Challenges of Nursing Care of the Paediatric Surgical Patient - PDF

Symposium Challenges of Nursing Care of the Paediatric Surgical Patient P. N. Okpara Department of Nursing Services, University of Ilorin Teaching Hospital, Ilorin, Nigeri...

Symposium Challenges of Nursing Care of the Paediatric Surgical Patient P. N. Okpara Department of Nursing Services, University of Ilorin Teaching Hospital, Ilorin, Nigeria Abstract Paediatric surgical nursing is the nursing care of children of age 0‑15 years who present with surgical problems. The nursing care of children is quite challenging in view of their peculiarities in social, psychological, emotional and physical reaction and response to illness and sometimes their inability to give necessary history and clue to assist in evaluating and management of their health problems. This paper intends to address the importance of history taking, assessment of the patient on admission, monitoring of vital signs, management of knowledge deficit in patient and parents, care of intravenous fluids/oral fluids and preventing of wound infection. The need to achieve drug compliance, post‑operative care, counselling, and health education were also discussed. Skilful nursing care is considered indispensable tools in improving outcome of paediatric surgical patients. Keywords: Close monitoring, knowledge deficit, nursing, paediatric Introduction clean start, no mistakes. The need for punctuality is therefore more critical to the nurse. Paediatric surgical nursing is the nursing care of children of age from 0 to 15 years who present with surgical problems. The nursing care of children within the above age bracket History Taking is quite challenging in view of their peculiarities in social, The following should be noted in history taking. Age – age will psychological, emotional and physical responses and reactions aid the nurse in planning where to nurse the patient e.g., a neonate to illnesses and sometimes because of their inability to give requires incubator nursing because of poor temperature control. necessary history and clue to assist in evaluating and managing Age will also help in ascertain the degree of weight loss – a child their health problems. should double the birth weight in 6 months and triple the birth weight in 1 year of life. For instance, age helps in formulating This paper aims at highlighting some of the nursing challenges nursing diagnosis of illnesses, which are age related for instance under the following headings: history taking, assessment intussusceptions occur between ages 3 months and 12 months. of the patient on admission, management of knowledge deficit in patients and parents, monitoring of vital signs, Age also guides drug administration. For instance, Phenergan, care of intravenous fluids/oral fluids, compliance to drug which causes temporary psychosis and convulsion in some administration, post‑operative care including, pain relief, children under the age of 2 years should be prescribed with wound care and prevention of infection. The need for high caution. skills of observation, child advocacy, psychological care, History of onset of illness will also give a clue towards counselling and advice on discharge will also be discussed. appropriate diagnosis as it reveals the pattern of development A nurse should be the first person to resume work in the hospital and manifestation of signs and symptoms. setting in order to enhance the shifting system. Patients need to be taken over physically with the sufficient time to enable the nurse get enough salient information that will ensure error Address for correspondence:  P. N. Okpara free care. Therefore, the key here is early rising, settled mind, Department of Nursing Services, University of Ilorin Teaching Hospital, PMB 1459, Ilorin, Nigeria. E‑mail: [email protected] Received: 01-02-2013    Accepted: 24-03-2013    Available Online: 05-08-2020 Access this article online This is an open access journal, and articles are distributed under the terms of the Creative Quick Response Code: Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to Website: remix, tweak, and build upon the work non-commercially, as long as appropriate credit www.afrjpaedsurg.org is given and the new creations are licensed under the identical terms. For reprints contact: [email protected] DOI: 10.4103/ajps.AJPS_28_13 How to cite this article: Okpara PN. Challenges of nursing care of the paediatric surgical patient. Afr J Paediatr Surg 2018;15:154-7. 