Liverpool Primary Care Trust

1. Assessment and Management of the Ill Child Katie Barnes, APNP, LJMU/LPCT Jo Ellis, APNP, Western Cheshire PCT Katie Jones, APNP, Liverpool PCT Claire McDonough, APNP, Liverpool PCT Archie McIntyre, APNP, Liverpool PCT Karen Murch, APNP, Liverpool PCT Kevin Urdhin, APNP, Liverpool PCT NHS Liverpool Primary Care Trust Western Cheshire

2. Learning Outcomes Articulate the paediatric-specific components of the history, physical, differential and management of the ill child Apply theory to practice → paediatric case presentations Discuss the role of documentation Identify resources available to the NP providing paediatric episodic care NHS Liverpool Primary Care Trust Western Cheshire

3. Outline • Basic Principles of Ill Children • The Paediatric Episodic History • Physical, Differential and Management • Consultation/Referral • Case Studies • Documentation • Paediatric Pearls and Resources NHS Liverpool Primary Care Trust Western Cheshire

4. Session Plan • (Quick) review of the fundamentals in paediatric episodic illness assessment and management (30 minutes) • Break out → APNP facilitated case study (30 minutes) • “Show and Share”(20 minutes) • Summary and Resources (10 minutes) Liverpool Primary Care Trust NHS Western Cheshire

5. Basic Principles: Ill Children • Regardless of the aetiology → information required for assessment and management is the same for all children (adolescents excepted). • A large percentage of paediatric episodic illnesses are relatively benign, easily managed, of viral aetiology and will likely resolve completely. • Initial presentation of viral and bacterial and serious and benign often with overlapping symptoms and non-specific findings → kids ‘go down the drain quickly’ Liverpool Primary Care Trust NHS Western Cheshire

6. Basic Principles: Ill Children • 1 Objectives of the paediatric consultation: • Identification of those conditions that are easily managed by the NP • Accurate diagnosis and management (to worry or not to worry) • Avoidance of missed pathology • Appropriate and timely referral (if necessary) • Consideration of the developmental context NHS Liverpool Primary Care Trust Western Cheshire

7. Basic Principles: Ill Children • A solid understanding of growth and development is the foundation upon which the history, physical, list of differential diagnoses and management plan are based. • Paediatric illnesses often have a developmental component (e.g. roseola, pathogenic organisms, peak ages of incidence, etc.) • The assessment and management of the ill child occurs within the family context. • Managing the parental anxiety, tiredness, confidence (or lack thereof) that accompany a sick child → challenging Liverpool Primary Care Trust NHS Western Cheshire

8. Paediatric Episodic History • Precipitating factors/events • Location: ‘one finger’ pointing • Character/quality: ‘totally kills or OK?’ • Quantity/severity: # of episodes, affecting activities (especially sleep), ‘smiling faces’ pain scale • Timing: onset, duration, frequency Liverpool Primary Care Trust NHS Western Cheshire

9. Paediatric Episodic History • Setting: symptoms on Saturdays? Recent travel? • Aggravating/relieving factors • Associated symptoms: (quick Review of Systems) • Parent (and child’s) perception of illness • Treatments tried so far and results (home and complementary therapies, Rx and OTC medications) Liverpool Primary Care Trust NHS Western Cheshire

10. Paediatric Episodic History • Anyone else ill with same symptoms and/or exposures? (siblings, nursery, school, play group) • How family is coping with the illness? (i.e. family disruption) • Is the child eating, drinking, playing, urinating? (What has ------ been doing for the last hour?) • Note: assumes past medical history is known (allergies, immunisations, major illnesses, medications, etc.) Liverpool Primary Care Trust NHS Western Cheshire

11. Paediatric Physical Exam • Developmental approach to the physical exam • Keep parent in the picture • Careful observation is KEY: a sick kid looks sick • Examination from head to abdomen is mandatory • Repeat observations/exam after fever relief → right dose → at the right time → of the right stuff (USE WEIGHT TO CALULATE DOSE) NHS Liverpool Primary Care Trust Western Cheshire

