Family Children Nursing - Essay Example

? Family Children Nursing Presented to Assessment: Clinical Practical Guideline Case Study Analysis Abstract Clinicians and researchers in various healthcare institutions use Clinical Practice Guidelines to provide and manage clinical care. The two parties develop the Clinical Practice Guidelines for various hospitals. The CPGs are designed statements developed systematically to assist in providing advice on clinical care. CPGs cannot be used for prescription because they give room for flexibility that helps the clinician in decision-making although they are used as critical links between quality clinical practice and the most suitable evidence. Introduction Case Study Serena, a young girl of 20 months old is brought by her parents to the emergency department of their local hospital at around 0200 hours. An assessment conducted on her reveals the following: 2/7 history of sore throat Fevers Profuse nasal discharge The girls developed barking cough in the evening and Experienced difficulty in breathing. The Clinical Problem Initially in the 20th century, croup like illness were often confused with diphtheria but today croup is a term used to refer to several respiratory illnesses that vary in inspiratory stridor, barking cough, and hoarseness that result from obstruction in the larynx regions. Classification and Epidemiological Features Historically, croup illnesses have changed over time, but with imprecise classifications. Laryngotracheobronchitis is a term used to describe a spasmodic croup or laryngotrachetitis. The common classes of croup are; spasmodic croup, acute laryngotracheitis, LTB and LTBP and Laryngeal Diphtheria. Croup is an illness that attacks infants and children less than 6 years in age but rampant incidences occur between 7 to 36 months. Boys are more prone to its attacks than girls at a rate of 1.5 times. It has a biennial midautmn peak and annual summer trough (Cherry 2008. P.384). Croup Host factors Parainfluenza virus infections, especially type 3 is common in infants as well as young children. Despite this, croup develops only in a small percentage of children exposed. Reoccurrence of croup in children is linked to allergy. Spasmodic croup is triggered by parainfluenza virus type 1 and 2. Levels of Assessment for Severity Croup The levels of assessment of severity croup are mild, moderate, severe and impending respiratory failure. The mild level is characterized by occasional barking cough. At a rest position, the infant has no audible stridor. Retractions of the skin of the chest wall could be mild. At a moderate level, barking cough becomes frequent with easily audible stridor when the child is resting. Suprasternal and sternal retractions with no agitations are noticed. In the severe stage, barking cough remains frequent; inspiratory becomes prominent with occasional expiratory stridor. The expiratory stridor is marked with sterna retractions, agitations and distress. At impending respiratory failure level, the barking cough fails to be prominent with hard to hear audible stridor when the child is at rest. The sterna retractions cannot be recognised as the child experiences lethargy. In the absence of supplemental oxygen, the infant appears dusky (Scally & Donaldson 1998 p. 67 &68). Strategies and Evidence Evaluation Croup illnesses differ in severity and treatment and therefore require differential diagnosis (Cherry 2008.p388). Other acute obstructive illnesses in the larynx region must be diagnosed. These include epiglottitis, foreign body, and angioneurotic edema of the epiglottis. Epiglottitis is signified by lack of a croupy cough, sitting position of the child, a pushed forward chin and reluctance in lying down. Apprehension and anxiety in the child is spotted rather than inspiratory difficulties. Foreign body and angioneurotic edema cause obstruction in the upper airway. These occur suddenly without fever and infection signs. Lower airway signs like crackles, air trapping, wheezing and pneumonia are discovered by use of a radiograph. These are symptoms of laryngotracheobronchitis and laryngotracheobronchopneumonia which are not found in spasmodic croup. In evaluation of croup, laboratory findings have not been very helpful. Clinical Practice Guidelines Assessment of Severity Various scoring systems have been developed in evaluation of croup severity. The most commonly used system is that of Westley et al. This scoring system evaluates croup on the basis of five factors: level of consciousness, cyanosis, stridor, air entry, and retractions. Although the system is of value in treatment trials, it has little use in routine clinical setting. Clinical practice Guidelines have been developed to assist in severity assessment. The CPGs have a general approach as follows: There is no stethoscope assessment. Assessment relies on what is seen, heard and felt as the patient enters the door. Step 1- Eyeball What can be seen are