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Spotting a Sick Child
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Transcript
Spotting a Sick Child
Lucy Andrews, Aneena Dominic, FEMY FRANCIS
start
What we plan to cover...
The challenges of spotting a sick child
Common Childhood Illnesses
Safeguarding.
Child specific A-E assessment.
Paediatric Early Warning Scores.
Medicines Management and Drug Calculations
Therapeutic Holding
We plan to have a break at 10.15, 12.00 and 15.30. CSW's and PA's can leave at 13.30 with qualified staff's lunch break being 13.15 to 14.00.
Assessing Pain in Children.
write a subtitle here
What do we know so far?
Test
go!
LET'S PLAY A GAME
Everything in children's nursing is FUN! So, in groups, get some ideas together on how we may make these observations fun!
feedback
What do we know so far?
Question 1/5
Test
What age group is classed as Newborn?
0-28 days
0-5 days
0-14 days
What do we know so far?
Question 2/5
Test
A PEWS Score should be considered alongside...
Nothing - a PEWS Score alone gives me everything.
My own clinical judgement.
My clinical judgement and parental concern.
WHat we know so far?
Question 3/5
Test
The usual respiratory rate for an infant 1-12 months is...
12-20 bpm
20-40bpm
30-60 bpm
introduction
Question 5/5
Test
What is a normal heart rate for a 5-12 year old?
60-110 bpm
60-90 bpm
80-120bpm
What we know so far?
Question 4/5
Test
Children compensate for longer than adults when unwell.
False
True
child vs adult
Children are not just mini adults - there are significant biological, cognitive and physiological difference. We need to keep these in mind when treating children.
Summary
children - the challenges
What do you think are the challenges of spotting a sick child?
Let's see
AIRWAY ASSESSMENT
StRidor
Grunting
Wheezing
Inspiratory sound due to air forced through a narrowed upper tracheal airway
Expiratory sound usually indicating alveolar collapse
Caused by air being forced through narrowed lower airways (can be inspiratory, expiratory or bi-phasic)
breathing ASSESSMENT
Respiratory Rate and rhythm
use of accessory muscles and recessions
chest expansion
use of accessory muscles and recessions
LIP PURSING IN OLDER CHILDREN
Intercostal and Subcostal Recessions
HEAD BOBBING
STERNAL RECESSION (8.58)
NASAL FLARING
TRACHEAL TUG
breathing ASSESSMENT CONTINUED
PULSE OXIMETRY
Facial expressions and behaviour
Colour
any questions?
next
BRB, gone for tea...
let's check our knowledge
what can you spot with this little one?
pHOEBE IS 6 MONTHS OLD AND MUM REPORTED SHE HAS HAD A COUGH AND COLD FOR 2 DAYS.
reflect
circulatory assessment
PULSE RATE, RHYTHM AND VOLUME
urine output
Blood pressure
SKIN TEMPERATURE AND COLOUR
Central and Peripheral CRT
DISABILITY assessment
avpu AND gcs (2.49)
Blood glucose
Pupil size and reaction
Signs of a raised ICp
exposure assessment
pain
rashes or wounds
core TEMPERATURE
let's check our knowledge
what can you spot with this little one?
pHOEBE IS 6 MONTHS OLD AND MUM REPORTED SHE HAS HAD A COUGH AND COLD FOR 2 DAYS.
reflect
let's check our knowledge
what can you spot with this little one?
maisie is 2 years old and mum has brought her to a&e as she has been complaining of ear pain.
reflect
let's check our knowledge
what can you spot with this little one?
JASON IS 6 YEARS OLD AND MUM REPORTS A 3 DAY HISTORY OF FEVER AND REDUCED APPETITE. SHE CALLED AN AMBULANCE TODAY DUE TO HIM BEING MORE SLEEPY AND HIS BREATHING BEING LABOURED.
reflect
PAIN
Pay attention to:
sbar
SBAR forms the basis for an efficient handover and escalation of concerns. Ineffective communication is the most common root cause of serious incidents. REMEMBER GIT.
GET THEIR ATTENTION
PAEDIATRIC ASSESSMENT TRIANGLE
next
BRB, gone for tea...
scenario
Ebony is a 4 month old brought to ED. Her mother states she has had difficulty in breathing for 2 days and has been worse overnight. The child has been coughing and feeding poorly. Her fluid intake has been half of her usual and she has had less wet nappies. She has a moist sounding cough and no audible wheeze.
What are the red flags?
