was not present, and Mary was amongst people who were not familiar to her increased her distress.

Plan: Mary must be given an age-appropriate way of communicating her pain to hospital staff and to her mother, upon discharge (May 1999). Marys mother must be briefed as to using the FLACC when administering pain medication at home in a responsible fashion so she does not over or under-dose her child.

Discharge plan

Medications: Depending upon Marys response to post-operative treatment, non-narcotic or opiod medications would be prescribed. Self-administered medication, given Marys age seems unwise.

Equipment: Wheelchair, to facilitate moving Mary without disturbing her.

Outpatient appointments: Physical therapist, orthopaedic, and paediatrician appointments are scheduled to engage in follow-up regarding Marys condition.

When to return to hospital: If Mary shows signs of acute distress, further intervention may be required. If vomiting makes appropriate nutrition impossible, Mary and her mother should return to the hospital.

Education: Marys mother must be acquainted with the FLACC and develop a method with Mary of communicating Marys pain

Exercise, activity, diet: Mary will meet with a physical therapist to discuss appropriate movement therapy. Marys regular activities will be restrained until meeting with an orthopaedic surgeon.

References

Max M.B. (2007). Pain. in: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd Ed.

Philadelphia, Pa: Saunders Elsevier.

May, L. (1999). “Ive got a tummy ache in my head”; Communicating with sick children.

Paediatric Nursing, 11(2), 21 — 23.

Merkel S.I., Voepel-Lewis T., Shayevitz J.R. & Malviya S. (1997). The FLACC: A

behavioural scale for scoring postoperative pain in young children Paediatric

Nursing 23:293-297.

Other references

Almond, C. (1998). Children are not little adults. Australian Nursing Journal, 6(3), 27 — 30.

Bruce, E., & Franck, L. (2000). Self-administered nitrous oxide (Entonox () for the management of procedural pain. Paediatric Nursing, 12(7), 15 — 19.

Manworren R. & Hynan L.S (2003) Clinical validation of FLACC: preverbal patient pain scale. Paediatric Nursing 29(2):140-146.

McInerney, M. (2000). Paediatric pain. Pulse Information Sheet of Royal College of Nursing,

Australia, 4. Stark, K. (1998). Clinical update: Paediatric pain management.

Australian Nurses Journal, 13, 1 — 4.

Sheridan, M. (1997). From birth to five years: childrens developmental progress. Revised & updated by Frost, M. & Sharma, a. (4th Rev. Ed.)..

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