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Week 10. The Child Having Surgery. Pediatric Surgery. Most surgical procedures performed as outpatient – day surgery More complex procedures may require hospitalization If elective – prepared by preadmit clinics If emergency-little time to prepare

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week 10

Week 10

The Child Having Surgery

pediatric surgery
Pediatric Surgery
  • Most surgical procedures performed as outpatient – day surgery
  • More complex procedures may require hospitalization
  • If elective – prepared by preadmit clinics
  • If emergency-little time to prepare
  • Chronic illness may require frequent hospitalization, procedures and even detah
hospitalization
Hospitalization
  • Confusing, complex & overwhelming
  • Strategies needed to prepare children & families
    • Identifying needs
    • Assessment of nonverbal & verbal behaviours
    • Validating information
    • Providing appropriate interventions
    • Teaching & communicating
    • Evaluate child & family’s competence in providing self care upon discharge
stressors of hospitalization
Stressors of Hospitalization
  • Limited understanding
  • Disruption of usual routine
  • Regression common
  • Separation anxiety
  • Loss of control- restrained, confined, invasive procedures
  • Fear & anxiety
  • Fear of bodily injury, mutilation or harm
hospitalization1
Hospitalization

Minimizing negative effects

  • Use of transitional items
  • Rooming-in, parents participate
  • Child-friendly environment
  • Therapeutic play
  • Atraumatic care
  • Allow child to manipulate equipment
nurse s role
Nurse’s Role
  • Nurse is primary person in care of child
    • Introduction
    • Building a trusting relationship
    • Making decisions
    • Providing comfort & reassurance
preparation for hospitalization
Preparation for Hospitalization
  • Educate what to expect to separate fantasy from reality
  • Describe intervention & sequence of steps
  • Avoid use of medical terms
  • Allow child to handle equipment
  • Teach steps of procedure
  • Show the room the child will be in
  • Introduce to health care personnel
  • Explain sounds
  • Adapt to cognitive & developmental stage
preparation for hospitalization1
Preparation for Hospitalization
  • Rehearsal of what will happen
  • Tour of the unit
  • Video, DVD or coloring books explaining procedure
  • Role playing
  • Give child a job to do
nursing diagnoses for child undergoing surgery
Nursing Diagnoses for Child Undergoing Surgery
  • Anxiety r/t surgery, fear of injury or bodily mutilation, separation from family or friends, changes in routine, painful procedures and treatments and unfamiliar events and surroundings AEB crying, fussing, withdrawal or resistance
  • Risk for powerlessness r/t lack of control over procedures, treatments and care & changes in usual routine
nursing diagnoses cont d
Nursing Diagnoses cont’d
  • Deficient diversional activity r/t confinement in bed or health-care facility, limited mobitilty, activity restrictions or equipment AEB verbalization of boredom, lack of participation in play, reading or schoolwork
  • Interrupted family processes r/t separation due to hospitalization, increased demands for caring for ill child, changes in role function, and effect of hospitalization on other family members such as siblings AEB parental verbalization of issues, parental presence in hospital and missed work
nursing diagnoses cont d1
Nursing Diagnoses cont’d
  • Self care deficit r/t immobility, activity restrictions, regression, equipment or treatments AEB inability to perform ADLs
  • Risk for delayed growth & development
  • Deficient knowledge r/t hospitalization, surgery, treatments, procedures, required care and follow-up AEB questioning, verbalization, lack of prior exposure
  • Kyle, Terri (2008) Essentials of Pediatric Nursing
preop care
Preop Care
  • Preadmit teaching
  • Consideration of developmental stage
  • Parental involvement
  • Consent
  • Physical preparation such as?
  • Documentation
  • Allergies

