Transcript NHS

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
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
Liverpool
Primary Care Trust
Western Cheshire
NHS
Outline
• Basic Principles of Ill Children
• The Paediatric Episodic History
• Physical, Differential and Management
• Consultation/Referral
• Case Studies
• Documentation
• Paediatric Pearls and Resources
Liverpool
Primary Care Trust
Western Cheshire
NHS
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
Western Cheshire
NHS
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
Western Cheshire
NHS
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
Liverpool
Primary Care Trust
Western Cheshire
NHS
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
Western Cheshire
NHS
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
Western Cheshire
NHS
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
Western Cheshire
NHS
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
Western Cheshire
NHS
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)
Liverpool
Primary Care Trust
Western Cheshire
NHS
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
Western Cheshire
NHS
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)
Liverpool
Primary Care Trust
Western Cheshire
NHS
Paediatric Differential
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T = Trauma (including child protection issues)
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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
Liverpool
Primary Care Trust
Western Cheshire
NHS
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.
Liverpool
Primary Care Trust
Western Cheshire
NHS
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.
Liverpool
Primary Care Trust
Western Cheshire
NHS
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.
Liverpool
Primary Care Trust
Western Cheshire
NHS
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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
Liverpool
Primary Care Trust
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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
Western Cheshire
NHS
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Liverpool
Primary Care Trust
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
Western Cheshire
NHS
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
Liverpool
Primary Care Trust
Western Cheshire
NHS
De-brief: Case Study #1
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Primary Care Trust
Western Cheshire
NHS
De-brief: Case Study #2
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Primary Care Trust
Western Cheshire
NHS
De-brief: Case Study #3
Liverpool
Primary Care Trust
Western Cheshire
NHS
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.
Liverpool
Primary Care Trust
Western Cheshire
NHS
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.
Liverpool
Primary Care Trust
Western Cheshire
NHS
Paediatric Pearls
Liverpool
Primary Care Trust
Western Cheshire
NHS
Paediatric Pearls
• Develop good relationships with the DGH paediatric staff,
they can be a good source of information for paediatricrelated 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).
Liverpool
Primary Care Trust
Western Cheshire
NHS
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/focu
s_on%3a_emergency_and_urgent_care_pathway.html
• Plug into your local NP programme → HL status
• www.ljmu.ac.uk Search → APNP
Liverpool
Primary Care Trust
Western Cheshire
NHS
Paediatric Resources
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[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
Smithdown Children’s NHS WIC, Liverpool: 0151285-4820
Liverpool
Primary Care Trust
Western Cheshire
NHS
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
Liverpool
Primary Care Trust
Western Cheshire
NHS
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
Liverpool
Primary Care Trust
Western Cheshire
NHS
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
Liverpool
Primary Care Trust
Western Cheshire
NHS
Thoughts?
Comments?
Many Thanks
Liverpool
Primary Care Trust
Western Cheshire
NHS