Chapter 11. Children with Special Healthcare Needs. Objectives. Definition 9/11/2012. Define children with special healthcare needs.

Transcription

1 Chapter 11 Children with Special Healthcare Needs Objectives Define children with special healthcare needs. Define technology-assisted children. Discuss specific assessment and management considerations for children with special healthcare needs. 2 Definition Children with special healthcare needs are those who have or are at risk for chronic physical, developmental, behavioral, or emotional conditions that necessitate use of health and related services of a type and amount not usually required by typically developing children 3 1

2 Definition Technology-assisted children are a subgroup of children with special healthcare needs that depend on medical devices for their survival 4 Assistive technology Definition Describes devices used by children and adults with a disability to compensate for functional limitations and to enhance and increase learning, independence, mobility, communication, environmental control, and choice 5 Special Healthcare Needs These children are particularly susceptible to medical problems involving the ABCs Vital signs may be controlled by the child s medical device Heart rate may be determined by a child s pacemaker Ventilator settings may determine the respiratory rate for a child on a home ventilator Equipment failure may result in a medical emergency 6 2

3 Special Healthcare Needs Many children with special healthcare needs are small for age Weight or baseline vital signs may fall outside the typical range for the child s age May require equipment sizes that differ from those estimated by age 7 Special Healthcare Needs Many children with special healthcare needs: Have sensory or motor deficits with or without normal cognitive function Physical and mental abilities may not be the same as those for other children of similar age 8 Special Healthcare Needs Examples of disorders and diseases of children with special healthcare needs: Cerebral palsy Cystic fibrosis Sickle cell anemia Hemophilia Neurofibromatosis Hydrocephalus Rheumatoid arthritis Cancer Premature infant Diabetes Club feet Dislocated hip Cleft palate Scoliosis Spina bifida Congenital GU and GI anomalies Some conditions of epilepsy Many muscle and nerve disorders 9 3

4 Unstable or Critical Patient A child with special healthcare needs who has any of the following conditions should be considered unstable or critical: Partial or total airway obstruction in children with tracheostomies Respiratory difficulties in ventilator-dependent children Bradycardia, irregular pulses, or signs of compensated shock in children with pacemakers Fever, nausea, vomiting, headache, or a change in mental status in children with CSF shunts Signs of worsening illness despite appropriate home therapy in any child with a chronic health problem Since ventilator-dependent children always require assisted ventilation, critical status applies only if one or more additional signs are present. 10 Assessment and Management Considerations 11 History Caregiver is often the best resource regarding the child s special healthcare needs Can usually tell you what is normal for the child regarding his or her: Mental status Vital signs Normal assessment findings and level of activity Ongoing health problems Medications Medical devices currently in use 12 4

5 History Look for a medical identification bracelet or necklace Ask the child s caregiver if an Emergency Information Form is available If completed, this form contains important information for use by healthcare personnel 13 Airway and Breathing Considerations Dyspnea Common in children with chronic illnesses Often occurs because of difficulty swallowing and handling airway secretions Excessive airway secretions and salivation may occur because of: Muscle weakness Brain stem injury Other diseases Increases risk of aspiration 14 Airway and Breathing Considerations Children vulnerable to airway obstruction: Child with a tracheostomy Child with a CSF shunt Child on home ventilator Child with CPAP or BiPAP devices 15 5

6 Airway and Breathing Considerations Some congenital syndromes or diseases are associated with limited cervical motion, making intubation difficult Klippel-Feil syndrome Congenital fusion of cervical vertebrae Severe shortness of neck Intubation can be difficult Inability to flex or extend neck 16 Airway and Breathing Considerations Down syndrome Often difficult to intubate Neck rigidity and a large tongue obscure visualization of glottis Curved blade may be more effective in these patients Better displacement of large tongue to the left Permits better visualization and easier intubation 17 Airway and Breathing Considerations Juvenile-onset rheumatoid arthritis May have arthritis involving: Temporomandibular joint Limits mouth opening Cervical spine Limits flexion and extension of neck Can be difficult or impossible to intubate these children 18 6

7 Circulation Considerations Technology-assisted children May have higher than normal resting heart rate Assessment compensated shock may be difficult Congenital heart disease May have chronic peripheral and/or central cyanosis Tetralogy of Fallot Consult caregiver about patient s baseline skin color 19 Cerebrospinal Fluid Shunts 20 Cerebrospinal Fluid Shunts Hydrocephalus ( water on the brain ) develops when there is an interruption of this normal circulation due to: An increase in CSF production Obstruction of CSF flow A decrease in CSF absorption 21 7