Shadow Buddies

latex allergy
Latex Allergy
  • Essential to notify OR to prepare latex free OR suite
  • Usually pt with latex allergy is first of the day –Why ?
  • Range of reactions from local  anaphylaxis
  • Goals:
    • Prevention of latex exposure
    • Identification of children with hypersensitivity
  • Create latex-safe environment
latex allergy1
LATEX ALLERGY
  • Has been linked to intraoperative anaphylaxis
  • Many with spina bifida have propensity for allergy due to repeated exposure over years
  • Health care workers also high risk
  • Must be managed in latex free environment
  • Many health care environments changing over to latex free
  • Medic -Alert bracelets
common sources of latex
Common Sources of Latex
  • Adhesive & elastic bandages
  • Airways, endotracheal tubes
  • Catheters
  • Gloves, hep loks, IV tubing
  • Stethoscopes, suction tubing
  • Disposable syringes, tourniquets
  • Elastic on clothing, balloons, chewing gum, many toys
  • Plastic storage bags, balls, dental equipment, feeding nipples, toothbrushes, rubber bands
  • Foods ie kiwi, banana, avacado, chestnuts
malignant hyperthermia
Malignant Hyperthermia
  • Potentially fatal genetic myopathy
  • Certain anesthetics trigger hypermetabolism, muscle rigidity & elevated temp
  • Early screening and ID of family history through preop questionnaires
  • Treatment – 100% oxygen, dantrolene IV, maintaining core temperature with cool saline IVs, cooling blankets
consent for treatment
Consent For Treatment
  • There is no minimum age for giving consent
  • Nurses use professional judgment, taking into account the circumstances and the client’s condition, to determine whether the young client has the capacity to understand and appreciate the information relevant to making the decision.
slide25
Which of the following should the nurse consider when having informed consent forms signed for surgery and procedures on children?

1. Only a parent or legal guardian can give consent.

2. The person giving consent must be at least 18 years old.

3. The risks and benefits of a procedure are part of the consent process.

4. A mental age of 7 years or older is required for a consent to be considered "informed."

hierarchy of substitute decision makers
Hierarchy of Substitute Decision-Makers

1. Guardian of the person — appointed by the court.

2. Someone who has been named as an attorney for personal care.

3. Someone appointed as a representative by the Consent and Capacity Board.

4. Spouse, partner or relative in the following order:

a. spouse or partner,

b. child if 16 or older; custodial parent (who can be younger than 16 years old if the decision is being made for the substitute’s child); or Children’s Aid Society;

c. parent who has only a right of access;

d. brother or sister;

e. other relative.

5. Public Guardian and Trustee is the substitute decision-maker of last resort in the absence of any more highly ranked substitute, or in the event two more equally ranked substitutes cannot agree.

slide28
Need consent for admission plus separate consents for specific treatments e.g. MRI, blood therapy
  • If child hemorrhages, need new consent to return to surgery
  • MD’s explain surgery and procedures, nurses witness consents and reinforce info
intraoperative care
Intraoperative Care
  • Parents accompany child to OR
  • Parental presence during anesthesia induction?
  • Parental presence in PACU
  • Encourage parents to
    • use positive facial expression
    • Use stroking or secure comfortable holding psitions
    • Use soft tone of voice
    • Allowing presence of parents reduces stress for parents & child
post op care
Post op care
  • Assessment of ABC
  • Inspection of surgical site
  • Hydration. Fluid & electrolytes, elimination
  • Pain management
  • Maintain safety how?
  • Manage anxiety how?
  • Parental involvement
  • Prevent complications such as ?
  • Others?
shock
Shock
  • Complex clinical syndrome – Tissue perfusion is inadequate to meet the metabolic demands of the tissues
  • Most common in Peds:
    • May lead to multi-organ failure
types
Types
  • Hypovolemic
  • Cardiogenic
  • Distributive (Septic, Neurogenic

& Anaphylaxis)