retractions, subcostal, intercostals and supraclavicular? Cyanosis, the level of consciousness and rashes. Step 2: Listen What can you hear? Stridor accompanied with crying and when at rest or an abnormal cry. What can’t you hear? Asthmatics that is too tight to wheeze. Step 3: What can you feel? Check the pulse rate Step 4: Look at the vital signs for normal state of a child. The vital signs vary by age. Simple rules should be used to verify paediatric vitals. Clinical Practice Guideline for Hospital Authority-Hong Kong According to CPG of Hospital authority in Hong Kong, three reviews are important. These are: Laboratory tests in viral croup The clinician should avoid any laboratory test that will inflict pain. Such like test is to reserve for uncertain cases. The clinician should: I. Complete blood picture. This will reveal mild leucocytosis and lymphocytosis. This finding is not specific. In most cases, it involves infliction of pain and need to be avoided. II. Arterial blood gas: This relates well with clinical severity and progression but involves infliction of pain. It is only recommended for severe or intubated cases. III. Lateral neck radiograph: this will show over distinction of hypopharynx and proximal larynx. The steeple sign resulting from subglottic swelling will be shown in the poster anterior film. This will cause agitation in the child. Radiographs are few and therefore not necessary for such an obvious case. Monitoring of children diagnosed with viral croup I. Pulse Oximetry: this is a non-invasive monitoring method and important for moderate to severe cases. Oxygen saturation needs to be monitored carefully because of hypoxaemia condition. II. Conscious level: This relates with the severity of the disease. The respiratory rate, heart rate and conscious state are useful in clinical diagnosis. III. Scoring system: although some clinical trials have been validated, there is no clinical study used to evaluate its usefulness in clinical practice. Management of Viral croup Mild cases are managed by out-patient clinic. Under this situation, the child needs a calm and warm environment. Minimal or no disturbance withy parental comfort is needed. Deteroriation signs like increasing stridor, fatigue and respiratory distress need to be watched. Incase of moderate to severe croup, Steroid Therapy is effective in reducing acute symptom. Research has revealed that corticosteroids are effective and oral administration of the drug is parenteral (Chow et al. 2002. P. 68-75). Clinical Practice Guideline- Australia According to this guideline, a structured assessment is carried out in child diagnosis. The structured approach is important in timely intervention for sick children. The assessment should be continuous and dynamic. A good history of the illness and vital factors to the infant must be established. This provides distinction for: A child who is now perfectly well although parents report a past of acute pallor that suggests conditions of seizure or sepsis or such like related conditions. A child on medication and prefer alteration in medication that may cause drowsiness or such like cases. Close observations must be made to ensure that subtle signs are detected. Areas of assessment are; airway, breathing, circulation, disability and level of consciousness, and fluids in and out. Assessment of airway Obstruction of the airway must be checked. It could be complete or partial. Incase there exists inspiratory noises, the airway is partially obstructed. The noise heard could be bubbly, snory or stridor. When the airway is obstructed by fluids, bubbly noises are produced. Snoring sounds are caused by decreased levels in consciousness that could occur when the infant lies supine or when the large occiput flexes the neck. Stridor occurs when the larynx or trachea is partially obstructed. Its loudness does certain the severity of croup. Partial obstruction may lead to complete obstruction. The seriousness of obstruction is assessed through: The respiratory rate Amount of respiratory effort Heart rate and Alertness. Incase the obstruction is severe; the baby will be agitated or appear drowsy. The secondary signs of airway obstruction include: Increased respiratory rate or effort, Decreased oxygen saturation Increased heart rate Worsening colour and Decreased level of consciousness or agitation (Statewide and Rural Health Services and Capital Planning 2011. P.9). Assessment of breathing The effort applied during breathing and efficacies in gaseous exchange are of importance during this assessment. If breathing is ineffective, agitation will arise, and cause unconsciousness. This is classified under any one of these categories; Apnoea Bradypnoea Tachypnoea Nasal flaring Gasping Accessory muscle use Grunting Cyanosis and Oxygen saturation (SpO2) Oxygen saturation is measured in room air and used as a good indication for efficacy of breathing (Statewide and Rural Health Services and Capital Planning 2011. P.10). Circulation