Care of the Child Within an Accident - Case Study Example

CARE OF THE CHILD WITHIN ACCIDECT AND EMERGENCY Introduction: This is a reflective case study of phenomena at my placement in Accident and Emergency delivering specialist nursing care to the children of age group 1 to 5 years. In this assignment I will critically, reflect on a range of childhood emergencies and illnesses in children of this age group, and this will comprise reflection on patients with meningitis, respiratory problems, orthopedic and head injuries, neurological observations, dressing, and burns and wound care. All such conditions presenting in to the Accident and Emergency would have representative patients with different age groups, consequently, the disease of presentation will have implications depending on physical and psychological milestones of the respective age range. The child whose care I am going to critically reflect on is a child with meningitis. This was a 2-year-old child who presented to the Accident and Emergency accompanied by anxious mother. This was a male child who presented to the A and E with loss of consciousness at home that was preceded by vomiting. This child was diagnosed to be a case of bacterial meningitis and I had to deliver care in the A and E. Milestones and Development: Obviously many children with the age group that I am going to discuss presented with different diagnoses during my placement in the Accident and Emergency, and milestones and development from both physiological and psychological perspectives have implications in diagnosis and management of these children. To discern an aberration, it is important that an overview of the normal milestones is done. Children accomplish maturation of different biological functions at an anticipated age with a margin of few months on the either side. Ideally, assessment of behavioural development should be interpreted from the time of appearance of definite skills while giving due considerations to environmental and social factors besides the stress of the actual clinical situation. In the phase between 2-3 years, the height increases further with 2.3 kg weight gain per year until the age of 5 years, and at the age of 2.5 years has a full set of 20 baby teeth (Rasen, D.S., 2004). Psychosocial Milestones: Psychosocially, negativism grows out of child's sense of developing independence and says "no" to every command. Ritualism is important to toddler for security. Temper tantrums may result from toddler's frustration in wanting to do everything for self. The child shows parallel play as well as begins interaction with others and engages in associative play. Fears become pronounced, and the child continues to react to separation from parents but shows increasing ability to handle short periods of separation. The child has daytime bladder control and begins to develop nighttime bladder control. The child becomes more independent and begins to identify sex (gender) roles. The child explores environment outside the home and can create different ways of getting desired outcome (Parker, S., & Zuckerman, B., 1995). Child in the Accident and Emergency: The primary concerns of this age group that is relevant to the care that I delivered are many. These include "separation anxiety" relationship with mother is intense. Separation represents the loss of family and familiar surroundings, resulting in feelings of insecurity, grief, anxiety, and abandonment. The toddler's emotional needs are intensified by the parents' absence. Presence and treatment in the hospital or A anb E would mean changes in rituals and routines, all of which are important to sense of security, become a source of concern. In this age group, the child has limited capacity to understand reality and passage of time. There is inability to communicate and understanding of language and this affords the child limited communication between self and the world. Moreover while being investigated, examined, or treated, this represents to him loss of autonomy and independence. The child sees self as a separate being with some potential control of own body and environment (Pillitteri, A., 2002). Compounded to that, the child has incomplete body integrity. This inaccurate understanding of the body results in fear, anxiety, frustration, and anger. An intravenous infusion, a restraint to control movement or avoid injury, or a lumbar puncture test that is essential in the investigation or management of meningitis, would lead to decrease in mobility, and this restricting mobility causes frustration. The child wants to keep moving for the pleasure it gives as well as for the feeling of independence, the opportunity to learn about the world, and the route it provides for coping with frustrations that cannot be verbally expressed. Physical interference with this freedom results in a sense of helplessness. The child would react to such a situation with protest with urgent desire to find parents with frequent crying and shaking the crib with rejection of attention by the nurse. With the parents, the child would show signs of distrust with anger and tears. It is a situation of gross despair for the child, and he feels increasingly hopeless about seeing his parents becoming apathetic, anorectic, listless, and sad accompanied by continuous or intermittent crying and taking recourse to thumb sucking or tightly