THE SPECIAL HEALTHCARE NEEDS CHILD

After this lecture the attendee will be able to:

–Describe an overall approach to evaluating children with special healthcare needs (SHCN)

–Discuss field and nursing interventions for children with technology assisted care

–Verbalize assessment strategies when caring for the special healthcare needs child

–Identify care considerations of the child with special needs

Objectives

The ‘Special Needs’ Umbrella is Ginormous!

• Learning disabilities

• Physical disabilities

• Cognitive impairment

• Food allergies

• Terminal illness

• Chronic illness

• Developmental delay

• Psycho/social issues

• Behavioral issues

•Cancer is the #1 cause of pediatric mortality

•Heart disease 5th leading cause death age 1-5 years

•1 in 10 has asthma

•1 in 13 has food allergies

•1 in 10 has ADHD

•1 in 6 has developmental disability

•1 in 20 has seizure disorder

•23% increase in juvenile diabetes!!!

http://www.focusforhealth.org/wp-content/uploads/2016/06/Chronic_Illness_in_US_Children_FINAL_3-3-2016.pdf?gclid=CjwKEAjwub7NBRDJ64nX0LTbhV4SJAD-8JU_Jg24ZLWF7AuTEnCPhP6fUNBzzWSfMbg2Cy1_VdvW1hoC8MLw_wcB

Pediatric Morbidity (from 2016 report)

Seeing More Special Needs?

•Advances in overall healthcare technology

•Increased survival rates

•Children thrive in home

•Enhanced community support programs

National Survey by Health and Human ServicesChildren with Special Health Care Needs

(2011-2012)

• National

–20% < 18 years

–14.6 million

–23% households have at least one child with a SHCN

•California

–1.4 million

–15% of children in California

•Many children have more than one special healthcare need.

•Children with special healthcare needs are over three times as likely as other children to require emergent ICU admission.

•Technology-dependent children are over 300 times more likely to require emergent ICU admission than other children with special health needs.

Schif, Jeff. Children with Special Health Needs in the EMS System.Minnesota Department of Health. Spring 2002

Statistical Relevance

Assessment should be based on the child’s own baseline vital

signs, anatomy, physiology & cognitive development

General Assessment

Pediatric Assessment Triangle

General Assessment• Require the same priorities as

other children

– Clear and patent airway

– Adequate ventilation

– Adequate oxygenation

• Ask what ‘normal’ saturations are for child

– Adequate cardiac output

• Perfusion indicators

• Understanding of Special Needs/Equipment

General Assessment• Ask parents/ caregivers about patient ‘norms’

• How does this child communicate?

• Cognitive level of development?

• How do we know patient is scared?

• Can child see/ hear?

• In pain? What comforts patient?

• Behavioral issues?

• Any other pertinent medical information?

• Medications? Up to date? Next due? Allergies?

• Recent growth spurt? (meds adjusted?)

• Recent exposures/ travel/ admissions?

Liveswith?

General AssessmentParents or caregivers are the best resources for helping you communicate with and ascertain information about the child.

Additional resources:

- Well known to receiving hospital?

- Emergency Information Form

- Reference material

• Remember- airway grows according

to AGE, NOT SIZE!Norms for a chronically ill child likely not found in a text book,

remember….they are SPECIAL and like to write their own

Technology – Assisted Childrengrowing population of children cared for at HOME

Secondary to:

• increased survival rates from critical injuries or disease

• advances in medical technology

• support services for homecare

• decreasing length of hospital stay

Technology-Assisted Children

• CSF Shunts/ ‘VP shunts’

• Tracheostomy

• Central Venous Catheters/PICC lines

• Feeding Tubes

• Home Ventilators

• BiPAP / CPAP devices

• Pacemakers/ AICD’s

• Vagus Nerve Stimulator

Hydrocephalus is an excessive

accumulation of CSF within

the ventricles of the brain,

resulting from CSF over-

production, malabsorption or

obstruction

Hydrocephalus

Most likely OBSTRUCTIVE in

children

• A flexible tube that drains CSF from the brain’s ventricular system into some other part of the body (peritoneum, right atrium, pleural space) where it can be absorbed

