OUR APPROACH

Professional nursing care is the core of patient-centered outcomes.

 ...and it starts with literature-based best practice.
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Nursing Evolutions' sole focus is the provision of the most outstanding, compassionate literature-based professional nursing care to medically fragile infants, babies, toddlers and children.

 

Current established standards for many trached and mechanical ventilator-dependent pediatric patients is (within 5-8 years) to:

  • wean (from mechanical ventilation dependence)

  • decannulate (close tracheostomy), and

  • discharge (from dependence upon medically-intensive nursing care services).

 

We consistently exceed these well-established (60 to 96 month) expectations and safely wean, decannulate, and discharge our patients within 7-24 months.  University-educated nurses safely accomplish these goals by deliberately and scientifically providing literature-based best nursing practice.

 

Each patient's immediate condition, health and functional status is meticulously assessed with the Nurses carefully collaborating with each patient's entire team of primary and specialty care providers to establish care (intervention) plans, goals, and timelines for outcomes.  The efficacy of interventions and the progress -or lack of progress made toward accomplishing goals are routinely and consistently assessed, evaluated, discussed and communicated among team members, then continued, re-defined, adjusted, or eliminated. 

We selectively recruit the most brilliant, kind, gentle, highly capable and accomplished Registered Nurses (RNs) to apply the literature-based best practice techniques necessary to optimize the health, function, and quality of life outcomes for each medically fragile infant, baby, toddler, and child. It is our honor and our privilege to provide this most outstanding care for each and every one of our precious patients.

 

Case Study; A typical Nursing Evolutions patient:

     Your 11-month-old female patient (pt), "MARY" is a 26-week premature triplet with bronchopulmonary dysplasia, severe gasto-esophageal reflux, tracheal malacia, and developmental delay.  Her pulmonary condition is further complicated by pulmonary hypertension and pulmonary hypoplasia.  She has a history of several aspiration pneumonias and five failed extubations prior to tracheostomy;

Three days ago, after an 11-month hospitalization Mary was admitted to Nursing Evolutions' Pediatric Intensive Field Care Services. Her insurer has authorized for Mary to receive Pediatric Critical Field Care (RN) for 16-hours per day, 7-days per week.  

 

PSYCHO-SOCIAL:

Mary's parents are responsible for provision of all necessary care at least eight hours per day, seven days per week.  Mary's parents have received extensive training on Mary's nursing care needs during 

 

MECHANICAL VENTILATION SETTINGS:

She is on an active circuit Trilogy ventilator receiving Intermittent Mandatory Ventilation (IMV) at a rate of 25 breaths per minute with a tidal volume (VTE) set at 90 cc's;  her trach cuff is inflated with 1.3 mL of sterile water;

 

While awake and active, the pt is taking between two and ten additional breaths (total respiratory rate of 27 to 35 breaths per minute) with tidal volumes ranging between 30cc and 130cc's.

When sleeping, the pt does not take additional breaths (over the set mechanical ventilation rate of 25 breaths per minute) and tidal volume do not vary from the set VTE of 90cc's.

SUPPLEMENTAL OXYGEN NEEDS:

Your pt is currently on a set supplemental oxygen dose of two liters per minute (2LPM) with SpO2's ranging between 95% and 97% while sleeping or being held. With increased activity, happiness or distress, your pt's SpO2's can drop to 83% to 88%. Several standard interventions (currently reflected in the pt's Plan of Treatment (POT)) can typically facillitate the recovery of SpO2 to acceptable levels (>94%) without requiring the RN to increase the supplemental oxygen administration (>2LPM).

 

According to documented laryngoscopies (airway studies), the pt's upper airway is patent but highly vulnerable. This study finding is validated by RN assessments noting air movement proximal to (above) the tracheostomy, including:

  • slight nasal flaring when pt is upset (i.e., during trach changes or other procedures when trach cuff is deflated)

  • noted slight presence of warm, exhaled air from pt's mouth and nose onto back of RN's hand when pt's trach cuff is deflated -either during trach changes or on a trial basis;

 

SUCTION REQUIREMENTS:

The pt requires airway suctioning approximately every 10" while awake and active, and approximately every 30" while asleep.  Airway secretions are generally thin, clear to white, and readily cleared from airway with current suction settings.  The pt has experienced two previous mucous plugs that were effectively cleared from the pt's airway with up to 0.5mL normal saline (NS) lavage, ambu bagging, and meticulous airway suctioning.

MECHANICAL VENTILATION WEANING & (TRACH) DECANNULATION PLANS:

There is no current plan to wean either mechanical ventilation, nor current oxygen supplementation dose.

 

There is no current decannulation (closing tracheostomy) plan. 

NUTRITION & HYDRATION:

Because of aspiration risk and severe GERD, the pt currently receives nothing per mouth (strict NPO);  She has a gastrostomy-jejunostomy tube (G-J-tube) currently in place; the G-J-tube stoma is in the lower edge of her left upper quadrant (LUQ);  the G-J stoma is clean, without exudate, erythema, or granulation; pt is receiving a continuous drip (gtt) J-tube feeding at 36mL per hour, 24 hours/day; because of gastric bloating, pain, discomfort, the G-tube is continuously vented.

There are no current plans to begin "taste" trials (po trials);

STRENGTH, BALANCE & MOBILITY:

pt is fully innervated but has very limited noted purposeful movement of upper extremities (UEs);  lower extremity (LE) movement occurs only with stimulation of LEs;  Upper and lower extremities are generally quite weak;

pt's torso muscles are nearly flaccid and neck muscles are notably weak;  pt is unable to hold-up her head or to sit-up without being completely supported on all sides;  the back of the pt's head is noted to be flat and bald; although pt does follow movement of family and nurses with her eyes, she does not move her head to continue following (RN's) movement when this movement exceeds what can be seen with only her eyes;

 You have appointments later this morning with the following Specialty Care Provider (SCP) teams:

  • Pulmonary team

  • Otolaryngology (ENT) team

  • Gastroenterologist (GI)

  • Physical and Occupational Therapists

  • Dietitian team 

  • What information are you hoping to obtain from the pt's SCPs?

  • What are your expectations and concerns?

  • What is your advocacy plan for your pt with each of these SCP teams?

 

Please coordinate with one another to answer this question, addressing:

          -Advancing from continuous gtt J-tube feedings

          -Progressive mobilization

          -Supplemental oxygen administration plan

          -Plan for reducing mechanical ventilation dependence

          -(eventual) Plan for tracheostomy decannulation

 

Optimize

-Health

-Function

-Outcomes

Minimize

-Infection

-Utilization of emergency services

-PICU re-admission rates and length of stay

Join Nursing Evolutions' exclusively RN Pediatric Critical Care Team