catching a toy or the blanket. When this is allowed to persist, the child enters into the phase of denial when he represses all feelings and images of parents and does not cry when parents leave. At this point, he may seem more attached to nurses and will go to anyone, but finds little satisfaction in relationships with people despite accepting care without protest (Ryan E and Steinmiller, E., 2004). Evidence-Based Practice: As a nurse, I had to intervene in such a situation allowing parents to participate freely in the examination and treatment procedure. This would provide the opportunity for the child to express some of his feelings about the situation with assurance that parents are not abandoning or punishing the child. This can also create an environment of periods of comfort that maintains the family bond even in the A and E. I had to re-establish trust through body contact and comfort, at the same time setting the limit so contact with parents does not affect treatment. I had to obtain from the parents key words in communicating with the child. I found out about nonverbal behavior as well. The parents were encourages to use familiar toys, blankets, pillowcases, that can reinforce the child's sense of security. I allowed the child to make choices whenever possible (Tacsi, YR and Vendruscolo, DM., 2004). In my placement in the Accident and Emergency, while delivering care, it was extremely important to deliver care in different common child hood acute illnesses, but in general, irrespective of family configurations, all families were noted to have some common concerns and needs that needed to be addressed when their child would have received emergency treatment. I have found that communication with the family was a more serious issue in some cases even when the accidental conditions were trivial in magnitude. This communication is necessary to keep the family abreast with accurate, timely, frequent, and honest information about the patient's condition, treatment, and prognosis (DiAnna-Kinder, F., 2006). This type of communication assures the family that the treatment is appropriate. Not only that frequent positive assurance is necessary to highlight the fact that all treatment rendered is in a competent and caring manner, so the family is able to trust the caregivers. This approach can be termed as family-centered care, where there is development of a mutually beneficial relationship between patient, family, and myself. Although, this is a derivative of the concept of consumerism enabling the consumer to participate in their own care, I achieved this by respecting and supporting families during examination and resuscitation in this acute care setting. Literature supports my view in that this can be achieved by respecting each family's dignity, expertise, values, and culture. The most important step was that, in every step I shared information with the family to allow them to make informed decision about their child's emergency care. In short, the family became collaborator in the care of this child in the enactment of an emergency treatment plan. It is also important to acknowledge the fact that family is a great source of information that has significance in diagnosis and care of children who cannot speak, and signs of disease are not prominent or classic in these children (Forgeron, P. and Martin-Misener, R., 2005). Collaborating with the family early in the treatment process in the A and E helped to assure compliance. It is also to be noted that during this child's investigation, invasive procedures such as lumbar puncture was done, and I ensured that family was present during that time. This has several benefits, although this is guided by the urgency of the situation and invasiveness of the procedure. In presence of the family, I felt comfortable, and there was no competent nurse available at that time. The family was able to support and comfort the child during the procedure or the treatment. The application of developmental principles and the initiation of family-centered care are the important pillars of pediatric emergency nursing, and indeed, I considered the family as a part of my team (Dixon, S.D., 2000). The Care of Meningitis: As mentioned earlier, a thorough history was taken that conforms with that of bacterial meningitis. Bacterial meningitis is an inflammation of the meninges that follows the invasion of the spinal fluid by a bacterial agent. Most cases are seen in children younger than age 5. The organisms most commonly causing bacterial meningitis in different age-groups. In the age group of this child, Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae are the common organisms. This kind of illness is frequently preceded by an upper respiratory infection, which is complicated by bacteremia. Bacteria in the circulating blood then invade the CSF. Rarely, this may occur as an extension of a local bacterial infection, such as, otitis media, mastoiditis, or sinusitis. This child had no penetrating injuries to suspect as the portal of entry, and the parents confirmed a sore throat that was treated by the primary care physician (Considine, J. and Brennan, D., 2007). This infective process is potentially dangerous due to the fact that this may result in inflammation, exudation, and varying degrees of tissue damage in the brain. The onset of the disease was fulminant, and truly