Transcript Week 10
The Child Having Surgery Week 10 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 • 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 • • • • • 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 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 is primary person in care of child – – – – Introduction Building a trusting relationship Making decisions Providing comfort & reassurance 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 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 • 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 • 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’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 • • • • • • • Preadmit teaching Consideration of developmental stage Parental involvement Consent Physical preparation such as? Documentation Allergies Shadow Buddies 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 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 • • • • • • • • 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 • 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 • 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. 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." 1. Only a ... 25% 25% 25% 25% 2.The pers... 3.The risk... 4.A mental... 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. • 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 • • • • 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 • • • • • • • • • 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 • 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 • Hypovolemic • Cardiogenic • Distributive (Septic, Neurogenic & Anaphylaxis) • *See Box 29-6 p 1194 Types 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: • 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 • • • • • • Cardiovascular Neurological Gastrointestinal Respiratory Renal MOFS (Multi-Organ Failure Syndrome) Therapeutic Management • • • • Ventilation Fluid administration Improvement of cardiac output General support Blood Products • Indicated for: – – – – – Anemia Shock Massive Blood Loss Sickle Cell Crisis Chronic Hemmorhage Types of Products • • • • • PRBC’s FFP Albumin Whole Blood Hetaspan or Pentaspan – 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) • 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 Myelodysplasias • Spinal canal and cord defects • Types: Occulta Meningocele Myelomeningocele Level of Defect & Mobility Management • Initial – Protect site from injury infection; monitor neurostatus • Surgery – Closure of defect, shunt if nec – Can be done in utero (see next slide) • Ongoing management of mobility, bowel, bladder, neuromuscular problems Fetal Surgery for Spina Bifida 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 •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 • head circumference, dilated scalp veins • IICP • High-pitched shrill cry • Irritability • Altered muscle tone • Projectile vomiting, not assoc. with feeding Later Manifestations • Child – – – – Headache on awakening Lethargy, irritability Ataxia Confusion • Long term effects: impaired vision, headaches, seizures, hormonal effects, destruction of cerebral cortex 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 • 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 •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 • 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, • 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 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 • 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 • 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 • • • • Speech difficulties Malocclusion Hearing problems Altered self-esteem and body image Orthopedic Conditions 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 Types & Features Box 39-4, 39-3 Pg. 1779 Healing & Treatment • Table 39-2 Pg. 1782 • Treatment • Repair with realignment by reduction [closed or open] • Immobilization with a splint, cast or traction Nursing Diagnoses • • • • • • • High Risk for Injury Impaired Mobility Impaired Tissue Integrity High Risk for Infection Altered Comfort: Pain Self-Care Deficit Knowledge Deficit 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 • 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 • 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 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 Esophageal Atresia 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) • 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) – 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) 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, flds, fiber, exercise plan Other Bowel Conditions • Intussusception • Meckel’s diverticulum • Peptic ulcers 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 • S&S-abd pain, recurrent vomiting, anemia, melena • Rx-antacids, anti-secretory agents • Surgery only if complications Diagnostic Endoscopy • Conscious sedation – OP basis *Nursing care • Risks: perforation • Used for: upper GI and lower GI (colonoscopy, sigmoidoscopy) Equipment Ulcer 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 • 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 • 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 • Requires immediate surgery • Rupture leads to peritonitis, paralytic ileus • Appendicitis may be confused with Meckel diverticulum, gastroenteritis, ectopic pregnancy 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 • • • • • • • • 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 • Genetic Disorders