Miranda is the mother, 35 years of age, of European ethnicity and a school teacher presently on maternity leave at 34 weeks gestation with her sixth healthy child. Her husband John, is 40 years of age, of Dutch ethnicity and has a high profile CEO position which means he is away from home a lot. Both Miranda and John have only been in Australia for three years and are slowly building a supportive network of friends through the church, community services, kindergarten, mother groups and the school their children attend yet neither Miranda or John have family living in Australia.
Ollie is a 9 year-old boy whom was born with mild Cerebral Palsy (normal cognition) and has a specialized teaching and learning program for special needs children at Chloe’s school. He has an intensive schedule of physio, language, speech, occupational and dietary therapy and is making remarkable progress. The whole family are extremely supportive and proud of Ollie yet he just wants to be one of the gang. Every night before he goes to sleep he wishes that when he wakes up he could just be ‘normal’ like the others.
This 2500 word assessment requires you to critically analyse the best evidence based appropriate paediatric care plan for a child (OLLIE). The care plan will be informed by a thorough systematic thorough top to toe holistic age appropriate nursing assessment, where planning, implementation and evaluation of care (APIE) is informed by guidelines, philosophy of care, diagnostics and the Nursing and Midwifery Board of Australia, Registered Nurse and Australian College of Children and Young People’s Nurses standards and scope of practice.
The assessment requires consideration on the implications of health and ill-health on the child, parent and family and how positive healthcare outcomes are promoted through contextually appropriate therapeutic conversations/relationships with the child, parent, family and multi-disciplinary healthcare team within community and hospital settings honoring a child and family focused approach.
2500 word assessment
Intorduction
Individualized focused care plan for OLLIE
Systematic top to toe assessment (AVPU and GCS, Hearing, Vision) (Appendix)
Critically analyse
Best evidence based care
Assessment, Plan, Intervention, Evaluation, Guidelines, diagnostics, pathways, NMBA, APHRA, ACCYPN
Age appropriate care
Child and Family Centered Care
Academic writing
Conclusion
- Critically analyse the best evidence based appropriate paediatric care plan for Ollie within the Haagan Daas Family.
- The care plan will be informed by a thorough systematic thorough top to toe holistic age appropriate nursing assessment attached as an Appendix.
- Planning, implementation and evaluation of care (APIE) must be informed by guidelines, philosophy of care, diagnostics and the Nursing and Midwifery Board of Australia, Registered Nurse and Australian College of Children and Young People’s Nurses standards and scope of practice.
- The assessment requires consideration on: the implications of health and ill-health on the child, parent and family and how positive healthcare outcomes are promoted through contextually appropriate therapeutic conversations/relationships with the child, parent, family and multi-disciplinary healthcare team within community and hospital settings honoring a child and family focused approach.
Introduction
Caring for a child with burns injury can be very challenging for nurses. This involves helping the child to navigate through the period of hospitalization, pain, anxiety and the distress that may be associated with the treatment procedures such wound dressing and debridement of the wound surface (Rode, Brink, Bester, Coleman, Baisey, & Martinez, 2016). In addition, nurses have got to deal with the family members of the affected child by way of explaining the treatment option, being empathetic, reassuring, providing education, including the family in decision making and providing support through involving of other members of the multidisciplinary team (Mortensen, Simonsen, Eriksen, Skovby, Dall, & Elklit, 2015). This is because having a child that is very ill in a hospital can present very stressful and challenging moments for parents especially with the concern of recovery and the long-term effects of the illness and hospital experience on the health and development of the child (Tallon, Kendall, & Snider, 2015).
The approach of care is aimed to focus on the child and family as the effects of hospitalization may vary across different family groups because of differences in the degree of support and resources to facilitate their emotional and psychological wellbeing. The interventions needed for the treatment of paediatric burns, and the recovery pathway take into account the child’s growth and developmental stage; these consider the extent of the child’s physical ability and the level of emotional and cognitive development at that stage, thus helping the medical team to develop a treatment plan which supports the developmental stage (Glasper, Coad, & Richardson, 2015). This essay will focus on the individualised care plan and the nursing assessment, planning, intervention and evaluation of a 5-year-old child who had 5% bilateral burns injury on the upper limbs from a hot cup of coffee. It also includes a top-to-toe assessment of the child and a child and family centred care designed to support the family during the child’s hospital experience.