does not follow a classic pattern since it depends on patient's age, the etiologic agent, and the duration of the illness when diagnosed. At the time of presentation, the child started to show irritability, lethargy, vomiting, lack of appetite, one episode of seizure, and fever within the last 2 days of presentation (Uphold, C.R. (Ed.), 2003). On interrogation, this child had altered sleep pattern and fever. On examination, there were both positive Kernig's or Brudzinski's signs. The neck was rigid and he had a sharp cry and was vomiting. His was normal. I did a lumbar puncture that clinically showed turbid CSF with high pressure. With a clinical diagnosis of meningitis, I sent the fluid for tests, and expect high cell count, low glucose level, elevated proteins, and positive Gram stain and cultures that can recognize the organism. It was of utmost importance to monitor the breathing pattern and circulatory status (Schwartz, M.W., 2003). I had to form a nursing diagnosis in this child that comprised of Ineffective tissue perfusion related to endotoxin release into the CSF, hyperthermia related to infectious process, acute pain related to neurologic effects from the disease process, risk for transmission of infection related to bacterial agents, ineffective tissue perfusion related to complications of infectious process, and anxiety of parents related to severity of illness and hospitalization (Hallstrm, I and Elander, G., 2005). What I immediately did was, inserted an IV line and administered an empiric intravenous antibiotic, took appropriate precautions to maintain this IV line patent without infiltration or phlebitis. I advised admission, and until the child was admitted, I made sure that vital signs, LOC, and neurologic status were monitored at frequent intervals. I knew that monitoring intake and output, weight, and head circumference daily to assess for hydrocephalus was very important (Hawksworth, D.L., 2000). It was also important specially to watch for lethargy or subtle changes in condition, which may indicate cerebral edema, and I admitted the patient with instructions to accurately chart the child's behavior and clinical signs. In the A and E, I also administered antipyretics, tepid sponge baths, and hypothermia blanket to reduce fever. Fever increases metabolic rate and energy requirements by the brain, and this may lead to hypoxemia and brain damage in the child with cerebral vascular compromise (Uphold, C.R. (Ed.), 2003). While in the A and E, monitoring for seizures and use of seizure precautions in the febrile child were instituted. This was done due to the fact that there is an increased potential for seizures in the febrile child. My job as a nurse was to ensure safety by using padded bed or crib rails and having airway and suction equipment on hand (Hickey, J.V., 2002). The setting of the management was designed to reduce the general noise level around the child and to prevent sudden loud noises. The nursing care was organized to provide for periods of uninterrupted rest. The general handling of the child was kept at a minimum. When necessary, the child was approached slowly and gently in an environment of subdued lighting as much as possible. I instructed all to speak in a low, well-modulated tone of voice (Uphold, C.R. (Ed.), 2003). I ordered medications for pain, avoiding opioids that cause CNS and respiratory depression. According to evidence, I had also responsibility to use precautions until at least 24 hours after initiation of appropriate antibiotic therapy. I practiced careful hand-washing techniques. I made sure that personnel with colds or other infections avoid contact with this child with meningitis and wear a mask when it is necessary to approach him. I took an opportunity to teach parents proper hand-washing and gown techniques and the reasons for those. I maintained sterile technique for the procedures I performed. I also asked parents to identify close contacts of this child with meningitis who might benefit from early prophylactic treatment (Glenn, K., 2005). Following the principles of family-centered care, although I had hardly any chance to counsel due to urgency of this situation, I required to encourage the parents to engage in quiet activities with their child, such as reading or listening to soft music; however, I did provide the parents with an opportunity to express their concerns and answer questions that they might have regarding the child's progress and care. I actively engaged the parents in the supportive care of the child so they may feel some control over the situation (Brook, I., 2003). Hospital management has certain other implications in the A and E setting. It has implications on the child and family, and it bears a special meaning in terms of professional, legal, and ethical issues involved in the care of the child (Committee on Pediatric Emergency Medicine, 2007). Family-centered care is the final common pathway to implement these principles. It promotes normality in the family unit in that care and teaching are in keeping with specific family needs and strengths, and by this method, family roles and close family interactions during time of stress are enhanced. This minimises separation anxiety for both parents and children and thereby decreases reactions of protest, denial, and despair of the ailing child by increasing the sense of