Respiratory rate is 60bpm. Temperature is 36.8 degrees celcius. Heart rate is 167bpm Saturations 97% Blood Pressure is 90/52 Use of accessory muscles and she is pink in colour.
THERAPEUTIC HOLDING
When children and young people are scared, worried or distressed, they may not be able to cooperate with what is being asked of them. Therapeutic holding is a way of providing support to a child or young person who is struggling to cope with a situation. Children use behaviour as a way to communicate, so using the parents knowledge of their child is essential in these situations. Before using therapeutic holding, consider distraction, role play, explaining the procedure or closed choices. Our play specialists are great to talk to about the above.
Example 1
Example 2
The role of parents and carers during invasive procedures is to cuddle, support and encourage their child. The role of the medical team in safe holding, for example, is to hold of the arm where necessary.
Example 3
Safeguarding
Safeguarding can be subjective and it is everyone's responsibility. Red flags include:
- Injuries not consistent with age.
- Unusual markings
- Burns in unusual places
- Bruises over fleshy tissue
- Delayed presentation
- Inconsistent or changing explanations
Common childhood illnesses
SEPSIS
Screening should take place for all infants and children who look unwell or are feverish. The treatment principles for patients with sepsis are identical regardless of the cause. Part of the reason sepsis can turn into a serious condition is because it is difficult to detect early in children.
Children have less cardiac reserve than adults and compensate differently - This means their blood pressure might decrease only much later in the sepsis process.
any questions?
next
further reading
WETFLAG Calculator
Patient Assessment Infographics
Peds Case - Scenarios
closure/SUMMARY
Key ideas to remember
Children are not just small adults and compensate for much longer.
Always ask for help if you're unsure.
Usually paediatric IV's are one vial doses... there are a few exceptions.
Parents know their child the best and don't forget to look after them too.
It's best to over escalate, than under escalate.
Always start with ABCDE - regardless
time for lunch.
Common childhood illnesses
viral induced wheeze
Viral induced wheeze is caused by a virus tightening the muscles around the airway, narrowing the bronchials.
Virus induced wheeze is similar but different to asthma. Some children with episodes of wheeze may go on to develop asthma. Children with asthma have symptoms in-between colds or chest infections.
Asthma
Common childhood illnesses
asthma
- No single diagnostic test for Asthma
- Usually diagnosed after the age of 5 to avoid misdiagnosis of Asthma during episodes of Viral Induced Wheeze.
Diagnosis is usually made from presence of more than one variable symptom of wheeze, cough, breathlessness, and chest tightness, family history of atopic conditions and some testings such as spirometry.
croup
Common childhood illnesses
croup
Croup - common presentation during the winter months. Important to identify and treat early, as the spectrum of disease ranges from a self-limiting illness (most common) to life-threatening upper airway obstruction.
Respiratory distress is more evident when the child becomes agitated or distressed, increasing the pressure and airflow through the narrowed structures.
Bronchilitis
Common childhood illnesses
bronchiolitis
Around a third of infants develop bronchiolitis before the age of 1. The incidence of bronchiolitis is linked with the winter period, typically lasting for 7-10 days. Usually symptoms peak at day 2-3, causing frequent reattendance.
Typical symptoms of bronchiolitis include:
- Persistent cough
- Wheeze
- Shortness of breath
- Fever, runny nose, cold
- Apnoea
- Poor feeding
- Reduced urine output or fewer wet nappies
DKA
Common childhood illnesses
dka
Abdominal pain
Common childhood illnesses
abdominal pain
How would you catch a urine?
Abdominal Pain often comes with diarrhoea and vomiting.
febrile convulsions
Common childhood illnesses
febrile convulsions
- seizure occuring whilst the child has a temperature with no CNS infection.
- antipyretics do not prevent febrile convulsions from happening in the first place, nor do they prevent them from recurring. (NICE guidelines).
concern over recurrent episodes, how to manage an acute seizure, or fears about subsequent complications, and the family's quality of life may be adversely affected
fever
Common childhood illnesses
fever
Fever is defined as a temperature over 38 degrees celsuis. A fever has a purpose within the body, therefore, antipyretics should not be used with the sole aim to reduce the body temperature. Tepid sponging and over/underdressing the child is also not recommended by NICE.
When using paracetamol or ibuprofen in children with fever:
- continue only as long as the child appears distressed
- consider changing to the other agent if the child's distress is not alleviated
- do not give both agents simultaneously
- only consider alternating these agents if the distress persists or recurs before the next dose is due.