Top-to-toe Assessment
The initial assessment of a child on admission is designed to obtain all relevant information about the child in order to form a baseline that will guide the planning of care and to prioritise intervention (Glasper et al., 2015). This involves a head-to-toe assessment of the child by the nurse following a systematic pattern in which information is obtained through the examination and reviewing of the body systems (Glasper et al., 2015). In relation to the child with the burns injury, it is important that the nurse conducts a rapid visual assessment of the child relative to the airway patency; effort, efficiency, and effect of breathing; circulation; any disability caused by illness or trauma; and any exposure to the source of injury (Ogden, 2016). This initial assessment involves the application of the paediatric assessment triangle (PAT) tool to assist the nurse to evaluate the child’s health status and prioritize the intervention (Ogden, 2016). It comprises of three physiological assessment of appearance, work of breathing, and circulation to the skin (Ogden, 2016).
This assessment tool has been shown to be reliable as it factors in consideration various components of the physiological states of appearance which include abnormal tone, interaction, abnormal look, consolation, and abnormal speech or cry; work of breathing to include abnormal sounds, abnormal position, retraction, nasal flaring and apnoea or gasping; and the circulation to skin to include pallor, cyanosis, and mottling (Ogden, 2016). Furthermore, the information obtained by the nurse following the assessment are complemented by objective assessments using the child early warning tool (CEWT); neurological assessment to ascertain the child’s level of responsiveness; and a skin assessment for the development of a wound care plan for the burns injury (Glasper et al., 2015).
Other initial assessments for the child would include a pain assessment using an age appropriate pain assessment tool, which for the 5-year-old child, using the Faces pain assessment tool will be appropriate. Whereby the child is distressed as a result of the trauma, and unable to self-report using the Faces pain assessment tool, the nurse can utilize the FLACC (Faces, leg movement, activity level, crying, and consolable) pain assessment tool to make a subjective deduction of the child’s level of pain (Forster & Fraser, 2018). In addition to this, it is necessary to complete a nutritional assessment for the child by taking the measurements of weight, height, and head circumference, to note the nutritional status of the child with respect to the expected developmental milestone (Glasper et al., 2015).
These information as obtained provide a guide to the overall health status of the child and it is made comprehensive by combining the interpretation of the data with the information obtained from the child’s family in history taking and from listening to and observing their interactions (Glasper et al., 2015). For a systematic top-to-toe assessment of the child with burns injuries, see appendix 1.
Evidenced-based Care – Assessment, Planning, Intervention, Evaluation, and Diagnostics
Developing a person-centred care plan forms one of the primary goals of nursing as they influence and guide the process in which a patient is cared for (Glasper et al., 2015). For a child with burns injuries, it is important that a care plan that is age-appropriate which is consistent and focuses on the needs of the child and family be developed to minimize the effect of hospitalisation and to improve clinical outcome (Rode et al., 2016). This process will involve a careful identification of the child’s needs while highlighting on the professional responsibilities and structured intervention, and a process of evaluating the outcomes of care delivered. Moreover, the care plan developed for the child, as with other care plans, will require reviews and updates in order to address any evolving needs of the child and the family, and to incorporate any significant change in the child’s condition (Glasper et al., 2015). It is important for nurses to facilitate the development of a mutually agreed care plan that takes into consideration the needs of the child and that of the carer or family (Mortensen et al., 2015). An evidenced-based care plan for the child with burns injuries will be developed using the nursing process as a guide.