security for the child. The family has also needs to care for their child physically and emotionally, and this fulfils the parents' desire to feel useful and important, rather than dependent and peripheral. Involving them in care decreases parental guilt feelings and increases parents' competence and confidence in caring for the sick child and leads to greater absorption of staff teaching by the family. This is also known to diminish post hospitalization reactions (Barnes, P., 1995). Although this is not always possible to implement these ethical principles in the A and E, I tried my best to help maintain a positive nurse-parent-child relationship and avoided actions that might cause parents feel threatened by me. I supplemented the family's abilities and role in achieving the common goal of the child's welfare. The parents' presence is especially important if the child is age 5 or younger, especially anxious, upset, or in medical crisis. I knew that the parents' decision is influenced by needs of other family members, as well as by job, home responsibilities, and personal needs. I developed a trusting, goal-directed relationship with the family. I obtained a thorough nursing history that provided information to assess broad consideration of strengths, relationships, and concerns; included family and individual stage of development, cultural, spiritual, social, material, and financial areas. I planned with the family toward mutual, realistic goals, and I recognized and acknowledged the care and consideration the child received from the parents (Schwartz, M.W., 2003). To be able to protect the child and his advocate, I also observed the parent-child relationship and evaluated the degree of participation and effectiveness of the parents in physical and emotional care. I observed the parents' attitudes, skills, and techniques and the child's behavior and response to them. I carefully assessed the learning needs, learning styles, and potential barriers to understanding and skill development; assist families that needed language interpretation. I performed nursing techniques safely and efficiently. I mutually with parents, assessed and interpreted the behavior of the hospitalized child, so appropriate understanding and intervention were reached (Davies, D., 2004). I assessed the child's and parents' understanding of essential medical care and wellness-focused information. I explained medical procedures and diagnostic tests and the preprocedure preparations required. Finally, I provided health teaching and anticipatory guidance concerning medically related information and wellness behaviours, parenting and child-rearing matters, and crisis intervention and community resources (Cleaver, K., 2003). Reference List Barnes, P. (1995). Personal, social, and emotional development of children. Boston: Blackwell Publishers. Brook, I., (2003). Unexplained fever in young children: how to manage severe bacterial infection. BMJ; 327: 1094 - 1097. Cleaver, K., (2003). Developing expertise - the contribution of paediatric accident and emergency nurses to the care of children, and the implications for their continuing professional development. Accid Emerg Nurs; 11(2): 96-102. Committee on Pediatric Emergency Medicine, (2007). Access to Optimal Emergency Care for Children. Pediatrics; 119: 161 - 164. Considine, J. and Brennan, D., (2007). Effect of an evidence-based paediatric fever education program on emergency nurses' knowledge. Accid Emerg Nurs; 15(1): 10-9. Davies, D. (2004). Child development: A practitioner's guide (2nd ed.). New York: Guilford Press. DiAnna-Kinder, F., (2006). Pediatric nursing: nurse practitioner provides holistic care for the entire family. Pa Nurse; 61(1): 23. Dixon, S.D. (2000). Encounters with children: Pediatric behavior and development (3rd ed.). St. Louis: Mosby. Forgeron, P. and Martin-Misener, R., (2005). Parents' intentions to use paediatric nurse practitioner services in an emergency department. J Adv Nurs; 52(3): 231-8. Glenn, K., (2005). Child development paper: theories and milestones in action. J Nurs Educ; 44(11): 527-8. Hallstrm, I and Elander, G., (2005). Decision Making in Paediatric Care: an overview with reference to nursing care. Nursing Ethics; 12: 223 - 238. Hawksworth, D.L. (2000). Simple febrile convulsions: Evidence for best practice. Journal of Child Health Care, 4(4), 149-153. Hickey, J.V. (2002). The clinical practice of neurological and neurosurgical nursing (5th ed.). Philadelphia: Lippincott Williams & Wilkins. Parker, S., & Zuckerman, B. (1995). Behavioral and developmental pediatrics: A handbook for primary care. Philadelphia: Lippincott Williams & Wilkins. Pillitteri, A. (2002). Maternal and child health nursing (4th ed.). Philadelphia: Lippincott Williams & Wilkins. Rasen, D.S. (2004). Physiologic growth and development. Pediatrics in Review, 25(6), 194-200. Ryan E and Steinmiller, E., (2004) Modeling family-centered pediatric nursing care: strategies for shift report. J Spec Pediatr Nurs; 9(4): 123-8, 134. Schwartz, M.W. (2003). Clinical handbook of pediatrics (3rd ed.). Philadelphia: Lippincott Williams & Wilkins. Tacsi, YR and Vendruscolo, DM., (2004). Nursing assistance in pediatric emergency services Rev Lat Am Enfermagem; 12(3): 477-84. Uphold, C.R. (Ed.) (2003). Clinical guidelines in child health (4th ed.). Gainesville, Fla.: Barmarrae Books. Read More