• A shunt usually remains in place for life

• Children are at life-long risk for developing shunt failure and revision surgeries

• Increased risk of infection

CSF Shunts

CSF Shunt Malfunction is an EMERGENCY

• Early Signs

– Altered level of consciousness

– Headache

– Nausea and vomiting

– Amnesia

– Changes in speech, drowsiness, agitation, restlessness, and judgment

• Late Signs

– Dilated, non-reactive, or unequal pupils

– Cushing’s reflex

• ↑BP, ↓HR, irreg resp

– Unresponsiveness

– Abnormal posturing patterns

***Watch for signs of increasing intracranial pressure***

Ask Caregivers

•Recent shunt revision?

•Where distal end of shunt terminates

•Where patient had surgery

•On medications? On schedule?

•Recent growth/ weight change?

•Seizures? Manifestations? How many per day? How/ when treated?

•Fever?

•Raise the head of the bed 30 degrees/ midline head position

•Assess and support the ABCs– Support a patent airway

– Provide oxygen as needed

– Provide assisted ventilation as needed

•Establish vascular access

•Anticonvulsants (if needed)

•ICP management

•Assess for shunt malfunction

•Avoid hypo/ hyperthermia

•Promote normal: temperature, Spo2, blood

pressure, glucose levels, sodium levels

Treatment

“Normal everything!”

• Fever- hypothermia may be more ominous

• May be life-threatening for the immuno-suppressed child– Cancer, Chemotherapy, Organ Transplant, Malnutrition,

HIV infection, Gut etiology

• Bacterial Sepsis common: Sepsis-3 guidelines apply (SIRS criteria for Pediatric though adults have moved to qSOFA)

Infections: Technology Assistance Increases Risk

Tracheostomies

• Placed due to upper airway obstructions, lower airway obstructions, lung disease or neurologic conditions

• May be used in conjunction with supplemental O2, positive pressure ventilation and suctioning

• Cuffed/ no cuff, fenestrated/ no fenestration, single/double cannula. Some require inner cannula changes daily.

• Most trach sizes are visibly printed on wings of tracheostomy.

• Secured around the child’s neck with ties or commercial Velcro collar.

Types of Tracheostomies

•Suction catheter size is chosen by multiplying size of trach (I.D.) x 2

Ex: A 4.0 Shiley- use an 8 French suction catheter

•Depth average is 5-6cm for children

•Avoid suctioning beyond the end of the trach cannula as this can cause airway trauma

•Suctioning in the healthcare setting

should be sterile to avoid acquired

bacteria and infections

•Only suction when necessary

Suctioning

•Use ‘A-DOPE’

A – Airleak (cuffed or uncuffed)

D - Displacement

O - Obstruction

P - Pneumothorax

E - Equipment

•Unscheduled, emergency trach changes are recommended for respiratory distress that does not respond promptly to suction, oxygen, and/or PPV

Troubleshooting

• There may be a stylette in the cannula that needs to be removed after insertion

• If you cannot put the same size back in, try the next smaller size

• ALWAYS ask parents for spare trach!

• If customized- ask why

• O2, Sx, BVM at ready

• Ask caregivers for intel so

you are not surprised

Changing a Tracheostomy

• If spare trach not available- may use an ETT

• If unable to cannulate the tracheostomy site, BVM while ensuring occlusive seal over stoma

Changing a Tracheostomy

Central Venous Catheters• An IV catheter surgically

inserted and tunneled under the skin into a large central vein

• Common insertion sites include the chest and arm. Also possible, but not as common are insertion sites in the scalp, leg, neck and groin

• Children may have a permanent central line in place for:

- At-home intravenous medications or nutrition

- Frequent blood draws

- Administration of chemotherapy

- Chronic condition and history of poor IV

access

Central Venous Catheters

Types of Central Lines

• Non-tunneled (short term CVL)

• Tunneled (Broviac)

• Peripherally Inserted Central Catheter (PICC)

• Implanted (Porta-cath)