  • *See Box 29-6 p 1194 Types of Shock
s s of shock
S&S of Shock
  • Tachycardia, tachypnea, pallor, hypotension, restlessness, agitation, respiratory stridor, low O2 sats, progressive cyanosis
  • If bleeding –Notify MD, bedrest, high-Fowlers, ice collar (T&A), calm environment
  • Start V/S q15min, prepare for possible return to OR
compensated vs decompensated
Compensated vs. Decompensated
  • Compensated:
      • vital organs are maintained by intrinsic mechanisms
      • Unexplained mild tachycardia, decreased perfusion of hands and feet
  • Decompensated:
      • Body can no longer compensate for the lack of tissue perfusion – microcirculation “shuts down”
      • Tachycardia pronounced, BP maintained but pulse pressure narrows
      • Poor capillary filling
      • Childs exhibits confusion, sleepiness, decreased repsonsiveness
  • Irreversible –
      • damage to vital organs
      • Pronounced vasoconstriction, hypoxia, hypotension, weak thready pulse, coma, anuria
effects on body systems
Effects on Body Systems
  • Cardiovascular
  • Neurological
  • Gastrointestinal
  • Respiratory
  • Renal
  • MOFS (Multi-Organ Failure Syndrome)
therapeutic management
Therapeutic Management
  • Ventilation
  • Fluid administration
  • Improvement of cardiac output
  • General support
blood products
Blood Products
  • Indicated for:
    • Anemia
    • Shock
    • Massive Blood Loss
    • Sickle Cell Crisis
    • Chronic Hemmorhage
types of products
Types of Products
  • PRBC’s
  • FFP
  • Albumin
  • Whole Blood
  • Hetaspan or Pentaspan –
selected surgical procedures
Selected Surgical Procedures
  • Myelomeningocele/spina bifida
  • Hydrocephalus
  • Cleft Lip & palate
  • Orthopedic surgery
  • Bowel surgeries
    • Pyloric stenosis
    • Hernias
    • Hischsprung’s
    • Bowel resections
    • Intussusception
myelomeningocele spina bifida
Myelomeningocele (Spina Bifida)
  • Usually also have Arnold-Chiari with hydrocephalus
  • Impairment of lumbar and sacral nerves
  • Level of defect influences degree of impairment
  • Paralysis; bladder, bowel complications; orthopedic problems
  • Tethered cord can occur later
slide42

Myelodysplasias

  • Spinal canal and cord defects
  • Types: Occulta

Meningocele

Myelomeningocele

management
Management
  • Initial
    • Protect site from injury infection; monitor neuro-status
  • Surgery
    • Closure of defect, shunt if nec
    • Can be done in utero (see next slide)
  • Ongoing management of mobility, bowel, bladder, neuromuscular problems
nursing diagnoses
Nursing Diagnoses
  • Risk for injury/infection r/t spinal defect
  • Impaired physical mobility r/t lower extremity impairment
  • Impaired urinary elimination r/t neurogenic bladder
  • Altered bowel elimination r/t neurological impairment
  • Risk for impaired skin integrity r/t sensory impairment & paralysis
  • Altered family process r/t demands of care for child
hydrocephalus
Hydrocephalus
  • Imbalance in production & absorption of CSF
  • Types:
    • Communicating (rare)
    • Non-communicating/obstructive
  • Enlargement of ventricles compresses brain tissues  brain damage
  • Developmental defect or after trauma, tumours
  • Diagnosed in utero by u/s, CT, MRI
  • Assoc. with myelomeningocele, Arnold-Chiari malformation
clinical manifestations in infancy
Clinical Manifestations in Infancy
  •  head circumference, dilated scalp veins
  • IICP
  • High-pitched shrill cry
  • Irritability
  • Altered muscle tone
  • Projectile vomiting, not assoc. with feeding
later manifestations
Later Manifestations
  • Child
    • Headache on awakening
    • Lethargy, irritability
    • Ataxia
    • Confusion
  • Long term effects: impaired vision, headaches, seizures, hormonal effects, destruction of cerebral cortex
treatment
Treatment
  • Surgery – insertion/ of shunt
    • VA shunt
    • VP shunt (shown)
  • Periodic revisions of shunt
  • Management of long-term problems
    • Developmental delay
    • Learning disabilities
    • Sensory problems
nursing care
Nursing Care
  • Monitor neuro-status, head circumference, fontanels
  • Pre-operative - prevent injury
  • Post-operative - shunt care, neuro-status, complications
  • Support & teaching – developmental screening, shunt care
cleft lip palate

Cleft Lip/Palate

Most common congenital craniofacial anomaly

1 in 700 births

Failure of maxillary processes to fuse with nasal elevations on frontal prominence at 6th week gestation