Its assessment involves measurement of heart rate, blood pressure and limb perfusion. The adequacy of circulation is determined by brain perfusion and vital organs. Assessment of fluids is done through check of fluid intake and fluid output. Case Study Analysis: Serena PHx stated that she was a well child with no prior admissions or presentations. OE: Pale, peripherally warm, Irritable. Marked inspiratory stridor, mild intercostals stridor recession and use of abdo muscles. Infrequent barking cough and profuse nasal discharge. SaO2 93% in RA RR 32/minute. HR 162/minute. Diagnosis: Viral croup Plan: Oral corticosteroids Temp 38.9° C per axilla Weight: 11.4 kilograms Recommendation: May require Oxygen therapy to maintain SaO2>95%. Fluid intake and output to be observed and the child be admitted to the children’s ward. A reassessment to be done in 4 hours. How should Serena be evaluated and treated? Is the clinician’s recommendation right? The normal heart rate for a child below 2 years is between 100-190. This implies that Serena’s heart (162per minute) rate is okay. A respiratory rate classified as abnormal is that which exceeds 60/ per minute. For Serena (32 per minute), her respiratory rate is okay. The oxygen saturation while breathing in ambient air for a normal child should be above 92%. From the diagnosis conducted on Serena’s 93%. This implies that the girl child is in a stable position and does not need oxygen therapy. The child’s body temperature and weight are normal. The recommendations done by the clinician are not appropriate. The drugs recommended for the child should not be administered. Serena’s situation requires two immediate and important actions. These are: Diagnosis for another disease rather than croup The symptoms diagnosed do not guarantee that the child is suffering from croup. There is only one sign that is related to the disease; Pale, peripherally warm, Irritable. Marked inspiratory stridor, mild intercostals stridor recession and use of abdo muscles. Infrequent barking cough and profuse nasal discharge. According to the CPG for Australia, the diagnosis made does not validate for Croup. Form this CPG, an assessment on the airway states that though the child has stridor, this sign does not implicate severity. Parental monitoring over the situation The philosophy of care states that; I. Parents should listen and believe their children. II. Both parties are partners in healthcare. III. Healthcare is both holistic and individualised. IV. Good healthcare must be family centred. V. Knowledgeable professionals should provide a collaborative and multi-professional approach in health care (Hordvik & Straume, no date p.7-9) and (Morrel, Woodfield, & Nelstrop 2002 p. 14). Recommendations The child should be given oral or intra-muscular dexamethasone, 0.6 mg/kg. Any situation like separation from parents and unnecessary examination, which can cause distress to the child, must be avoided. The child should be observed for improvement between a period of 1-4 hours. In case the patient improves, discuss with the parents the probable cause of illness and when to seek additional healthcare. This is done after the child no longer experiences stridor when resting. The child can now be discharged home. If there will be no improvement after the fourth hour, the patient should be hospitalized. Conclusion Clinical Practice Guidelines are important to clinicians for diagnosis. Although they vary depending on country to country and even hospital to hospital, they need to be implemented since they give room for the clinician to evaluate and validate the best healthcare to offer. This flexibility makes CPGs appropriate in various and for several diseases. Parents who are central to healthcare of their children also take part in the guideline. Their support assists clinicians in decision making. This develops trust between the parties and improves the quality of healthcare. Bibliography Cherry, D. J. (2008). CLINICAL PRACTICE; Croup. The NEW ENGLAND JOURNAL of MEDICINE. Vol. 358; 4. London: Massachusetts Medical Society. Statewide and Rural Health Services and Capital Planning (2011). Recognition of a Sick Baby or Child in the Emergency Department, 2nd Edtn; Clinical Practice Guideline. NSW Department of Health. www.health.nsw.gov.au. Accessed on 14th Nov. 2012. Chow, P.Y et al. (2002). Clinical Guideline on Management of Viral Croup. KH J Paediatr (new series); Vol 7: 68-75. Hong Kong; Hospital Authority. Hordvik, E. & Straume, M. (no date). Sick Children in the Family. U.S.A. Morrel, C., Woodfield, T. & Nelstrop, L. (2002). Clinical Practice Guidelines; The recognition and assessment of acute pain in children. London: Royal College of Nursing. Scally, G & Donaldson L.J. (1998). Clinical governance and the drive for quality improvement in the new NHS in England. British Medical Journal (317):61-65. Scrivener, R., Doorbar, P., Llewellyn, N. & Duff, L. (2000). All about pain. London: RCN Publishing. Read More