12. Paediatric Physical Exam • Key areas: • G = general appearance (ease of movement, cry) • E = engagability (smile, turn head, consolability, activity) • R = respiratory effort (listen ‘under’ the noise) • H = hydration (check turgor on abdomen, add in RR and cap refill) • T = temperature • V = vital signs (affected by fever and age) • S = skin (rashes inside and out) • P = perfusion (cap refill < 2 seconds→ warm hands, heart level) Liverpool Primary Care Trust NHS Western Cheshire

13. Paediatric Differential • Think BROADLY • Consider age-specific pathogens and aetiologies • Consider the epidemiological features of different illnesses in your thinking (e.g. seasonality of some infections, likelihood of exposure, incubation periods, community outbreaks) NHS Liverpool Primary Care Trust Western Cheshire

14. Paediatric Differential • T =Trauma (including child protection issues) • H = Haematology • I = Infection (viral, bacterial, parasites, etc.) • N = Neoplasm (leukaemia, lymphoma, OS) • N = Neurological • E = Endocrine • D = Developmental or congenital • V = Vascular (Kawasaki) • I= Immunological (vaccine reactions, Henoch-Schönlein • M = Medicines (including poisonings), MH, MSK (limp, fractures, sprains) and Miscellaneous • P = Psychological (and or behavioural) and polypharmacy NHS Liverpool Primary Care Trust Western Cheshire

15. Paediatric Management • Additional diagnostics: FBC and urine dipsticks (leukocyte esterase and nitrites) are tests of choice (careful with collection) • Pharmacotherapeutics: usually not necessary; consider issues such as administration, refrigeration, scheduling, length of treatment and TASTE. NHS Liverpool Primary Care Trust Western Cheshire

16. Paediatric Management • Behavioural Interventions: nutritional management, supportive care (fever control), special therapies (include ‘homework/jobs’ for the child to promote self-care). • Patient Education: aetiology of illness; infection control; ‘expected’ course of illness (return to school); when to return/phone for ‘unexpected’; follow-up instructions; REASSURANCE and PRAISE for carer’s management. NHS Liverpool Primary Care Trust Western Cheshire

17. Paediatric Consultation and Referral • Any child in whom presentation or history fall outside the NP’s comfort level, expertise or scope of practice. • Any child in whom there is a gravely ill appearance or whose clinical condition has deteriorated. • Any child requiring specialist intervention or expertise. • Young, febrile infants and neonates are at much greater risk of serious infection (and as such) will likely require referral. NHS Liverpool Primary Care Trust Western Cheshire

18. Case Study #2 • 9 year old girl • Cough and cold for 2 days • ‘sounds wheezy’ • 2 puffs salbutamol 2 hours ago • HR: 92/min • RR: 32/min • Sa02: 93% in RA • Temp: 37.3° C • Case Study #1 • 10 week old boy • 1 day history of vomiting • Vomited x 4 in past 24° • HR: 158/min • RR: 48/min • Sa02: 98% in RA • Temp: 38.4° C NHS Liverpool Primary Care Trust Western Cheshire

19. Case Study #3 • 4 year old girl • Unwell for the past 12 hours • ‘Not her normal self’ • HR: 106/min • RR: 48/min • Sa02: 95% in RA • Temp: 37.2° C NHS Liverpool Primary Care Trust Western Cheshire

20. Case Studies Format • History sketchy → flesh out in your groups • P/E → what are your clues and non-clues • Differential → identify a #1 but consider a list as wide as possible • Management → • Additional diagnostics • Pharmacotherapeutics • Behavioural interventions and Patient education • Paediatric Pearls → identify some • Resources → identify some • Show and Share → quick summary to me for slides NHS Liverpool Primary Care Trust Western Cheshire