• Port-a-caths require insertion of a special needle to access and use

• Other catheters may be accessed by a capped or leuer-lock mechanism

• Be aware of potential heparinized lines

• When drawing labs, first draw should be

used for blood culture or waste and then

use another syringe to draw remaining labs

Accessing the Catheter

• Always let the child know what you are going to do with the line

eg. draw blood or infuse medication/ fluids

• Some children are sensitive to the sensation when lines are flushed quickly

• Some kids require pre-medication with lidocaine cream to site before accessing implanted devices

Kids and Their Lines

•Line dislodgement – apply pressure to site and above insertion point

•Save dislodged line to verify length and rule out thrombi of line tip

•Always ensure caps are snug as hemorrhage or air emboli can occur in a short period of time from disconnected catheters

•If you are not sure about using the line you can always place a PIV/ IO until the line has been verified

Line Emergencies

• A gastrostomy is a surgically created opening of the stomach that enables us to feed a child or easily remove air and fluids from the stomach

• Common names:

– g-tubes

– PEG

– Mickey button

Enteral Feeding Tubes

Nissen Fundoplication

• Ask parents if patient also has a fundoplication

• Surgery to treat persistent reflux

• Upper part of stomach is wrapped around lower part of esophagus

• Nissen failure may result in micro-aspirations

G-tubes are inserted and terminate in the stomach. They can be used for any oral medication, bolus or continuous feedings

G-tube vs. J-tube?

G-tube vs. J-tube?

J-tubes are inserted in the stomach wall and then have a tube that is directed into the jejunum. These tubes should only be used for continuous feedings (not bolus) and there may be restrictions on the types of medications that can be administered into them

• Babies with birth defects of the mouth, esophagus, or stomach (for example, esophageal atresia or tracheal esophageal fistula)

• Kids who cannot swallow correctly

• Kids who cannot take enough food by mouth to stay healthy

• Children who are at risk for aspiration

Reasons for Placement

• Some tubes have a lumen with a plug that can be accessed by a leuer tip syringe

• Some button types may require an additional attachment that clips on, parents should have this with them at all times

• After accessing a tube, placement can usually be verified by aspiration

Accessing a G/J-tube

• Some tubes are prone to occlusion due to small lumen size. This can also occur when certain medications mix together in the tubing and “cement” together

• Occlusions can often be relieved

by aspiration, warm water….or soda?

(soda is controversial in literature)

Occlusions and Air

• G-tubes can also be vented to remove air and contents from the stomach. This may be especially important in cases of:

- respiratory distress

- procedures requiring anesthesia

- intubation

- after PPV with a BVM

Occlusions and Air

• When faced with a dislodged g-tube, cover the site with 4x4’s. Watch for skin breakdown from gastric output

• J-tubes that have migrated into the stomach may not be tolerated for feedings and usually require interventional radiology to confirm placement or for replacement

– Check for ‘negative pop-off’ by aspirating tube, if able to aspirate air, probably no longer in jejunum

Displaced and Dislodged Tubes

Home Ventilators• Can obtain orders to

use their vent

• Some children are very sensitive to ventilator changes

• Bag-valve respirations may not be well tolerated

• Settings on home vent may not correlate with different ventilator

CPAP, BiLevel, NIV?

Pacemaker/ AICD

• Pacer alone- treats bradycardia

• AICD- automatic implantable cardioverter-debrillator

– Treats tachy and bradydysrhythmias

• Ask which one patient has indwelling

AICD

• Battery life 5- 10 years

• May be remotely interrogated- ask parents for ‘card’

• Lead fracture #1 cause of malfunction in kids

• Magnet will disengage cardioversion/ defib capabilities but pacing still enabled

Vagal Nerve Stimulator

Vagal Nerve Simulators• In Pediatrics, mostly used

as ADJUNCT therapy to treat seizures

– May help decrease incidence of seizures

– May help decrease duration of seizures

• In adults, may be used to treat depression

• Studies ongoing for its use in patients s/p MI

Summary

• Parents and caregivers are important sources of information

• Find out normal values/baseline for the child you are treating

• Organized approach

• Ascertain specifics of SHCN that may impact treatment choices

Questions