2009 Pediatric Trends Conference

Children’s National Medical Center Cindy Thrasher, RN, CPN RN III Division of Diagnostic Imaging & Radiology

Objectives 1. 2.

3. 4.

Evaluate current and emerging trends in three different pediatric care delivery settings. Analyze clinical practice through use of evidence based concepts into the assessment, management, and communication of nursing care provided to medically complex pediatric patients. Relate early signs of clinical deterioration and intervene with clinical expertise to prevent or reduce the risk of complications. Examine health systems and care processes to accelerate treatment time to prepare, communicate and rescue complex pediatric patients.

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Practice in motion

I’m going to see the Boss this weekend for the 300th time!!!!!!!

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Case # 1 ƒ Request for PICC line placement ƒ 2 week old full term infant with h/o hydrocephalus and s/p VP shunt placement ƒ Infant now presents with 5 day h/o wound breakdown and leaking clear fluid ƒ As per PMD, parent to apply hydrocortisone ointment and antibiotic cream to incision line

SBAR Report Rec’d S: 2 week old infant VP shunt infection, NPO for sedation. B: Admitted for long term ABX treatment an externalization of VP shunt A: No acute distress, VS WNL R: Order to sedate with chloral hydrate 50mg/kg by mouth for PICC line placement

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Nursing Assessment Patient On Arrival to Interventional Radiology • Infant on CR monitor • AF depressed • Somnolent, & Non interactive

Physician Order’s Less than 6 months: Chloral Hydrate ____mg ( Maxdose: 50 mg/kg/dose) Greater than 6 months: Chloral Hydrate ____mg (Max dose: 75 mg/kg/dose) (Max adult dose 1 gram/dose or 2gram/24 hours) P. Chloral hydrate _____mg (25 mg/kg/dose) PO PRN 20 minutes after dose if sedation not achieved.

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Nursing Care Provided

Evidence Based Practice Withheld Sedative- Hypnotic Drug Used Instead: Sweeties – Sucrose Water packaged ELMAX – topical application of anesthetic Music Mobile – Attached to Crib from Home

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Case # 2 Request for MRI 18 year Obese female with Downs syndrome, developmentally delayed, H/O pneumonia, FUO, abdominal pain, NPO for several hours, ASA airway classification III, non cooperative patient and very upset parent due to late afternoon appointment and repeated procedure delays

SBAR S: request for abdominal MRI to determine etiology of abdominal pain B: Downs syndrome congenital cardiac defect, enlarged tonsils, fearful of environment and mask induction sedation A: Arrived to MRI anxious, somewhat combative, developing respiratory distress as agitation increased, and based on appearance looked likely to have risks for airway compromise (short neck in flexed position) R: Sedate patient, plan to reduce stimulation, create non threatening environment in partnership the mother. Implement alternative approach to basic mask induction.

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Anesthesia Bay

Music: Is the Universal Language

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Evidence Based Practice • Implemented Distraction Techniques Adjunctive Procedural Support Music Therapy in the Healthcare setting • Used family presence and participation in child’s care to reduce anxiety and provide developmentally delayed child with coping strategy • Use of SEVO GAS in the induction phase of sedation administered by the Anesthesiologist -

Dr. Becker

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NIKKI & LANCE

Solar Sedation

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References Chloral Hydrate- General Monograph Sedative-Hypnotic., Rx Med: Pharmaceutical Information 2009 Cortellazzi P., Lamperti M., Minati L., Falcone C., Pantaleoni C., Caldiroli D., Sedation of Neurologically Impaired Children Undergoing MRI : a Sequential Approach. Paediatric Anesthesia. 2007 Jul; 17(7) :630-6 Kain ZN., Caldwell-Andrews AA., Krivutza D.M., Interactive Music Therapy as a Treatment for Pre-Operative Anxiety in Children: A Randomized Controlled Trial. Anesthesia Analogs 2004, 98:1260-1266 Lefrak, L. Burch K. Caravantes R. et al Sucrose Analgesia: Identifying Potentially Better Practices. Pediatrics 2006;118;S197-S202 Walworth D.D., Procedural Support Music Therapy in the Health Care Setting: A Cost Effective Analysis. Journal of Pediatric Nursing. Vol. No. 4 (Aug. 2005)

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