154 © 2020 African Journal of Paediatric Surgery | Published by Wolters Kluwer - Medknow  Okpara: Challenges of nursing care of children Duration of Illness with tepid sponging, exposure to fresh air and use of antipyretic Seeking information on duration of illness will also give a when indicated. Derangement in vital sign may need prompt clue towards diagnosis and severity. For instance, duration of attention of the managing clinician. abdominal distension and pain in a child with febrile illness will suggest typhoid intestinal perforation and its duration. Care of Intravenous Fluids Signs and symptoms Fluid administration in paediatrics is guided, approximately Skilful history taking will reveal such symptoms as non‑passage 100 mlkg/day. It should be calculated properly to avoid of meconium in a neonate which is a pointer to intestinal under or over hydration. For instance, a 3 kg child’s daily obstruction like Hirschsprung’s disease or Anorectal fluid requirement is 100 ml × 3 = 300 ml/24 h. If given with malformation. This can further be confirmed in by an inability to drip set (20 drops = ml)/4 drops/min, if with burette given insert a rectal thermometer. An excessive salivation may indicate set (solucet) 60 drops = ml/12 drops/min. Use of solucet is both oesophageal atresia, which will require frequent suctioning and prudent and proactive against over hydration in the new born nursing patient in lateral position to ensure a patent airway. whose body compartment is 70% fluids. Close observation is needful. Paediatric fluid chart helps in calculating intake hourly so as to note any deviation from normal early. If drugs like Assessment of the Patient on Admission potassium chloride (KCl) are added, the drip must not exceed The patient’s general condition should be assessed to note how the prescribed rate to avoid its potentiating action on the cardiac severe the illness is, to enable the nurse plan adequate care. For muscle with resultant tachycardia. Two years ago, we have a instance, a child with abdominal distension and breathlessness, 10‑year‑old female child that had a transient tachycardia to KCl preparation will be made for nasogastric intubation, positioning post exploratory laparatory for typhoid intestinal perforation. and oxygen administration. Her pulse was 90 beat/min before setting up Intravenous fluid Weighing (IVF) of 4.3% D/saline containing KCl, the pulse rose to 120 The child should be weighed for accurate calculation and beat/min with KCl, and dropped to 92 cpm after the fluid was administration of drugs and intravenous fluids. Adequate discontinued (personal experience). Accurate intake and output hydration is essential for optimal recovery in child undergoing recording is mandatory as a guide to monitoring renal function surgery. and subsequent fluid replacement. Nutritional status The child’s nutritional status should be assessed. Optimal Management of Knowledge Deficit nutritional status will ensure speedy recovery, as well as reduce Both patients and parents should be made to know the cause the period of hospitalization, reduce the financial burden, of the illness, mode of acquisition, signs, and symptoms, period of absence from school and unnecessary morbidity need for early hospital care, danger of patronizing quacks and and mortality. preventive measures. Furthermore, what to expect pre‑  and post‑operation. Passage of Naso‑Gastric tube to decompress Hydration status: Adequate hydration will ensure optimal renal the stomach pre‑ and post‑operative to relieve operative‑site of function and saver respond to drugs, especially in neonates. tension to encourage healing. If the child needs colostomy Personal hygiene the mother should be taught hygienic colostomy care. The Adequate personal hygiene reduces the risk of wound infection challenge for nurses is to intervene effectively with information and other nosocomial infection. and support in the context of a trusting and collaborative relationship. Jaundice The child should be assessed for jaundice which is often a pointer to the seventy of infective process and sometimes is Prevention of Infection indicative of an obstructive illness like biliary atresia. This is a major concern in surgical units. Such measures such as adequate hand washing before and after procedures, in between Full examination patients, frequent and prompt change of bed linen and soiled This will also reveal hidden abnormality like spinal bifida, anal dressings, turning off fans before opening wounds, adequate stenosis, undescended testis and hypospadia which the mother autoclaving of dressing materials and packs, individualization may consider insignificant. of dressing packs and optimal nutrition will go a long way in preventing infection especially, nosocomial infections Monitoring of Vital Signs which are often sturborn to treatment because of resistance to antimicrobial agents. Because children may not be able to verbalize their feelings and symptoms, vital signs should be closely monitored and documented. The various values for the different age grades Need to Achieve Drug Compliance must be known to the nurse so that appropriate measures will Ignorance and poverty are major huddles in the care of the be taken promptly. Pyrexia and hyperpyrexia should be treated paediatric surgical patients. Non‑compliance to medication African Journal of Paediatric Surgery ¦ Volume 15 ¦ Issues 3 & 4 ¦ July-December 2018 155  Okpara: Challenges