Can be unilateral or bilateral

Development of cleft occurs early in pregnancy

Lip fuses by 5-6 weeks

Palate closes by week 9

Occurs frequently in association with other anomalies such as heart defects, ear malformations, skeletal deformities & genitourinary abnormality

pathophysiology
Pathophysiology
  • Alcohol consumption & smoking, prenatal infection, advanced maternal age
  • Drugs- phenytoin, valproic acid, thalidomide and pesticide dioxin cause CL & CP
  • Usually diagnosed at birth
  • CL can be diagnosed 14-16th week gestation,
slide58
CL/CP-varies in severity and degree affects feeding-can’t create –ve pressure to create suction in oral cavity
  • can have speech impairment, inefficient function of muscles of soft palate & nasopharynx, improper tooth alignment [missing, malformed or malpositioned] & maxillary arches, & varying degrees of hearing loss[PE tubes], inadequate nasal airway & mouth breathe
treatment1
TREATMENT
  • CL- surgical repair and scar revision
  • CP-often surgical repair in neonatal period
  • Stage 1 repair
      • at 0-18 mons-align maxillary segments
  • Stage 2 repair
      • at 2-5 yrs-reposition maxillary segments & correction of a cross-bite
  • Stage 3 repair
      • At 10-11 yrs-correct faulty occlusion of teeth
  • Stage 4 repair
      • At 12-18 yrs
nursing interventions
Nursing Interventions
  • Preventing injury to suture line
  • Promote adequate nutrition
    • At risk of aspiration
    • Breast feeding-is possible with proper positioning
  • Encouraging infant-parent bonding
  • Providing emotional support
  • Care plan pg 466-468
slide61
Feeding-
    • Milk escapes thru nose,
    • Position upright, pg 459,
    • CL/CP nurser, watch for facial signal[elevated eyebrows, wrinkled forehead],
    • Needs to swallow, burp frequently since they swallow excess air,
    • Syringe[Breck feeder] with tubing
    • -Sucking strengthens muscles
complications
Complications
  • Speech difficulties
  • Malocclusion
  • Hearing problems
  • Altered self-esteem and body image
fractures
Fractures
  • Causes: MVA’s, falls & abuse
  • Clavicle most common, then humerus, radius, ulna, femur
  • Diagnoses: x-rays & labs Hgb, HCT, AST & LDH
  • S&S: Five “P’s” plus deformity, edema, bruising, muscle spasm, loss of function, altered mobility, crepitus, shock, refusal to walk
healing treatment
Healing & Treatment
  • Table 39-2 Pg. 1782
  • Treatment
  • Repair with realignment by reduction [closed or open]
  • Immobilization with a splint, cast or traction
nursing diagnoses1
Nursing Diagnoses
  • High Risk for Injury
  • Impaired Mobility
  • Impaired Tissue Integrity
  • High Risk for Infection
  • Altered Comfort: Pain
  • Self-Care Deficit
  • Knowledge Deficit
nursing care1
Nursing Care
  • Assess 5 “P’s”
  • Maintain infection control measures
  • Administer analgesics
  • Cast and/or traction care
  • Assess for nerve compression, compartment syndrome
  • Monitor for emboli
  • Health teaching re home care
gi dysfunction assessment
GI Dysfunction - Assessment
  • History
    • Feeding history, growth pattern
    • Spitting up, regurgitation, vomiting
    • Bowel habits
    • Pain
  • Physical exam
    • Ht./wt
    • Abdominal exam
    • Hydration, I&O
    • Pain, fever
pyloric stenosis
Pyloric Stenosis
  • Hypertrophy, hyperplasia of pyloric sphincter leads to obstruction
  • Regurgitation projectile vomiting
  • Good appetite, weight loss, upper abdomen distention, dehydrated
  • Palpable olive-shaped mass
  • Visible peristaltic wave left  right
nursing care2
Nursing Care
  • Pre-op: restore hydration & electrolyte balance e.g. IV with glucose
  • Post-op: IV, start oral rehydration, small amounts until tolerating feeds
  • Supervise feedings, I&O, pain control
hirschsprung s
Hirschsprung’s
  • Dilated colon, with constipation, diarrhea, fecal impaction