8 Untreated Hydrocephalus 22 Cerebrospinal Fluid Shunts A shunting system is surgically implanted into brain Drains excess CSF into another part of the body Reduces intracranial pressure 23 Causes of CSF Shunt Malfunction D Displacement (catheter migration) Disconnection of shunt components Drainage overdrainage or inadequate drainage O Obstructed or fractured catheter, kinking of distal catheter P Perforated abdominal viscus, peritonitis, pseudocyst E Erosion of the equipment through the skin 24 8

9 Cerebrospinal Fluid Shunts Infection Pseudocyst 25 Management If increased ICP, increased risk of vomiting and aspiration Ensure suction equipment is readily available Administer supplemental O 2 Assist ventilation as necessary Be prepared to intubate If signs of shock or hypotension present: Aggressive volume resuscitation using isotonic fluid If BP is reduced, so is cerebral perfusion pressure 26 Management Check the child s blood sugar Administer IV dextrose if indicated Treat seizures if indicated If CSF shunt infection, systemic antibiotics Tapping the reservoir of the CSF shunt and aspirating fluid to temporarily lower ICP may be necessary Should be performed by an experienced physician 27 9

10 Gastric and Gastrostomy Tubes 28 Gastric Tubes Gastric tubes and gastrostomy tube Used to provide nutrition to an infant or child who is unable to take food by mouth for an extended period Gastric tube Small tube passed through nose or mouth into stomach Small tube diameter Uncomfortable for patient Associated with irritation of nasal and mucous membranes Gastrostomy performed when prolonged or permanent enteral nutrition is needed 29 Gastrostomy Tubes Jejunostomy tube (J-tube) Feeding tube Passed through abdomen into small intestine, bypassing stomach Gastrostomy tube (G-tube) A tube or a button (skin level device) Surgically placed into stomach through the abdominal wall 30 10

11 Gastrostomy Tubes 31 Gastrostomy Tubes Conditions for which gastrostomy tubes are used: Swallowing dysfunction Esophageal atresia Severe gastroesophageal reflux Esophageal burns or strictures Craniofacial abnormalities Chronic malabsorption Severe failure to thrive Severe facial injuries secondary to trauma 32 Management Gastric Tubes If possible aspiration: Suction the airway Administer oxygen Monitor oxygen saturation and cardiac rhythm Repeat primary survey frequently 33 11

12 Management Gastric Tubes If tube is partially dislodged: Can be removed without harming the child Remove tape from child s face and tube Gently pull the tube out through the nose or mouth 34 Management Gastric Tubes Skin irritation can be evaluated by child s physician If signs of infection are present, physician evaluation If bleeding present, apply direct pressure with sterile dressing If the tube is dislodged: Cover the hole with a sterile dressing Avoid using occlusive dressings In the emergency department, assess insertion site to determine if a temporary tube can be inserted 35 Tracheostomy Tubes 36 12

13 Tracheostomy A tracheostomy is a surgical opening into the trachea between the second through fourth tracheal rings Opening (stoma) may be temporary or permanent 37 Tracheostomy Tubes Cuffed TTS (tight to shaft) tracheostomy tube. When completely deflated, the cuff collapses tight to the shaft of the tube. Air-filled cuff Foam cuff 38 Single Cannula Tracheostomy Tubes One lumen is used for airflow and suctioning of secretions When changing the tube, insert new tube quickly When a new tube is inserted, an obturator is placed inside tube After the tube is in position, remove obturator 39 13

14 Double Cannula Tracheostomy Tubes Consists of an outer cannula (main shaft), inner cannula, and an obturator (stylet) When inner tube is removed for cleaning, outer tube keeps airway open Once outer tube is in place, inner cannula is inserted and locked in place Inner cannula may be disposable or reusable 40 Fenestrated Tracheostomy Tubes A fenestrated tracheostomy tube has small holes in the side of the tube Helps the child: Learn to breathe through the upper airway Expel secretions Allows the child to talk 41 Fenestrated Tracheostomy Tubes Decannulation cap (plug) Blocks air flow through the stoma Air flow is redirected through the holes in the tube and out through the nose and mouth 42 14

15 Peds Pearl Assume that any infant or child with a tracheostomy and signs of respiratory distress has an obstructed tube. Possible causes of the obstruction include: Increased secretions A mucous plug An obturator that was inadvertently left in the tracheostomy tube Equipment failure 43 Trach Tube Assessment If signs of respiratory distress are present: Consider a lower airway obstruction History of fever Gradual worsening of respiratory status Consider a mucous plug Sudden onset of symptoms Symptoms associated with a change in consistency of tube secretions 44 Trach Tube Assessment Consider a displaced or obstructed tracheostomy tube: Signs/symptoms consistent with possible obstruction If worsening respiratory symptoms: Question caregiver about possible recent change in home ventilator settings Possible ventilator malfunction 45 15