of nursing care of children will result in significant morbidity and mortality and increase High Observation Skill overall health cost. The nurse therefore, needs to go extra‑mile Skilful observation is needful especially in the new born or in persuading the parents, to ensure availabilities of prescribed younger children who cannot communicate. The neonate drugs to ensure sustained improvement. has to be observed for evidence of cyanosis. The problem of poor temperature control due to functional immaturity of Pain Control the temperature regulating centre and large incubator surface The paediatric surgical nurse should know how to recognize area has to be overcome by using incubators with inbuilt and assess pains in young children who may not be alarm. If the neonate is febrile exposure to fresh air without verbalized pain. Signs of pain in children may be fretfulness, tepid sponging is often enough to control the temperature. It restlessness or excessive cry. Children may see the pain should be noted that extremes of temperature is a killer to the as punishment and may react with regressive behaviours. new born. Non‑pharmacological steps of pain relief such as involving parents during procedures, explaining what to expect to the Post‑operative Care older child, answering their questions in clear language, In the immediate post‑operative period, the level of cold or warm compress, proper positioning and support as in consciousness should be ascertained by calling the child scrotal pain or splinting fractured limb have been employed by name or pinching the skin. This will serve as a guide with reasonable positive effects. Hypnosis has also been to frequency of checking vital signs and administration effective in reducing the pain and associated with anxiety in of narcotic analgesic. If unconscious, non‑narcotics like children. Analgesics can also be used Pro‑Re Nata in severe injection Paracetamol (PCM) 10 mg/kg/dose should be given pain as in the case of extensive burns. A recent approach until full consciousness is regained. Operation site should to pain relief is the use of computer‑controlled infusion be observed closely for bleeding. If the patient had nose or pump that permits a patient to administer medication by throat surgery the patient should be observed for trickling of pressing a button. Patient controlled analgesia can be used blood from the mouth or nose or frequent swallowing which by adolescents. Empathy should always be demonstrated by is evidence of bleeding. Patent airway should be ensured by health care provider when managing patient with a painful placing the child in left or right lateral positioning. Pulse condition. A child may actually interpret pain as punishment should be monitored for rapidness. The normal range for or even wickedness from a well‑meaning health care giver. various age groups should be known to the nurse. To overcome the negative impact of a child’s understanding Intravenous f luid (IV) f luids should be properly and reaction to pain the use of a local anaesthetic, an calculated, labelled, documented and monitored. oil‑water emulsion of lidocaine and prilocaine eutetic Urinary output: Urine in the bag on arrival to the ward must mixtures of local anaesthesia (EMLA) on the intended site be emptied immediately, measured and documented in of venipuncture 60 min prior to the procedure is advocated. terms of the amount, character and volume. Subsequently, It hinders initiation and conduction of nerve impulses that hourly monitoring is carried out – normal 1‑2 ml/kg/h. conduct pain.[5,6] This EMLA ensures higher success rate in If urine output is below 1 ml/kg/h, adequacy of the fluid venipuncture, fewer blood vessel damage, as well as spare should be ensurened and the attention of the surgeon sought. more healthy vessels for later use. Nasogastric tube should be aspirated 2‑4 hourly, effluent measured, documented and replaced volume for volume with Wound Care normal saline to avoid electrolyte imbalance. The benchmark in wound care is asepsis. In the immediate Need for warmth‑pt should be kept warm because of post‑operative period, the wound should be observed for exposure to air conditioner in the operating theatre. bleeding. Any blood stain on the dressing should be noted Furthermore, observe for a sign or symptoms of an unduly and observed closely as increasing stain size and a rapid tight plaster of paris. pulse suggest on‑going bleeding and should be reported immediately to the surgeon: Subsequently, the wound should Psychological Care be observed for serosanquinous discharges, pus and yellowish Nurses are most involved during the critical times in the child’s or greenish discharge which should also be documented and life, at diagnosis and during times of surgery or complications. reported. Soiled dressings should be carefully, aseptically These times of increased chaos and stress are opportune for and promptly changed with sterile packs, and surgical nurses to offer parents ideas about devising rituals as a way gloves. Prompt and guarded suture removal is required. Use of coping with their challenges. Psychological support of antiseptic solutions like providone iodine will reduce the augments every other aspects of nursing care. Because of risk of infection. If the wound does not heal with primary sickness in a single child disrupt a whole family system. intension and is sloughy, natural honey will both act as Therefore, approach should be both holistic and empathetic. anti‑slough as well as increase blood supply to enhance By empathetic means “I could have been one” attitude which wound healing.