21. De-brief: Case Study #1 NHS Liverpool Primary Care Trust Western Cheshire

22. De-brief: Case Study #2 NHS Liverpool Primary Care Trust Western Cheshire

23. De-brief: Case Study #3 NHS Liverpool Primary Care Trust Western Cheshire

24. Documentation • Importance • Liability issues • Quality review/audit • Good patient care • Document • 8 key points (G-E-R-H-T-V-S-P) • Bright-eyed and interactive. Well hydrated, good perfusion, afebrile, without rashes or respiratory distress. NHS Liverpool Primary Care Trust Western Cheshire

25. Paediatric Pearls • General appearance and engagability are important indicators; sick kids look sick – trust your instincts. • You are not just treating the child, it is the whole family. • Get some good paediatric reference books – keep them handy. • Use age-appropriate vital signs and lab values. NHS Liverpool Primary Care Trust Western Cheshire

26. Paediatric Pearls NHS Liverpool Primary Care Trust Western Cheshire

27. Paediatric Pearls • Develop good relationships with the DGH paediatric staff, they can be a good source of information for paediatric-related questions. • Don’t overlook the urine as a potential source of infection. • Head to abdomen exam; look ‘inside’ and ‘outside’ for rashes. • Respiratory effort is an important observation; listen ‘underneath’ the noise (use your bell). NHS Liverpool Primary Care Trust Western Cheshire

28. Paediatric Resources • www.contemporarypediatrics.com • www.cutepdf.com • www.library.nhs.uk • Link to: Guidance → International Guidance • Link to: Specialist Libraries → Child Health • NHS Institute for Innovation and Improvement: Emergency and Urgent Care for Children: http://www.institute.nhs.uk/quality_and_value/high_volume_care/focus_on%3a_emergency_and_urgent_care_pathway.html • Plug into your local NP programme → HL status • www.ljmu.ac.uk Search → APNP NHS Liverpool Primary Care Trust Western Cheshire

29. Paediatric Resources k.barnes@ljmu.ac.uk jo.ellis@nhs.net katie.jones@liverpoolpct.nhs.uk archie.mcintyre@liverpoolpct.nhs.uk kevurdhin@hotmail.com Smithdown Children’s NHS WIC, Liverpool: 0151-285-4820 NHS Liverpool Primary Care Trust Western Cheshire

30. Paediatric Resources Hay, A., et al. (2008). PITCH studies. BMJ Steiner, M. (2004). Is this child dehydrated? JAMA, 291(22): pp. 2746-2754 Armon, K. et al. (2001). An evidence and consensus based guideline for acute diarrhoea management. Archives of Diseases in Childhood, 85:132-142. BTS Standards of Care Committee. (2002). The BTS/SIGN guidelines on the management of community acquired pneumonia in childhood. Thorax, 57(Suppl 1). Available from: www.brit-thoracic.org.uk NHS Liverpool Primary Care Trust Western Cheshire

31. Paediatric Resources BTS Cough Guidance Group. (2007). Recommendations for the assessment and management of cough in children. Available from: www.brit-thoracic.org.uk Brown, M. (2001). The effect of environmental tobacco smoke on children: information and implications for PNPs. Journal of Pediatric Health Care, 15(6):280-286. SIGN. (2006). National Clinical Guideline 91:Bronchiolitis in children. Available from: www.sign.ac.uk NICE. (2008). Clinical Guideline 69: respiratory tract infection: antibiotic prescribing. Available from: www.nice.org.uk NHS Liverpool Primary Care Trust Western Cheshire

32. Paediatric Resources NICE. (2007). Feverish illness in children. London: National Institute for Health and Clinical Excellence. Available from www.nice.org.uk NICE. (2007). Urinary tract infection in children. London: National Institute for Health and Clinical Excellence. Available from www.nice.org.uk 2 new Cochrane releases: 2x daily dosing in AOM and grommet use in children (2008). Available of NHS Library for Health Child Health Specialist Library NHS Liverpool Primary Care Trust Western Cheshire

34. Comments? Thoughts? Many Thanks NHS Liverpool Primary Care Trust Western Cheshire