16 Tracheostomy Tube Suctioning Use suction catheter of appropriate size Catheter should be no more than ½ the internal diameter of the tube being suctioned Use a length-based resuscitation tape Or multiply the external diameter of the tracheostomy tube (in millimeters) by two If trach tube is 4 mm in diameter, use an 8 French suction catheter Set suction pressure to -100 mm Hg or less 46 Tracheostomy Tube Suctioning 47 Bag-valve-stoma Ventilation 48 16

17 Removing and Replacing a Trach Tube 49 Home Ventilators 50 Ventilator Emergencies Possible reversible causes of acute deterioration in an intubated child: Displaced tube (e.g., right mainstem or esophageal intubation) or Disconnection of tube or ventilator circuit Reassess tube position, ventilator connections Obstructed tube (e.g., blood or secretions are obstructing air flow) Suction Pneumothorax (tension) Needle thoracostomy Equipment problem/failure (e.g., empty oxygen source, inadvertent change in ventilator settings, low battery) Check equipment and oxygen source 51 17

18 Ventilator Emergencies If suspected ventilator malfunction: Disconnect ventilator tubing from tracheostomy tube Attach a bag-valve device to trach tube Provide manual ventilation with supplemental oxygen Watch and listen for equal chest rise and breath sounds 52 Ventilator Emergencies If the patient s chest rise is shallow: Reassess (and readjust if necessary) position of the patient s airway Ensure the bag-valve device is securely connected to the tracheostomy tube If chest rise does not improve, assess the tracheostomy tube for obstruction 53 Noninvasive Mechanical Ventilation 54 18

19 CPAP Continuous Positive Airway Pressure Delivery of slight positive pressure to prevent airway collapse and improve oxygenation and ventilation in spontaneously breathing patients May be used to assist ventilation in children with: Neuromuscular weakness Chronic pulmonary edema Tracheomalacia Obstructive sleep apnea 55 Bilevel Positive Airway Pressure In BiPAP therapy, two (bi) levels of positive pressure are delivered: One during inspiration (to keep the airway open as the patient inhales) Other (lower) pressure during expiration to reduce the work of exhalation Uses: Patients with chronic respiratory failure May be helpful in transition from invasive to noninvasive respiratory support 56 Assessment and Management A child who requires noninvasive mechanical ventilation has a higher-than-average risk for partial or total airway obstruction May be removed from a CPAP or BiPAP device if it interferes significantly with assessment and interventions Child will be still able to breathe, but may tire easily Administer supplemental oxygen or provide assisted ventilation as necessary 57 19

20 Vascular Access Devices 58 Vascular Access Devices Although several types of VADs are available, they can be classified into three general categories: Central venous catheters (CVC) Implanted ports Peripherally inserted central catheters (PICC) 59 Central Venous Catheters Also referred to as tunneled catheters, Broviac, Hickman Catheter is surgically inserted into external jugular, subclavian, or cephalic veins Catheter tip in superior vena cava, just above right atrium Other end of catheter is tunneled SC and exits skin on anterior chest wall May have a single, double, or triple lumen 60 20

21 Central Venous Catheters 61 Implanted Ports Portacath, Mediport, or Infusaport Surgically placed completely below the skin Catheter tip lies at junction of superior vena cava and right atrium Other end is tunneled SC and is attached to a port (reservoir) Port can be palpated as a raised disk under the skin A special Huber needle is used to access the port 62 Implanted Ports 63 21

22 Implanted Ports 64 Peripherally Inserted Central Catheters Also called nontunneled catheters Inserted into antecubital vein and then advanced into the subclavian vein Small (23 to 16-gauge) single or double lumen catheters Small size is advantageous for use in infants and small children 65 Peripherally Inserted Central Catheters Does not require surgical placement Can be inserted at bedside, usually by a specially trained nurse Less expensive and associated with fewer complications than central venous catheters 66 22

23 Peripherally Inserted Central Catheters 67 Vascular Access Device Emergencies Emergencies from central venous catheters may result from local or systemic complications associated with their use: Infection or allergic reaction Breakage and leakage Air embolism Infusion errors Catheter migration Catheter obstruction 68 Emergent Use of Vascular Access Devices Do not administer medications or fluids through a central venous catheter unless: Other methods of vascular access cannot be obtained (e.g., peripheral or central line access) You have received special training to access central catheters An emergent condition exists 69 23

24 Questions? 70 24