  • 1:5000; males 4:1
  • Due to lack of ganglion cells in rectosigmoid area
  • Rx-bowel resection
inflammatory bowel disease ibd
Inflammatory Bowel Disease (IBD)
  • Different than IBS
  • Consists of
    • Ulcerative colitis (UC)
    • Crohn’s disease (CD) increasing incidence
  • Characterized by periods of remission & exacerbations
  • Diagnosis difficult as S&S insidious
  • Affects whites & Jews - higher socioeconomic status
  • High risk for carcinoma of colon long term
  • Causes multifactorial – genetic, immune factors, environment, infectious agents, diet, familial tendency 20-25%
crohn s disease cd ulcerative colitis uc
Crohn’s disease (CD) & ulcerative colitis (UC)
    • CD – affects “gum to bum”
    • Growth failure, more disabling, serious complications
    • May require potent medication ie prednisone, methotrexate or bowel resections for strictures
    • Metronidazole (Falgyl) & Cipro for flare-ups
    • New drug – Remicade
  • UC affects colon only
    • May be cured by colectomy but often results in ostomy, JPOUCH OR Kock pouch
  • May require enteral feeds through NG tube to promote growth & prevent malnutrition
  • Support from Crohn’s & Colitis Foundation of Canada (CCFC)
slide88
IBS
  • S&S-abd pain, bloating, distention; alternating constipation & diarrhea; mucous in stools
  • Cause: unknown
  • Affects women 3:1
  • Rx-rule out any pathology, dietary changes, áflds, fiber, exercise plan
other bowel conditions
Other Bowel Conditions
  • Intussusception
  • Meckel’s diverticulum
  • Peptic ulcers
meckel diverticulum
Meckel Diverticulum
  • Blind pouch in lower portion of ileum
  • Can have bowel obstruction, bleeding from peptic ulcer[currant jelly stools] and strangulation
  • intussception
  • May mimic acute appendicitis
  • Rx-surgery if needed
  • most asymptomatic; 1-4% of population
peptic ulcers
Peptic Ulcers
  • S&S-abd pain, recurrent vomiting, anemia, melena
  • Rx-antacids, anti-secretory agents
  • Surgery only if complications
diagnostic endoscopy
Diagnostic Endoscopy
  • Conscious sedation – OP basis *Nursing care
  • Risks: perforation
  • Used for: upper GI and lower GI (colonoscopy, sigmoidoscopy)
care of child with bowel surgery
Care of Child with Bowel Surgery
  • Pain r/t surgical incision
  • Risk for infection r/t invasion of bowel
  • Risk for fluid volume deficit r/t NPO, vomiting, surgery
  • Altered nutrition < body req. r/t NPO, vomiting
  • Altered bowel elimination r/t bowel surgery
  • Anxiety r/t hospitalization and surgery
hernias
Hernias
  • Protrusion of a structure through the muscle wall
  • Congenital defects or collagen synthesis, trauma, or surgery
  • Common: umbilical and inguinal; can strangulate or incarcerate[confined]
  • RX-surgery or mechanical reduction
appendicitis
Appendicitis
  • Most common cause of emrgent abdominal surgery in children
  • 2x more often in males
  • S&S
    • Rebound pain RLQ- McBurney’s point
    •  WBC
    • N & V
    • Look ill
    • CT scan
slide104
Requires immediate surgery
  • Rupture leads to peritonitis, paralytic ileus
  • Appendicitis may be confused with Meckel diverticulum, gastroenteritis, ectopic pregnancy
nursing care3
Nursing Care
  • Heat is NEVER used over a suspected inflammed appendix for relief of pain
  • Flexing legs may relieve pressure
  • Perforation: sudden relief of pain
  • May require NG tube for prevention of abdominal distention
discharge instructions
Discharge Instructions
  • Provide in writing
  • Discuss expected progression of activity after discharge
  • Discuss dietary restrictions
  • Discuss possible signs and symptoms & medications to take
  • Discuss warning signs that may require consulting physician or hospital
  • Provide emergency numbers to call
  • Discuss comfort measures
  • Discuss & document follow-up appointments
next week
NEXT WEEK
  • Genetic Disorders