PERSPECTIVES Fostering Improved Nutritional Status for the Pediatric Burn Patient Louella Dorsey, MSN RN CRRN; Beth C. Diehl, MS RN C CCRN
P
ediatric patients who have experienced a bum injury are a unique and challenging population. Components of routine care must be interwoven with appropriate growth and development principles. The parameters of nutritional management can be problematic for the bum patient due to tremendously increased metabolic needs. This case study presents but one management approach in fostering improved nutritional status for a pediatric bum patient.
Case history J.W. was a 5-year-old black male with second- and third-degree bums covering 82% of his body. He was one of three brothers bumed as a result of playing with matches. He was the youngest of the three and the first to be admitted to the rehabilitation facility, which was 2 hours away from his home. J.W. hadbeenhospitalizedinaregional bum center for 5 months. At the time of admission to the rehabilitation facility, his two brothers remained in an acute care hospital that was 1 hour from the parents’ home. At the time of admission, J.W.’s weight was 24.7 kgs and his height was 125.5cm. He was at the 35th weight percentile for his height. During his hospitalization, J.W.’s weight fluctuated dramatically (see Figure 1). Despite multiple interventions-offering high-calorie foods, frequent snacks, special access to cafeteria services on a 24-hour basis, and his favorite homecooked foods brought to the hospital by his parents-at 5 months after admission, J.W.’s weight had plummeted to less than the third percentile for his height. This
dramatic decline caused tremendous concem for the interdisciplinary team. From a developmental perspective, growth and developmental parameters of a 5-year-old reflect certain issues related to nutritional intake. According to Erickson (1963),the child enjoys initiative and energy displayed in action and assertiveness. For the hospitalized child, loss of control is overwhelming, and eating patterns may vacillate between overeating and not wanting to consume certain foods. Finger foods are afavorite with this population, but J.W. did not have the finger dexterity to eat them. His oral-motor ability also was impaired due to scarring, which lengthened his mastication time. These developmental issues were incorporated into team plans and actions.
Treatment program During interdisciplinary team discussion, various feeding approaches were explored. There were two options that were considered viable to help J.W. achieve positive weight gain: supplemental nasogastric tube feedings at night and a behav-
iormodificationprogram.Table 1provides an overview of the advantages and disadvantages of these options. The team decided to implement a behavior modification program. Implementing a program of this magnitude required the cooperation and expertise of all team members. Members of the psychology staff were responsible for the initial development and ongoing modifications of the behavioral program. Child life staff and J.W.’s social worker provided long-term rewards for J.W.’s demonstrated compliance. Nutritional services staff explored with J.W. his food likes and dislikes (including the textures he preferred) and allowed maximum flexibility for food consumption. Nursing staff, volunteers, child life workers, family members, and medical staff all participated in monitoring and immediately rewarding food consumption. Guidelines were instituted for the program, including a reward system in which J.W. received a penny for each bite he ate (see Figure 2). Program modifications: As J.W.’s food consumption consistently in-
Figure 1. J.W.3 Weight Throughout Hospitalization 28
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Address correspondence to Louella Dorsey, 218-20 Midlines Court, Owings Mills, MD 21I 17.
Oct
Nov
Dec
338/Nov-Dec 1992/Rehabilitation NursingJVol. 17, No. 6
Jan Feb Months
Mar
Apr
May
Table 1. Treatment Alternatives Treatment Nighttime nasogastric feeding
Behavior modification program
Figure2. Behavioral Program Guidelines for Improving J.W.’s Nutritional Intake
Only 30 minutes of eating time were permitted per meal. For every bite of food eaten, J.W. receivedapenny. Penniesthenwere tallied at the end of each meal and added to a bank total. Every Friday evening, J.W. was taken by the child life staff out into the community with the money he had accumulated throughout the week. He could spend the money as he desired, although he was encouraged to spend it on food.
creased, the program was altered. Instead of being awarded a penny for every bite, J.W. received pennies according to the percentage of the food he ate at each meal (i.e., if he consumed 50% of the meal, he received 50 cents). During the latter part of the program, the monetary awards were eliminated. As long as J.W. continued to consume 50% of each meal three times a day, he was treated to dinner out on Friday evening. The program was terminated when J.W.’s weight reached the 30th percentile for his height. At this time, weekend therapeutic leaves of absence with his family were encouraged tocontinue appropriate meal socialization and to prepare him for his impending discharge.
Advantages Insertion of the tube would provide sufficient calories for growth.
Disadvantages Insertion of the tube would cause discomfort to the patient. The presence of a nasogastric tube would havea negative impact on the patient’s body image.
