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 Mary's mother is not present.

The unfamiliarity of the hospital environment is exacerbated by Mary's 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 child's pain. Mary's reactions of grimacing and squirming suggest a '2' rating for pain on the FLACC.

Diagnosis 2: Vomiting

Outcome: Treating Mary's 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 child's condition.

Outcome: If Mary's 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 Mary's nausea and a member of the hospital staff was assigned to watch Mary until Mary's mother returned to the hospital. Mary's mother briefed as to her daughter's 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 Mary's 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, Mary's grimacing, discomfort, and expressed distress rated a '2,' indicating more pain medication was required.

Assessment: Mary's physical distress was exacerbated...

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). Mary's 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 Mary's response to post-operative treatment, non-narcotic or opiod medications would be prescribed. Self-administered medication, given Mary's 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 Mary's 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: Mary's mother must be acquainted with the FLACC and develop a method with Mary of communicating Mary's pain

Exercise, activity, diet: Mary will meet with a physical therapist to discuss appropriate movement therapy. Mary's 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). "I've 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: children's developmental progress. Revised & updated by Frost, M. & Sharma, a. (4th Rev. Ed.). London, New York. Routledge.

Wong, D., Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2006). Maternal child nursing care (3rd Ed.). St. Louis: Mosby.