REFERENCE CARE PLAN: Mitrofanoff Procedure

Transcription

1 REFERENCE CARE PLAN: Mitrofanoff Procedure PATIENT POPULATION Patients admitted to the inpatient surgery unit following the mitrofanoff procedure. DEFINITIONS Abdominal drain: a drain inserted into the abdomen; drains fluid from the surgical site. Bladder Augmentation: a procedure to make the bladder bigger. Cecostomy tube: a tube inserted through the abdomen into the large bowel; used to keep the bowel clean and to allow it to heal. Mitrofanoff: a small tunnel from the bladder to the outside of the body that is used to empty the bladder. Nasogastric tube: a tube inserted through the nose into the stomach; keeps the stomach empty and allows the intestines to rest. Suprapubic catheter: a tube inserted through the abdomen into the bladder; keeps the bladder empty and allows it to heal. Stents: very small tubes that go into the ureters of the kidney; help keep the bladder empty so it can heal. /Potential Pain and discomfort related to surgery. Child will be comfortable as evidenced by: Normal vitals and SaO 2 Respirations easy and unlabored Pain score results indicate pain is controlled Verbally stating they are comfortable Decreasing analgesic requirements Assess and document pain every 4 hours and as needed using developmentally appropriate scale. Administer analgesic as ordered. If analgesic ineffective call most responsible physician. NOTE: Consider giving around the clock pain management for the first hours post-operatively even if it is ordered as needed. Ensure distraction techniques are also used to supplement the pharmacological approach. Distraction techniques include: Movies Regular assessment guides the selection of appropriate pain interventions and provides a baseline for their efficacy. Treating postoperative pain routinely provides consistent relief and lessens the chance of the patient getting in a pain crisis. Diverting a child s attention can help reduce pain perception and decrease anxiety. Page of 10

2 /Potential Music Toys Books Alteration in fluid balance related to: Surgery NPO status Nausea and vomiting NG, drains Inadequate fluid administration Child will maintain: normal vital signs electrolyte stability moist mucous membranes good skin elasticity balanced intake & output Assist with repositioning q2-4h prn. Monitor Vital Signs routinely every four hours and more as needed based on patient status. Calculate the patients daily fluid requirements and ensure that they are meeting their minimum needs from all fluid sources. Consult the most responsible physician if fluid orders need to be increased or decreased. Alleviates discomfort and aids in prevention of potential pressure ulcers. Vital signs changes such as increased heart rate, decreased blood pressure, and increased temperature may indicate inadequate fluid status and/or shock. To ensure adequate hydration. Maintain strict intake and output records and ensure totals are done at minimum every 12 hours. Accurate documentation helps identify fluid losses or replacement needs and influences intervention selection. Assess and document the amount, color & consistency of urine output from all sources (i.e. catheter, stents, etc.). Ensure patient is maintaining a minimum of 0.5 ml/kg/hr of urine output. If urine output is low, consider getting an order to irrigate the catheter. To ensure catheter is patent and facilitate drainage. Anticipate the need to begin routine Page of 10

3 /Potential bladder irrigations on post-op day 1 or 2. It is recommended to irrigate with ml of saline solution 2-3 times a day. To prevent the buildup of mucous in the bladder from the transplanted bowel tissue. To clear out blood clots in the immediate postoperative period. Infection related to surgical procedure. Child will be free from: signs or symptoms of infections wound infection bladder/urinary tract infection Monitor electrolytes and other blood work as ordered. Assess temperature with vital signs. Perform a sepsis screen as per protocol if fever is present. Monitor wound for signs and symptoms of infection including: - redness extending beyond the immediate wound edge - pus-like/purulent drainage - worsening pain - foul odor from wound - wound slow to heal - Fever >38.5 If signs are present, inform the most responsible physician for further direction These measurements assist in fluid management interventions. Early recognition and treatment of infection improves patient outcomes. Monitor for signs of a bladder/urinary tract infection, including: - foul smelling urine - cloudy urine - fever > 38.5 Potential bleeding from surgical sites. Child will be free of potential bleeding from Assess dressings for active bleeding: q1hr for first 8hrs post-op Some bleeding is to be expected. Bleeding that persists 8 hours after surgery or requires the Page of 10