Assessment
Assessing the child with burns is the first step in the nursing process and this involves collecting and documenting the information regarding the incident of the burns, medical history of the child, family and social history, immunization records, nutritional status, and noting the effects of the burns incident on the family (Rode et al., 2016). The child presented with blisters to the right and left arms from a hot cup of coffee spill resulting to a 5% bilateral burn injury. Following the history taking, a comprehensive objective assessment was conducted. On neurological assessment, the child was spontaneously responsive but guarded both arms that were affected with burns and would not let anyone touch them. This indicated that the child was in pain as evidenced by his guarding of the affected hands. Baseline CEWT score was 2 as a result of the pain. He had a Glasgow coma scale of 14/15 with a reduced motor response to the upper limbs however, the strength to the upper limbs could not be assessed as the child felt distraught when attempts were made to assess the arms.
Neurovascular assessment indicated a peripheral oxygen concentration of above 98% on the pulse oximeter and a heart rate within the range of 100 to 130 beats per minute depending on the child’s activity level and a capillary refill of less than 2 seconds. The objective nutritional assessment indicated a head circumference within the 50th percentile, a height of 107 cm and weight of 17.2 kg. A pain assessment using the Faces pain assessment tool could not be completed as he was withdrawn but felt consoled by the mother however the FLACC indicated the child had an unhappy face with increased leg movement as attempt was made to reach for his hand, a reduced activity level, and cries occasionally but consolable by the mother. There were no signs of respiratory distress or poor circulation. During this process, the mother was well incorporated as consent was obtained from both the child and the mother prior to each assessment and explanations were given on the needs and outcomes in a manner that reflected the four principles of Child and Family Centred Care (CFCC) of communication, respect, consent, and participation.
Planning
The planning of care was dependent on the interpretation of the evidence obtained in the assessment and developed to meet the specific needs of the patient together with the concerns of the family as supported by (Mortensen et al., 2015). The goals set to be achieved with the plan was designed to reflect a comprehensive need between the child and the mother and incorporated other members of the multidisciplinary team as their inputs were needed to improve the overall health outcome for the patient in line with the Nursing and midwifery Board of Australia [NMBA] Standards 2.2, 2.4, and 5.2. Following the assessment outcome for the child, the planning of care included a pain management plan, wound management plan for the blisters, increased monitoring for effects of dehydration and the calculation of amount of rehydration fluid from the percentage burn to encouraging oral hydration. Where oral hydration is not effective in rehydration and to maintain the required fluid intake, an intravenous fluid therapy will be included in the plan. A food chart was also put in place to monitor the food intake of the child for effective nutrition. As a result of the burns injury, the inclusion of an antibiotic therapy was necessary to minimise the chances of infection thus a plan for oral care in the patient hygiene plan was included. Other plan necessary to improve the health outcome for the child were pressure area care and falls education.
As prolonged hospital stay often may cause a regression or delay in the developmental milestone of children, it is important to communicate effectively with the family and to include the services of the play therapist, social worker, physiotherapist and occupational therapist in the plan of care to provide the necessary psychological, social, and emotional support for the child and the primary carer or family (Glasper et al., 2015). Diagnostic plan for the child included laboratory tests for full blood count to ascertain possible deficiency of any blood component; urea and electrolyte test to check for a possible shift in electrolyte balance of deficiency; and a micro-culture swab test for the presence of any methicillin resistant staphylococcus infection.
Intervention
In this phase of the nursing process, measures are taken to implement the plans set out in the planning phase of the process. This is the stage in which decisions are made by the healthcare team on how best the plans are to be implemented and monitored to achieve the goals set to improve the outcome for the patient (Forsey, Salmon, Eden, & Young, 2013), as is consistent with the guiding principles of the Australian Health Practitioners Regulatory Agency [AHPRA].
The interventions required to implement the plan of care for the child will include administering the prescribed analgesia to abate the severity pain and improve comfort and rehydrating the child to compensate for the fluid deficit volume. Furthermore, in consultation with the wound care specialist, dressing the burns wounds with the recommended wound dressings was completed and documented. This necessitates the administering of prescribed antibiotics and the continued scheduled monitoring of the CEWT signs to ensure the prompt intervention in the event of any deviation in the expected normal parameters for the child (Glasper et al., 2015). The neurovascular assessment was continued to monitor the child’s level of responsiveness, peripheral circulation and the level of comfort following the interventions. These processes were communicated to the child’s mother and where possible, choices were provided and incorporated during the intervention.