SEPSIS
LET'S test our skills
Please remember, THIS IS NOT A TEST! It's a opportunity to put the skills you've learnt into practice in a safe enviroment.
Next
any questions?
next
BRB, gone for tea...
paediatric emergency drug chart
WETFLAG
Tommy is 4 years old - calculate his WETFLAG...
10
PAEDIATRIC FLUID REQUIREMENTS
MEDICATIONS MANAGEMENT
MTW GUIDELINES
Single checking is suitable for most medications. With regards to paediatric medication administration, a medication must be double checked if:
- it is for an under 12 and the practioner is not a qualified paediatric nurse or neonatal nurse
- if the medication is IV.
- Any weight based doses
- If the medication requires a drug calculation
- Medications administered via an infusion device
- Controlled drugs
Drug calcuations
medicines management
lets practice
A 5 month old baby has Meningitis and required Gentamicin IM. They weigh 6.2kg. What dose should be given?
BNFC!
6.2kg x 2.5mg =15.5mg 8 hourly
Always check your answers make sense. Should the volume you calculated be equal to, or less than, or more than the volume of the stock ampolue.
nEXT
medicines management
lets practice
A child is prescribed 180mg of paracetamol. Stock is 120mg in 5 ml. Calculate the volume to be given.
180 divided by 120 = 1.51.5 x 5 = 7.5 7.5ml to be given.
next!
medicines management
Now it's your turn
go!
medicines management
test
Question 1/5
A child is prescribed erythromycin. Recommended dosage in the BNFC is 40mg/kg/day, 4 doses daily. If the child’s weight is 15kg, calculate the size of 1 single dose.
40mg
600mg
150mg
medicines management
test
Rosie needs 300mg of Paracetamol and this is the bottle we have in stock. How much would you give?
11.5ml
10ml
12.5ml
medicines management
test
Freddie needs 100mg of Flucloxacillin and this is the bottle we have in stock. How much would you give?
4ml
3.5ml
4.5ml
medicines management
test
Arlo needs 1.5mg of Clonazepam and this is the bottle we have in stock. How much would you give?
0.6ml
1.5ml
0.5ml
medicines management
test
Rochelle needs 20mg of Pethidine and this is the IV ampoules we have in stock. How much would you give?
0.4ml
1ml
0.6ml
medicines management
test
Rowan needs 15mg of Gentamicin and this is the IV ampoules we have in stock. How much would you give?
1.5ml
1ml
0.75ml
medusa
Gerald is 26kg - what is his dose? how would you prepare it? how would you give it?
next
medicines management
Now it's your turn
go!
any questions?
This is the time to review and check we have covered everything you wanted to?
next
closure/SUMMARY
Key ideas to remember
Children are not just small adults and compensate for much longer.
Always ask for help if you're unsure.
Usually paediatric IV's are one vial doses... there are a few exceptions.
Parents know their child the best and don't forget to look after them too.
It's best to over escalate, than under escalate.
Always start with ABCDE - regardless
further reading
WETFLAG Calculator
Patient Assessment Infographics
Peds Case - Scenarios
You've done a wonderful job!
Before leaving, please provide honest feedback on the evaluation forms so we can improve and adapt the session for future cohorts.
home
a.dominic@nhs.net femy.francis@nhs.net
Facial expressions and behaviour
A child may naturally adopt a tripod position when having difficulty in breathing. Take note of the child's facial expression - they may look tense, tired or anxious. In a child who is verbal, it is advisable to talk directly to them to assess their response to questions and if they are talking in stilted sentences
Circulation - Pale centrally.Lots of information we cannot acertain just lookingDisability - Alert although no verbal communication/babbling. Muscle tone appears normal. Exposure - Rash to face and chest. Appears centrally mottled?
circulation, disability and exposure Assessment
Chest Expansion
Infants display diaphragmatic breathing (abdomen rises on inspiration and chest expansion is minimal). By the age of 7, the chest and abdomen should move together. If the diaphragmatic breathing is exaggerated - it can be a sign the lungs are less complaint - this is known as see-saw breathing . The child's chest should be fully unclothed and observed for equal, symmetrical, bi-lateral chest movement.
Where would you place a Sats Probe on a newborn?
Where would you place a Sats Probe on a baby?
Where would you place a Sats Probe on a child?