4 /Potential surgical sites: Pink color Normal vitals and SaO 2 Cap Refill < 3secs Dressings remain dry and intact q2hr for following 16hrs q4hr or prn after post-op day #1 Monitor patients cardiovascular status by assessing: cap refill peripheral pulses urinary output routine vital signs changing of 2+ dressings requires the notification of the most responsible physician. Establishes a baseline and can track changes to patient's status. All indicators of adequate circulating volume and tissue perfusion. Decreased blood volume leads to poor perfusion of tissues. Potential for respiratory infection Child will be free of respiratory problems as evidenced by: Normal vitals and SaO 2 Easy, unlaboured, and full respirations Clear lung fields Pink colour Cap refill < 3 secs Refer to surgeon specific orders regarding dressing changes. Observe general appearance and work of breathing. Measure vitals as ordered. Focused respiratory assessment at minimum q12h. Encourage normal lung function: Encourage coughing (support incision sites with pillow when coughing) Coach patient in deep breathing exercises Provide incentive spirometry as needed Encourage early ambulation Consult physiotherapy as needed Determines effectiveness of breathing. Establishes a baseline to track and compare changes in patient's status. All indicators of adequate circulating volume and tissue perfusion. Mechanical support to the abdomen decreases strain on wound and leads to a more effective breathing pattern. Incentive spirometry promotes deep breathing and lung expansion by providing a visual indicator of breathing effectiveness. Long term immobility leads to atelectasis. Ambulation promotes full lung expansion and restimulation of lung elasticity. Lab values can indicate early compensation for Page of 10

5 /Potential Monitor lab results as reported. tissue hypoxia. Impaired physical mobility related to postoperative pain. By hospital discharge, the patient will return to preoperative mobility, as evidenced by ability to ambulate or mobilize as per patient s normal status. Before activity observe for and, if possible, treat pain. Administer analgesic as ordered. Ensure that the patient is not over sedated. Encourage and assist patient with position changes, mobility exercises, and ambulation. Pain limits mobility and is often exacerbated by movement. These actions reduce postoperative atelectasis, pneumonia, thrombophlebitis, and ileus. Early mobilization shown to decrease duration of hospitalization. Family anxiety related to hospitalization Parent copes with child's condition and receives adequate support to help control the anxiety Encourage participation in developmentally appropriate self-care and diversional or recreational activities. Encourage family involvement in daily care of child with the purpose to normalize and promote optimum healing Encourage parents to say what they feel and offer support to family This will enhance self-concept and sense of independence. To promote parent participation and to promote sense of control over situation To promote family functioning and coping Discharge planning: The family and child will be prepared to go home and able to manage in the The patient and their family will demonstrate an understanding of their condition, treatment, and Seek referral to psychology as appropriate Provide direction to: Family Support & Resource Centre BCCH Urology Clinic Webpage BCCH Urology Clinic contact information Page of 10

6 /Potential community medications. They will also express realistic plans for home care by discharge. Ask the patient and parents to explain in their own words their understanding of the condition, symptoms, treatment, and follow-up care. Ensure families are provided with written information upon discharge to outline the following: pain management activity wound care care of drainage bags & tubes information on bladder irrigation Effective clinician-patient communication, a clear understanding of patient literacy, and use of the Teach-Back Method are useful tools in helping patients to better understand their own medical conditions. Educated patients are able to manage their medications, better participate in their treatments, and follow protocols to achieve the goal of safe quality care. NOTE: Refer to Mitrofanoff/Bladder Augmentation handout BCCH1945 Ensure Urology Nurse Clinician has consulted with patient and family prior to discharge for teaching and follow-up. Ensure family has medical supplies arranged for home care. Contact the Urology Nurse Clinician for guidance and support if a supply list is not already completed. Provide family with teaching and demonstration of the following and ensure they have time to practice these skills prior to discharge: Page of 10