Evaluation
The evaluation stage is a continuous and ongoing process of analysing the outcome of the implemented plan of care at the intervention stage (Glasper et al., 2015). It takes into account the needs of the child and subsequent response to the interventions implemented to ascertain the effectiveness or need to adjust such plan (Glasper et al., 2015). Evaluating the implemented intervention involved the appraising of the effectiveness of the pain management, the relative stability of the child’s homeostasis as indicated by the consistency of the CEWT scores, evaluating the nutritional and fluid intake and monitoring the child’s weight during the hospital stay. In addition, evaluating the progress of the wounds and checking for the signs of infection, nature and colour of the wound bed, provided indicators to assess the healing progress of the wounds. At this stage, it is also important to appraise the level of confidence and trust that the child’s mother has in the entire process and to observe her level of engagement with the care of the child.
Age appropriate care
The care delivery intended for a child is one that takes into consideration the immediate needs of the child as they relate to the emotional, psychological, and social well-being. It is designed to meet with the age and associated with stage and developmental milestone of the child. These include age appropriate pattern of communication and relating with the child; respecting the child’s preference to the mode of care, for instance allowing the mother to administer certain oral medications, and where the child is able to do so if it is safe. It also involves creating a child-friendly environment and activities that will distract the child from the psychological impact of hospitalisation. These may include setting up of play toys and simulating any invasive procedure on toys to demonstrate to the child the action to be taken. These according to Erickson’s psychoanalytical theory will enhance his initiative to try out new things and explore his environment thus enhancing his psychosocial needs (Austrian, 2013). It is important that the nurse aims to understand the child’s needs and to appropriately respond to them and those of the family (Tallon et al., 2015). while attending to the child’s wound dressing, it is necessary that the nurse manages the pain prior to the time and to distract the child with play toys where possible. An age appropriate care will also require the inclusion of the child’s mother in any care process as this the most comforting means to keep the child reassured and to reduce agitation due to anxiety (Glasper et al., 2015).
Child and Family Centred Care
Understanding that the child’s family is the primary source of comfort and support while upholding the child’s needs and interests are necessary to the delivery of an effective CFCC (Glasper et al., 2015). Child and family centred care is designed to focus the nurses’ attention on both the child and the family needs relative to the child’s hospital experience (Tallon et al., 2015). It involves working with the families to plan, implement and evaluate interventions aimed to optimise the child’s hospital experience and to provide support to the family (McDougall, 2013). In addition, providing support and education for the family during the child’s hospital experience forms a part of this care. This form of support may include completing a psychological evaluation of the child’s mother to assess the impact of the child’s condition on her well-being; a referral to the allied health professionals such as the social worker of counsellor; and communicating with the mother and involving her in decision making.
Upon discharge, it is important to educate the mother of the need to keep the home environment free from hazards and to ensure that the child’s safety is given a high priority. Making a follow-up appointment with the out-patient clinic for the wound dressing should be completed and the schedule should be communicated to the mother. Other information relating to the medications and signs of infections such as fever, rashes, or exudates should be given to the mother. This should also give room for the mother to ask questions and be clarified so the nurse can be assured that the information delivered are well understood. According to Tallon et al. (2015), caring for a child in the context of the family results in improved outcome for both the child and family. This model of care has at its core the principles of respect for the child and family, communicating and educating the family, encouraging the participation of the family in the care of the child, and obtaining consent from the child and parent (Glasper et al., 2015).
Conclusion
Caring for a child with burns comprises a wide range of nursing skills that are employed not just to focus on the recovery of the child, but on the overall well-being of the child and the family. It involves the nurses’ ability to assess and identify the actual and potential needs of the child in order to set and prioritise a plan of care to meet these goals and support the child in achieving the expected developmental milestones. Furthermore, it takes into account the importance of Child and family centred care and to understand that the child’s family forms a core source of support. It is also pertinent to note that prolonged hospitalisation can have an adverse effect on a child’s developmental mile stones and as such, creating an environment to support the child’s daily function is necessary to achieving the desired positive health outcome.
Sample Solution