Airway - Talking, no additional airway sounds. Breathing - Would need to expose the chest. Colour is pink. No obvious increased WOB. Circulation - Pink in colour. Lots of information we cannot acertain just lookingDisability - Alert and babbling. Muscle tone and movement appears normal. Exposure - Mark to bottom lip. Would need to expose the child to fully assess.
a-e Assessment
Airway - Inspiratory ?stridor, ?wheeze Breathing - Seesaw breathing, intercostal and subcostal recessions, tracheal tug, posturing?, flushed in colour. Circulation - Flushed cheeks, pale centrally.Lots of information we cannot acertain just lookingDisability - ?AVPU. Posture appears normal. Exposure - Flushed cheeks, no obvious rashes.
a-e Assessment
Blood Pressure
The arm should be used for measuring blood pressure, but if this is not possible in infants, the lower leg can be used ensuring alignment with the artery. Sucking, crying or eating can affect the BP and should be noted. The cuff should cover 100% of the circumference of the arm and 2/3 of the length of the upper arm or leg. The bladder must cover 80% of the arm’s circumference. If there is a consistently high BP reading, a manual BP should be taken.
The mother's arm would possibly be better over the top of the child's arm. Notice they're using a book as distraction.
RESPIRATORY RATE AND RHYTHM
Newborn and Infants (0 - 1 year) - 30-60 bpm Toddler (1 - 5 years) - 24-40 bpm Child (5 - 12 years) - 18-30 bpm Older Child (12+ years) - 12 - 16 bpm Respirations should be rhymic at a rate of 1:2 (inspiration:expiration) - prolonged inspiration indicates upper airway obstruction and prolonged expiration indicates lower airway obstruction. Slight irregular breathing patterns or short apnoeas (less than 15 seconds) in infants can be considered normal, therefore, breathing should be counted for a full minute. Tachypnoea is usually the first sign of respiratory distress. As the child tires the respiratory rate decreases, therefore, a 'normalising' respiratory rate should be treated with caution.
Pulse
Newborn/Infant (0-1 years) - 80-160 bpmToddler and School Age (1-12 years) - 60-110 bpm Young Person (12+) - 50-90 bpm Pulse rate can be impacted by distress, fever, excitement and exercise and it is important to ensure a good trace on the machine if using the pulse rate from the monitor. Volume can be described as weak, thready, normal or bounding and this should be checked centrally and peripherally.
Rashes in Children
Rashes are common in children but it is extremely important to check the full body for rashes and assess if they are blanching.What do you think these rashes might be? (More examples can be found on the NHS website)
temperature
In infants under the age of 4 weeks, measure body temperature with an electronic thermometer in the axilla. In children aged 4 weeks to 5 years, measure body temperature by one of the following methods: electronic thermometer in the axilla chemical dot thermometer in the axilla infra-red tympanic thermometer. However, a tympanic may not be appropriate until the child is older. Oral measurement of temperature is suitable from age 5 years onwards, although, NICE recommend this is not routinely used. When taking temperature, consider cold sepsis.
Challenges
They have compensatory mechanisms that can mask deterioration. However, when they can no longer compensate they become critical very quickly.Difficulties communicating how and what they are feeling. Children have age-specific physiological responses to illnesses.
Because of these factors, children are at high risk of undetected clinical deterioration.
COLOUR
Mucous mebranes of mouth and nail beds of fingers and toes should be pink, indicating central and peripheral colour. Mottling on the skin often indicates inadequate oxygenation. Note: Newborns may have a normal peripheral cynosis and some babies are normally slightly mottled. Asking the question 'Is this normal for them?' is your best friend!
Comfort Hold
Both child's hands held firmly.
Leg hooked over child's legs.
Airway - Expiratory WheezeBreathing - Trachael TugSubcostal recessions ?Nasal Flaring Tachypnoea (Fast Breathing) Pink in colour (?compensating)
Airway and breathing Assessment
Raised ICP
DrowinessIrritability or a high pitched cry Headache Vomiting Bulging fontanelle Sunsetting eyes Posturing and muscle tone
Ebony is a 4 month old brought to ED. Her mother states she has had difficulty in breathing for 2 days and has been worse overnight. The child has been coughing and feeding poorly. Her fluid intake has been half of her usual and she has had less wet nappies. She has a moist sounding cough and no audible wheeze.
- Emotionally and cognitively immature
- Child’s communication skills are not well developed until later school age.
- The family constitutes an essential part of the child’s support system.
- The child and parents or primary caretaker must be treated as a unit.