This ward and her father is loking after

This essay looks at the case study of
Emily. Emily is a four-year-old girl who has been admitted to hospital with
symptoms of gastroenteritis following decreased urine ouput and not being able
to tolerate oral fluids. The doctors have advised that Emily is dehydrated and
will need IV fluids.  Emily’s mother is
staying with Emily on the ward and her father is loking after her sibling at
the family home.

This essay will look at the definition
of Gastroenteritis and its causes and presentation. It will explore how it is
spread from person to person and what precautions can be undertaken in Emily’s situation.
The author will indentify the NICE guidelines in relation to looking after
children with gastroenteritis including the identification of red flags which
are indicators of further decline and illness. Secondly the author will discuss
the dangers of dehydration and shock in a child suffering from
gastroenteritis.  It will discuss the
areas of capacity to consent to treatment, pain management and will link to
Paigets developmental theory.  Finally
the author will explore the relevant theorical principles of caring for Emily
and her wider family whilst identifying the key professional NMC codes of
practice. The author will conclude this essay with a summary of the main
findings and any identification of areas for future learning.

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Gastroenteritis in children can be
described as an inflammation of the digestive tract including the stomach and
intestines, that results in vomiting and diarrhoea (REFERENCE). It is often
caused by a viral infection rather than a bacterial infection or because of
protozoal infections. The most common route of infection is via the facecal
oral route this means that the infection has been spread by eating or drinking
contaimintated food or fulids or insgesting food containing toxins cused by
bacteria..

It is likely that Emily is suffering
from rotavirus which is the most common cause of gastroenteritis in children. This
is a common illness among children, but if not treated effectively it can be
very dangerous and lead to dehydration and shock. Emily is presenting with symptoms
of diarrhoea and abdominal cramps, and is showing signs of being dehydrated.
Accordinly to     chiildren will
typically suffer from the following symptonms, fever, nausea, diarooea, stomach
pain

Gastroenteritis is easily spread by
person to person contact and contact with contaminated objects, therefore Emily
should be isolated  as she is an
infection risk. Limiting her contact with others will also reduce the risk of
infecting others. Anyone entering the room needs to wear protective equipment
such as gloves and aprons, making sure they wash their hands with soap before
and after entering the room. This is particularly important for Emily’s mother
who is staying with her on the ward in order for her not to be become ill herself.  .   Medical equipment will need to be deep cleaned
 and sufaces and objects cleaned with
disinfectant. All bedding and dirty clothing should be washied on a hot wash.
By taking these precautions it will mimise the pread of infection to others. Recently
a vaccine has been made available to infants aged two to three months to
protect them against rotavirus as it decreases the likelyhood of them
contracting the illness, however there is a lot of controversy around the
subject of vaccination in our modern society (reference).   Precautions still need to be taken even when
a child appears to be well following gastroenteritis and they should remain in
isolation for 48 hours  before socialise
with others.  Emily should not avoid
swimming for two weeks following her recovery as gstrotenertenis  can still be easily spread.Parental education is also important as this is a common
illness among children and may need to remind Emily of the importance of good
hygiene to prevent re infection.

As Emily is suffering from
gatroentertis  its is key that nursing
staff are aware of the sypmptons or signs that Emily is may be deteroritating.  The NICE  guidelines (2017) describe these indicators as
“Red flags”.  NICE (2017) further
described these reg flags as a child who “appears to be unwell or
deteoritating”, has “altered responsiveness’ (meaning they appear more irritable
or lethargic), have sunken eyes, tachycardia, tachynoea, and reduced skin
tugor.  The NICE
guidelines (2017) go on to state that “children
who have passed more than five diarrhoeal stools in 24 hours and children who
have vomited more than twice in 24 hours” are at high risk of being dehydrated”. Emily’s diarhea coupled with her inablity
to retain oral fluids means that she is clinically dehydrated. As a result it
is inportamt to accurately
measure urine output. The normal  urine
output for a child of emilys age should be 600-700mls per hour. Inflammation of
the colon and small intestines  would
mean they are unable to function normally as their ability to reabsorb water is
affected.. Due to the lack of water in the body the brain signals the kidneys
to retain water, meaning that urine will appear a darker yellow as it is more
concentrated. Passing
many loose stalls  can be dangerous as
the body is not absorbing any nutrients or fluids. The Bristol stool chart
shows that a normal stool would be type 2 and 3 (see appendix 1). Diarrhoeal stools
are classified as type five, six and seven.  This tool is a 
helpful tool in the monitoring emilys condtion in a standardised way.