7 /Potential catheter irrigation changing urinary leg bags to and from overnight urinary drainage bags what to do if the tube falls out Discuss prescribed medications and their purpose, side effects, dose and administration route. Ensure parents have arranged appropriate adaptations to promote the patient s independence. Ensure patient and family are aware of follow-up appointment in the urology clinic. Typical follow-up is 4 to 6 weeks for additional teaching and tube removal. CROSS-REFERENCES 1. Family Support and Resource Centre 2. Fluid Replacement 3. Fluid Replacement Documentation Example Documentation%20Example-May-2017.pdf 4. Home Care of a Suprapubic Catheter Page of 10

8 5. Meningomyelocele SCP ments/neurology%20care%20plans/meningo-older%20children.pdf&action=default 6. Mitrofanoff/Bladder Augmentation 7. Nursing Assessment and Documentation CC Feb pdf 8. Pre and Post-Operative Care 9. Wound Cleansing and Irrigation REFERENCES Baulch, I. (2010). Assessment and management of pain in the paediatric patient. Nursing Standard, 25(10), Beevi, A. (2012). Pediatric Nursing Care Plans. New Delhi: Jaypee Brothers Belman, A.B., Kramer, S.A., King, L.R. (2002). Clinical Pediatric Urology. 4th Ed. London: Martin Dunitz Bennett, E. (2002). Intermittent self-catheterization and the female patient. Nursing Standard, 17(7), Boles, J. (2016). Preparing children and families for procedures or surgery. Pediatric Nursing, 42(3), 147. Breathnach, C. (2013). Guidelines on the Care of Urinary Catheters (Urethral & Supra-pubic). Our Lady s Children s Hospital. Retrieved from Page of 10

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10 Perry, S., Hockenberry, M., Lowdermilk, D. & Wilson, D. (2013). Maternal Child Nursing in Canada. Toronto: Elsevier (Mosby) Schultz, R.J. & Hockenberry, M.J. (2011). The child with cerebral dysfunction. In M.J. Hockenberry, & D. Wilson (Eds.), Wong s Nursing Care of Infants and Children (9 th ed., pp ). St. Louis, Missouri. Elsevier Mosby. Talbot S. The Pediatric Patient. 2nd ed. St. Louis, MO: Saunders Elsevier; Tamura-Lis, W. (2013). Teach-back for quality education and patient safety. Urologic Nursing, 33(6), 267. doi: / x Taussig, L.M. & Landau, L.I. (1999). Pediatric Respiratory Medicine. St. Louis: Mosby Thomas, R. (n.d.). Management of Urinary Drainage Tubes and Drains. Retrieved from Twycross, A., & Finley, G. A. (2014). Nurses aims when managing pediatric postoperative pain: Is what they say the same as what they do? Journal for Specialists in Pediatric Nursing, 19, Twycross, A., Finley, A., & Latimer, M. (2013). Pediatric nurses postoperative pain management practices: An observational study. Journal for Specialists in Pediatric Nursing, 18, Twycross, A., Forgeron, P., & Williams, A. (2015). Paediatric nurses postoperative pain management practices in hospital based non-critical care settings: A narrative review. International Journal of Nursing Studies, 52, Wagner, K.D., Johnson, K., Kidd P.S. (2006). High Acuity Nursing. 4th Ed. USA: Wagner Wakimizu, R., Kamagata, S., Kuwabara, T., & Kamibeppu, K. (2009). A randomized controlled trial of an at-home preparation program for Japanese preschool children: Effects on children s and caregivers anxiety associated with surgery. Journal of Evaluation in Clinical Practice, 15, Vera, M (2014). 13 Surgery (Perioperative Client) Nursing Care Plans. Retrieved from Page of 10