A behavior modification program
A behavior modification program
would help the patient achieve positive weight gain while improving his self-esteem.
must be highly consistent to be effective.
Conclusion Over a 2-month time frame, the behavior modification program resulted in a weight increase of more than 6 kg. This provided J.W. with a positive nitrogen balance and reestablished appropriate eating patterns without restricting or inhibiting his ability to make choices. As the focus of the program was interdisciplinary in nature, no single discipline was taxed in terms of workload during daily meal times. This entire program effectively demonstrates the team approach to rehabilitating the pediatric bum patient from a nutritional perspective. J.W. was subsequently discharged and underwent successful reconstructive surgery. Upon readmission to postacute care after the reconstructive surgery, J.W. evidenced positive eating behaviors with no behavioral interventions. This further supports the team’s effectiveness in shaping appropriate food consumption behaviors. Louella Dorsey is a clinical nurse specialist at the Kennedy Krieger Children’s Hospital in Baltimore. Beth C. Diehl is director of nursing educationat Mt. Washington Pediatric Hospital, Inc., in Baltimore.
Discharge Follow-Up by Telephone Marcia Garland, MBA RN
D
epending on each patient’s family and home situation and the patient’s abilities, limitations, and requirements at discharge, the discharge process can be an overwhelming experience. Therefore, in February 1990, a discharge follow-up telephone call project was begun by the author incollaborationwith the nurse manager on the rehabilitation unit at William Beaumont Hospital in Royal Oak, MI, with two primary objectives: (a) to assess the success of the implementation of discharge plans and (b) to provide follow-up assistance to patients and their families (i.e., to answer questions and solve problems that may arise in the first weeks after discharge). Patients and families require varying degrees of support during the discharge planning process and in the immediate postdischarge phase. The discharge follow-up program continues this support. Literature review North, Neeqsen, and Hollinsworth ( I 99 1) demonstrated the advantages of
References Erickson, E.H. (1963). Ckildbood and society(2nded.). New York: W.W. Norton & Company, Inc.
Address correspondence to Marcia Garland,MBA RN, Clinical Nurse, Rehabilitation Unit,WilliamBeaumont Hospital, 3601 W. Thirteen Mile, Royal Oak, MI 48072.
Vol. 17, No. G/Rehabilitation Nursing/Nov-Dec 1992/339
P
ediatric patients who have experienced a bum injury are a unique and challenging population. Components of routine care must be interwoven with appropriate growth and development principles. The parameters of nutritional management can be problematic for the bum patient due to tremendously increased metabolic needs. This case study presents but one management approach in fostering improved nutritional status for a pediatric bum patient.
Case history J.W. was a 5-year-old black male with second- and third-degree bums covering 82% of his body. He was one of three brothers bumed as a result of playing with matches. He was the youngest of the three and the first to be admitted to the rehabilitation facility, which was 2 hours away from his home. J.W. hadbeenhospitalizedinaregional bum center for 5 months. At the time of admission to the rehabilitation facility, his two brothers remained in an acute care hospital that was 1 hour from the parents’ home. At the time of admission, J.W.’s weight was 24.7 kgs and his height was 125.5cm. He was at the 35th weight percentile for his height. During his hospitalization, J.W.’s weight fluctuated dramatically (see Figure 1). Despite multiple interventions-offering high-calorie foods, frequent snacks, special access to cafeteria services on a 24-hour basis, and his favorite homecooked foods brought to the hospital by his parents-at 5 months after admission, J.W.’s weight had plummeted to less than the third percentile for his height. This
dramatic decline caused tremendous concem for the interdisciplinary team. From a developmental perspective, growth and developmental parameters of a 5-year-old reflect certain issues related to nutritional intake. According to Erickson (1963),the child enjoys initiative and energy displayed in action and assertiveness. For the hospitalized child, loss of control is overwhelming, and eating patterns may vacillate between overeating and not wanting to consume certain foods. Finger foods are afavorite with this population, but J.W. did not have the finger dexterity to eat them. His oral-motor ability also was impaired due to scarring, which lengthened his mastication time. These developmental issues were incorporated into team plans and actions.