 

As emilys is dehydrated  she is at risk of going into shock.

Dehydration
occurs when the body does not take in enough fluid or too much fluid is lost.
It can be a life-threatening illness and so needs to be treated effectively.
Due to children having less developed temperature control systems and fluid
regulating systems they are at higher risk of dehydration than adults.
Additionally, children have a higher metabolic rate meaning that they have a
greater baseline fluid requirement. Emily shows signs of being dehydrated as
she has decreased urine output meaning that her body is trying to retain water.
Also, she is not able to retain fluids orally meaning that she has no fluid
entering her body to replace the fluid that leaves. Dehydration can be treated
using ORS (oral rehydration solution) but because Emily is not able tolerate
fluids this treatment is not suitable for her and so instead she needs to receive
fluids via an intervenous drip. Dehydration can result in hypovolemic shock
which can be deadly as it can cause organ failure. A child is considered to
have shock when it is clinically recognised that the cells in their body are
not receiving enough oxygen and other metabolic substances to function
adequately. A child with shock may show signs of tachycardia, impaired organ
function (including decreased urine output), delayed peripheral perfusion,
temperature instability and tachynea. Emily needs to be monitored closely to
avoid her going into shock. Once she begins to receive fluids she should be
re-evaluated to see if her vital signs and urine output have improved and are
within the normal parameters.

The doctor has
recommended Iv fluids. The principle
we use to judge capacity in children to consent to medical treatment is known
as the Gillick Competence . Gillick
competency is defined by the National Health Service to be the belief that
children have enough ” intelligence, competence and understanding to fully appreciate
what’s involved in their treatment” ( reference).A person under the age of 16
is not Gillick competent and therefore is deemed to lack the capacity to
consent to treatment then this is given on their behalf by someone with
parental responsibility or by the court. However, there is still a duty to keep
the child’s best interests at the heart of any decision, and the child or young
person should be involved in the decision-making process as far as possible. As Emily is four year old she is unable
to consent to her treatment and therfor consent needs to be gained from her
parents  In order for Emily to be involved in her
treatment the Doctor should
explain to Emily what is going to happen and why. For her parents to fully
consent they must agree and understand the reasons why she needs cannulation
and may have to sign documentation in order to show this.

 

Cannulation
can cause pain so it is important that Emily is well prepared and so are her
parents as it may cause distress for both. Pain is
different to each individual person, it can be described as an unpleasant or an
uncomfortable feeling. As Emily is four year old it is helpful to consider Piaget
. Piaget (   )  developmental theory describes Emily as in the
 preoperational stage ( 4 – 7 year old)
who focus on pain as a physical sensation and are unable to understand the link
between cause and affect of their pain . Some children may see pain as
punishment for incorrect behaviour, so it is important that Emily is reassured
constantly to remind her that the pain she is experiencing is not a punishment
and that the people around her are trying to stop the pain and make her feel
well again. Twycross and Williams (2014) described pain as a bio-psycho-social
event that is divided into 3 factors, psychological, biologival and social
factors. The biological pain would be the abdominal pain Emily is feeling
as  a result of having diarrhra but alos
the impact od her age and congivitve ability .The way emily’s family respind to
her pain can influence her reaction for example if her parents are
overprotecting and ‘baby’ her she may say she is in a lot of pain when in reality
she is not. Also pain can influence her behaviour as she may feel grumpy and
upset and so she will act out or behave badly as a way to cope with her
feelings. The pain she experiences is individual to her, what might be
painful for Emily may not be painful for others. She may begin to associate the
pain she feels with being in hospital which could impact the way she behaves
around medical staff and result in her developing her schemas and relating
hospital and medical staff to the emotions of pain and fear.

 

For Emily’s pain to be managed
appropriately she will need to be regularly assessed using pain assessment
tools and also the nurse should use observation skills to fully gage Emily’s
pain. If Emily is in pain and in need of medication she will only be able to
have paracetamol via intravenous drip as she is unable to retain oral fluids
and so regular liquid paracetamol is not suitable. Using an IV reduces the
risks of Emily vomiting the medicine. Ibuprophen is a nsaid ( non sterile anti
inflammatory drug) and so in Emily’s case it is not suitable for her to have as
it can cause stomach irritation which would hinder her recovery and may make
her illness worse. Unlike adults it is not appropriate for children to have
codeine as it can cause server breathing problems. If Emily is in constant pain
she should be given the correct dosage of paracetamol via iv every couple of
hours rather than take a stronger/harsh painkiller.