[8,9] will be far reassuring and makes the patient and parents 156 African Journal of Paediatric Surgery ¦ Volume 15 ¦ Issues 3 & 4 ¦ July-December 2018  Okpara: Challenges of nursing care of children confide in the nurse who has become a friend in need and Advice on Discharge not just a worker. Their questions should be answered in At discharge parents and patients are advised on the need clear language. Good listening skill is a must. Show them to book and keep the follow‑up appointment, continue on a convalescents from similar problems. balanced diet, use take home drugs. Child Advocacy Conclusion Because of high level of ignorance, taboos and poverty some Nursing is concerned with the experience of illness as Nigerian children are still prey to preventable illnesses, it affects the patient and family. Thus, skilful nursing prolonged suffering, morbidity and wasteful mortality. The care are considered indispensable tools in addressing the United Nations Rights of the child should be made known to challenges related to the growing number of parents whose the parents as follows: babies “beat the odds” as well as devoting ourselves to Freedom from discrimination. advancing the frontiers of care of children with surgical Right to develop physically and mentally in freedom and conditions. dignity. Right to adequate nutrition, housing, recreation and Acknowledgement I wish to thank the paediatric surgery team for their motivation medical care. to write this manuscript. To receive special treatment if handicapped. When recruited into a research, consent must be obtained Financial support and sponsorship from the older child and confidentiality ensured. Nil. To be loved, understood and given material care. Conflicts of interest Right to education, development of his skills and ability. There are no conflicts of interest. To be the first to receive protection in disaster. To be brought up in the spirit of friendship among people. References The nurse should also serve as liaison officer between the child 1. Whallay LF, Wong DL. Essentials of Pediatric Nursing. USA: Mosby; and other health care provider. 1982. 2. Rempel GR. Technological advances in pediatrics: Challenges for parents and nurses. J Pediatr Nurs 2004;19:13‑24. Counselling and Heath Education 3. Asnes RA. Pain. In: Dershewitz RA, editor. Ambulatory Pediatric Care. Philandelphia: Lippincott; 1993. p. 676‑9. Religious and philosophical views may influence how parents 4. Jacobson AF. Intradermal normal saline solution, self‑selected music, respond to the birth of an infant with a medical condition. Fatalism and insertion difficulty effects on intravenous insertion pain. Heart Lung and guilt feelings in relation to congenital malformations or 1999;28:114‑22. genetic conditions have an influence, while poverty and illiteracy 5. Choy L, Collier J, Watson AR. Comparison of lignocaine‑prilocaine cream and amethocaine gel for local analgesia before venepuncture in negatively affect access to health care. Therefore, counselling children. Acta Paediatr 1999;88:961‑4. form an integral part of care. The older child and parents should 6. Lander J, Hodgins M, Nazarali S, McTavish J, Ouellette J, be health educated on the cause of the illness, transmission of Friesen E. Determinants of success and failure of EMLA. Pain 1996; 64:89‑97. infection, need for personal and environmental hygiene and 7. Squire SJ, Kirchhoff KT, Hissong K. Comparing two methods of topical proper disposal of waste, food and water hygiene, especially in anesthesia used before intravenous cannulation in pediatric patients. case of typhoid intestinal perforation. J Pediatr Health Care 2000;14:68‑72. 8. Adigun IA. Honey as a wound dressing: A better alternative in At discharge, it is expected that the older child and parents developing countries. Niger J Plast Surg 2004;2:10‑6. become actors and not observers in educating members of 9. Agbaje EO, Ogunsanya T, Aiwerioba OI. Conventional use of honey as antibacterial agent. Ann Afr Med 2006;5:78‑81. their community on how to avert the preventable problem that 10. Woodring BC. The role of the staff nurse in protecting children and brought them to the hospital. families involved in research. J Pediatr Nurs 2004;19:311‑3. African Journal of Paediatric Surgery ¦ Volume 15 ¦ Issues 3 & 4 ¦ July-December 2018 157