Treatment program During interdisciplinary team discussion, various feeding approaches were explored. There were two options that were considered viable to help J.W. achieve positive weight gain: supplemental nasogastric tube feedings at night and a behav-
iormodificationprogram.Table 1provides an overview of the advantages and disadvantages of these options. The team decided to implement a behavior modification program. Implementing a program of this magnitude required the cooperation and expertise of all team members. Members of the psychology staff were responsible for the initial development and ongoing modifications of the behavioral program. Child life staff and J.W.’s social worker provided long-term rewards for J.W.’s demonstrated compliance. Nutritional services staff explored with J.W. his food likes and dislikes (including the textures he preferred) and allowed maximum flexibility for food consumption. Nursing staff, volunteers, child life workers, family members, and medical staff all participated in monitoring and immediately rewarding food consumption. Guidelines were instituted for the program, including a reward system in which J.W. received a penny for each bite he ate (see Figure 2). Program modifications: As J.W.’s food consumption consistently in-
Figure 1. J.W.3 Weight Throughout Hospitalization 28
26
24
22
20
18
Address correspondence to Louella Dorsey, 218-20 Midlines Court, Owings Mills, MD 21I 17.
Oct
Nov
Dec
338/Nov-Dec 1992/Rehabilitation NursingJVol. 17, No. 6
Jan Feb Months
Mar
Apr
May
Table 1. Treatment Alternatives Treatment Nighttime nasogastric feeding
Behavior modification program
Figure2. Behavioral Program Guidelines for Improving J.W.’s Nutritional Intake
Only 30 minutes of eating time were permitted per meal. For every bite of food eaten, J.W. receivedapenny. Penniesthenwere tallied at the end of each meal and added to a bank total. Every Friday evening, J.W. was taken by the child life staff out into the community with the money he had accumulated throughout the week. He could spend the money as he desired, although he was encouraged to spend it on food.
creased, the program was altered. Instead of being awarded a penny for every bite, J.W. received pennies according to the percentage of the food he ate at each meal (i.e., if he consumed 50% of the meal, he received 50 cents). During the latter part of the program, the monetary awards were eliminated. As long as J.W. continued to consume 50% of each meal three times a day, he was treated to dinner out on Friday evening. The program was terminated when J.W.’s weight reached the 30th percentile for his height. At this time, weekend therapeutic leaves of absence with his family were encouraged tocontinue appropriate meal socialization and to prepare him for his impending discharge.
Advantages Insertion of the tube would provide sufficient calories for growth.
Disadvantages Insertion of the tube would cause discomfort to the patient. The presence of a nasogastric tube would havea negative impact on the patient’s body image.
A behavior modification program
A behavior modification program
would help the patient achieve positive weight gain while improving his self-esteem.
must be highly consistent to be effective.
Conclusion Over a 2-month time frame, the behavior modification program resulted in a weight increase of more than 6 kg. This provided J.W. with a positive nitrogen balance and reestablished appropriate eating patterns without restricting or inhibiting his ability to make choices. As the focus of the program was interdisciplinary in nature, no single discipline was taxed in terms of workload during daily meal times. This entire program effectively demonstrates the team approach to rehabilitating the pediatric bum patient from a nutritional perspective. J.W. was subsequently discharged and underwent successful reconstructive surgery. Upon readmission to postacute care after the reconstructive surgery, J.W. evidenced positive eating behaviors with no behavioral interventions. This further supports the team’s effectiveness in shaping appropriate food consumption behaviors. Louella Dorsey is a clinical nurse specialist at the Kennedy Krieger Children’s Hospital in Baltimore. Beth C. Diehl is director of nursing educationat Mt. Washington Pediatric Hospital, Inc., in Baltimore.
Discharge Follow-Up by Telephone Marcia Garland, MBA RN
D
epending on each patient’s family and home situation and the patient’s abilities, limitations, and requirements at discharge, the discharge process can be an overwhelming experience. Therefore, in February 1990, a discharge follow-up telephone call project was begun by the author incollaborationwith the nurse manager on the rehabilitation unit at William Beaumont Hospital in Royal Oak, MI, with two primary objectives: (a) to assess the success of the implementation of discharge plans and (b) to provide follow-up assistance to patients and their families (i.e., to answer questions and solve problems that may arise in the first weeks after discharge). Patients and families require varying degrees of support during the discharge planning process and in the immediate postdischarge phase. The discharge follow-up program continues this support. Literature review North, Neeqsen, and Hollinsworth ( I 99 1) demonstrated the advantages of
References Erickson, E.H. (1963). Ckildbood and society(2nded.). New York: W.W. Norton & Company, Inc.
Address correspondence to Marcia Garland,MBA RN, Clinical Nurse, Rehabilitation Unit,WilliamBeaumont Hospital, 3601 W. Thirteen Mile, Royal Oak, MI 48072.
Vol. 17, No. G/Rehabilitation Nursing/Nov-Dec 1992/339
