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LiverpoolPrimary Care Trust
Western Cheshire
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
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LiverpoolPrimary Care Trust
Western Cheshire NHS
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
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LiverpoolPrimary Care Trust
Western Cheshire
Outline
• Basic Principles of Ill Children
• The Paediatric Episodic History
• Physical, Differential and Management
• Consultation/Referral
• Case Studies
• Documentation
• Paediatric Pearls and Resources
NHS
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LiverpoolPrimary Care Trust Western Cheshire
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)
NHS
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LiverpoolPrimary Care Trust
Western Cheshire
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’
NHS
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LiverpoolPrimary Care Trust
Western Cheshire
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
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LiverpoolPrimary Care Trust Western Cheshire
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
NHS
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LiverpoolPrimary Care Trust Western Cheshire
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
NHS
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LiverpoolPrimary Care Trust Western Cheshire
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)
NHS
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LiverpoolPrimary Care Trust Western Cheshire
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.)
NHS
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LiverpoolPrimary Care Trust Western Cheshire
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
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LiverpoolPrimary Care Trust Western Cheshire
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)
NHS
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LiverpoolPrimary Care Trust Western Cheshire
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
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LiverpoolPrimary Care Trust Western Cheshire
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
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LiverpoolPrimary Care Trust Western Cheshire
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
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LiverpoolPrimary Care Trust Western Cheshire
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
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LiverpoolPrimary Care Trust Western Cheshire
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
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LiverpoolPrimary Care Trust Western Cheshire NHS
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
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
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LiverpoolPrimary Care Trust Western Cheshire NHS
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
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LiverpoolPrimary Care Trust Western Cheshire
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
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LiverpoolPrimary Care Trust Western Cheshire
De-brief: Case Study #1
NHS
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LiverpoolPrimary Care Trust Western Cheshire
De-brief: Case Study #2
NHS
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LiverpoolPrimary Care Trust Western Cheshire
De-brief: Case Study #3
NHS
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LiverpoolPrimary Care Trust Western Cheshire
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
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LiverpoolPrimary Care Trust Western Cheshire
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
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LiverpoolPrimary Care Trust Western Cheshire
Paediatric Pearls
NHS
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LiverpoolPrimary Care Trust Western Cheshire
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
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LiverpoolPrimary Care Trust Western Cheshire
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
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LiverpoolPrimary Care Trust Western Cheshire
Paediatric Resources
• [email protected]• [email protected] • [email protected]• [email protected]• [email protected]• Smithdown Children’s NHS WIC, Liverpool: 0151-
285-4820
NHS
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LiverpoolPrimary Care Trust Western Cheshire
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
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LiverpoolPrimary Care Trust Western Cheshire
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
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LiverpoolPrimary Care Trust Western Cheshire
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
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LiverpoolPrimary Care Trust Western Cheshire NHS
Thoughts? Comments?
Many Thanks