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Week 10

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Week 10

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  1. Week 10 The Child Having Surgery

  2. 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

  3. 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

  4. 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

  5. Hospitalization Minimizing negative effects • Use of transitional items • Rooming-in, parents participate • Child-friendly environment • Therapeutic play • Atraumatic care • Allow child to manipulate equipment

  6. Nurse’s Role • Nurse is primary person in care of child • Introduction • Building a trusting relationship • Making decisions • Providing comfort & reassurance

  7. 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

  8. 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

  9. 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

  10. 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

  11. 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

  12. Preop Care • Preadmit teaching • Consideration of developmental stage • Parental involvement • Consent • Physical preparation such as? • Documentation • Allergies Shadow Buddies

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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.

  18. 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."

  19. 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.

  20. 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

  21. 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

  22. 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?

  23. 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

  24. Types • Hypovolemic • Cardiogenic • Distributive (Septic, Neurogenic & Anaphylaxis) • *See Box 29-6 p 1194 Types of Shock

  25. 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

  26. 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

  27. Effects on Body Systems • Cardiovascular • Neurological • Gastrointestinal • Respiratory • Renal • MOFS (Multi-Organ Failure Syndrome)

  28. Therapeutic Management • Ventilation • Fluid administration • Improvement of cardiac output • General support

  29. Blood Products • Indicated for: • Anemia • Shock • Massive Blood Loss • Sickle Cell Crisis • Chronic Hemmorhage

  30. Types of Products • PRBC’s • FFP • Albumin • Whole Blood • Hetaspan or Pentaspan –

  31. Selected Surgical Procedures • Myelomeningocele/spina bifida • Hydrocephalus • Cleft Lip & palate • Orthopedic surgery • Bowel surgeries • Pyloric stenosis • Hernias • Hischsprung’s • Bowel resections • Intussusception

  32. 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

  33. Myelodysplasias • Spinal canal and cord defects • Types: Occulta Meningocele Myelomeningocele

  34. Level of Defect & Mobility

  35. 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

  36. Fetal Surgery for Spina Bifida

  37. 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

  38. 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

  39. Clinical Manifestations in Infancy •  head circumference, dilated scalp veins • IICP • High-pitched shrill cry • Irritability • Altered muscle tone • Projectile vomiting, not assoc. with feeding