Pediatric P.O.I.N.T.S. to Ponder. Allan Joseph V. Cresencia, MSN, CPN, RN Children s Hospital Los Angeles PACU
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1 Pediatric P.O.I.N.T.S. to Ponder Allan Joseph V. Cresencia, MSN, CPN, RN Children s Hospital Los Angeles PACU
2 Thank you!! PANAC ASPAN s SPG- Pediatrics ICPAN ASPAN CHLA
3 Financial Gains, Disclosure and Conflict of Interest for this Lecture Nada!! None!!
4 Objectives/Goal/Aim 1. Identify and discuss the most common complications related to anesthesia with the pediatric population. 2. List and discuss common and/or basic pediatric surgeries in a general (adult) surgical setting. 3. Discuss key nursing care management when dealing with pediatric surgical patient
5 P is for PLAY Onlooker play Solitary play Parallel play Associative play Cooperative play
6 Onlooker Play
7 Solitary Play
8 Parallel Play
9 Associative Play
10 Cooperative Play
11 P is for PLAY Play box Crayons & coloring book Child Life Specialist (if available) Favorite toy from home
12 Play box
13 Crayons & Coloring Books
14 Child Life Specialist
15 O is for OBSTRUCTION Stridor - sound Croup - LTB Laryngospasm muscle Bronchospasm Trachea/Bronchi Aspiration Pneumonia
16 O is for OBSTRUCTION Tips & Techniques Non-invasive & invasive Positioning Airways (Oral & Nasal) Non-pharmacological Jaw thrust (head tilt) Pharmacological Paralytics Surgical (if necessary) Tracheostomy
17 I is for INTUBATION Role of nurse before, during and after Basics of tracheal intubation Comfort, frequency, similarity & differences Endotracheal tube versus Laryngeal mask Preference by anesthesia team Combo tube and newer versions Benefits versus risks Extubation (in OR versus PACU) Some Children s hospital do so at PACU
18 I is for INTUBATION Resources if not comfy with PEDS client Seasoned adult nurses with pediatric experience Textbooks in pediatric nursing care Textbooks in pediatric anesthesia care Handouts, booklets, manuals in pediatric anesthesia care Colleagues at nearest Children s Hospital and of course Conferences!!
19 N is for NEUROLOGICAL STATUS Neurological status normal versus abnormal Pediatric vital signs Pain assessment versus irritability Aldrete (PARS & PARSAP) Score ASA Classification
20 Neurological Status What is normal versus abnormal? Was midazolam involved pre-op? Is this the normal behavior? Could it be the side effect of? Is that the baseline?
21 Temperature Pulse Respirations Blood Pressure Pulse Oximetry Pain Assessment FLACC FACES NCCPC-PV Pediatric Vital Signs
22 Pain Assessment vs Irritability Is it real surgical pain? Could it be a side effect of anesthesia gasses? Is this just plain irritability? Could it be emergence delirium? Patient went to sleep like that!!!
23 Aldrete (PARS & PARSAP) Score PARS Post Anesthetic Recovery Score: Aldrete scoring system PARSAP Post Anesthetic Recovery Score for Ambulatory Patients: Modified Aldrete scoring system In PEDS, modified even more!!!
24 ASA Classification ASA 1 a normal healthy patient ASA 2 a pt with mild systemic disease ASA 3 a pt with severe systemic disease ASA 4 a pt with severe systemic disease that is a constant threat to life ASA 5 a pt who is not expected to survive without the operation ASA 6 a brain dead pt whose organs are being removed for donor purposes
25 N is for NEUROLOGICAL STATUS Ready for discharge? Where to? Home Floor Protocols versus Policies & Procedures Practice versus safety Anesthesiologist versus Surgeon Who s signing out of PACU? Who s going to write admission orders?
26 T is for Types of Surgery General Surgery Appendectomy Cholecystectomy Orthopedic Surgery Fractures & Casts (CRPPelbow, hips); SCFE Scopes ENT T & A PET
27 T is for Types of Surgery Respiratory L & B Biopsy Cardiac PDA Cardiac cath. & biopsy GI Pyloromyotomy Ph probe
28 T is for Types of Surgery GU Orchiopexy Hydrocelectomy Integumentary Nevus Tissue expanders Reconstructive Rhinoplasty
29 T is for Types of Surgery Reconstructive (continuation) Cleft lip Scar revision Burn revision Skin tag and/or cyst In-grown toe-nail Special Cases Autism Spectrum Disorder Syndromes Dental patients
30 T is also for Temperament & Timing The easy child The difficult child The slow-to-warm-up child The degree of fit concept
31 S is for Skills in Nursing Assessment Skills Adult versus pediatric anatomy (airway!!) Significant straw shape versus inverted cone shape Equipment Do you have PEDS specific sizes? Family centered care How do you view family? Separation & Separation anxiety Some are delayed and some are prolonged Education & Discharge Instructions Who s really listening to you?
32 S is for Skills in Nursing Commonly used meds in PEDS PACU Acetaminophen (10-15 mg/kg) versus Ibuprofen Morphine ( mg/kg) versus Meperidine (versus Fentanyl) & Dilaudid (0.015 mg/kg) Ondansetron (1-4 mg) versus Metoclopramide Atropine versus Lidocaine (anesthesia induction) Decadron versus Solu-medrol (anti-inflammatory)
33 S is for Socialization Key points & Care management HHH & D (Hugs, hugs, hugs & DRUGS!!) 3-M s (Mommy, milk and MORPHINE) Pain control versus Parental control Is pain being caused by the parents? Trust from patient versus parent Establish this!! Can I really take care of pediatric patients? Should I start taking care of pediatric patients?
34 References Browne, N. T., Flanigan, L. M., McComiskey, C. A. & Pieper, P. (2007). Nursing care of the pediatric surgical patient. (2 nd ed.). Massachusetts: Jones and Bartlett. Cote, C. J., Lerman, J., Anderson, B. J. (2013). Cote and lerman s a practice of anesthesia for infants and children. (5 th ed.). Pennsylvania: Elsevier Saunders. Hockenberry, M. J. & Wilson, D. (2009). Wong s essentials of pediatric nursing. (8 th ed.). Missouri: Mosby Elsevier. Odom-Forren, J. (2013). Drain s perianesthesia nursing a critical care approach. (6 th ed.). Missouri: Elsevier. Schick, L. & Windle, P. E. (Eds.) (2010). Perianesthesia nursing core curriculum: preprocedure, phase I and phase II pacu nursing. (2 nd ed.). Missouri: Saunders Elsevier. Stannard, D. & Krenzischek, D. A. (2012). Perianesthesia nursing care: a bedside guide to safe recovery. Massachusetts: Jones and Bartlett. Steward, D.J. & Lerman, J. (2001). Manual of pediatric anesthesia. (5 th ed.). New York: Churchill Livingstone.
35 Any QUESTIONS??
Pediatric PACU Nursing: Are you competent? By Allan J. Cresencia, MSN, RN, CPN Clinical Research Nurse I Anesthesiology Critical Care Medicine
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