Due to Emily being four it means that
her understanding and communication is limited and so to help with the pain
distraction therapy can be used in which trained play specialist spend time
getting to know Emily and are then able to explain to her what is going on
using tools such as dolls or video. They can find out what things she doesn’t
understand and what scares her about being hospitalised. The play specialist
can use tools such as iPads, games, books, dolls and toys to distract her
during cannulation or any other time she feels discomforted.

h

Faces
pain scale developed by Wong and Barker ( appendix 2) in is suitable for ages
three years plus, this means that Emily should able to use this pain assessment
tool and understand what each face means. However, as she is going through and
egocentric period of her development she may relate more to the oucher pain
scales developed by Beyer et al. 2009 ( appendix 3) may be more
suitable as
she will be able to recognise the feelings more. The oucher pain scale has been
developed to have different ethnicities so that the child using it can relate
more and be able to read and understand the scale better. Both the oucher and
faces pain assessment tool are a type of self-report as the child is telling
the nurse how they feel instead of their pain and emotions being assessment and
recorded by someone else. That type of assessment is known as a FLACC which is
a pain assessment tool that can be used to assess all ages. This type of assessment
would be carried out by the nurse caring of Emily and is familiar with her
normal behaviour. This tool looks at the way the child behaves and compared it
to a chart which then gives a score ( appendix ). In Emily’s case the most
appropriate pain tool would be the oucher pain assessment as due to Emily’s
egocentric view point it should be easy for her to associate her own emotion to
those in the picture on the scale. Compared to the faces pain tool the oucher
is better suited as she may not recognise the cartoon faces and could be misled
by them. A FLACC assessment is not suitable as Emily is perfectly capable of
communicating her pain.

 

Mum
can help care for Emily by helping give her medication when she begins to
accept oral fluids such as paracetamol because Emily would be used to her
mother doing it at home, also it would help her mum feel involved in her care.
For parents to aid care they need to have the correct information about their
child illness and be aware of the nurse’s care plan. It is important that her parents
are made to feel comfortable and included in Emily’s care, however a nurse
cannot expect all parents to want to be involved. There needs to be constant
communication about what they parent can and cannot do. Family centre care main
aim is to make the parents as involved as much as possible in the care of their
child. Depending in her family circumstances it may be difficult for her father
and sibling to visit due to work and childcare commitment.

 

The preferences of Emily and her family need to be taken into account.
It is important that her family are involved in her care and assisted by
healthcare professionals this idea of based on Casey’s model of nursing (  ). Emily’s normal
routine would be interrupted as she would have less contact with her father and
sibling and would also miss many days off school meaning that she may feel
isolated, as she would not be socialising with many people. The fact that she
is away from her family home also means that she would not see her family
together as one unit which may cause confusion and upset. Her mother could also
share this feeling of isolation as she too is separated from her husband and
other child meaning that she may feel lonely and upset. Emily and her mothers
lack of socialisation could cause a strain on the relationship they share with
each other as well as other people. For example, as Emily’s mother is staying
with her during her hospitalisation she may begin to alter her schema and
associate being uncomfortable and feeling unwell with being around her mother.
Also, her mother’s relationship with her dad might get damaged due to time
spent apart and the emotional strain of having a poorly child. Her sibling may
also feel confused and upset about the lack of attention they receive their
parents. She may feel more lethargic and irritable which could be due to
medication or the hospitals facilities. If there is no playroom or she is not
encouraged to get up and about then she may just want to lay in bed all day
which can lead to other issues such as body aches. Intellectual: due to her
hospitalisation she would be missing days off schooling meaning that she would
fall behind on her class work. The days she has missed from school may cause
her to fall behind her other peers meaning she would have a lot of work to
catch up on which may cause her stress. To avoid this build-up of wok it may be
possible for the hospital school to provide Emily with some school work as she
would not be able to physically attend the hospital school as she is an infection
risk. By providing her with worksheets and other educational tasks she can continue
to learn whilst receiving treatment for her illness. Although the school
teacher may not be able to remain in the room Emily’s mother will be present
and therefore should be able to help her with work. Emily’s culture may impact
her stay in hospital as it could impact her treatment as she may not be able to
have certain medications or eat certain foods. What may be normal for one culture
can be viewed as abnormal by another and so it is important that healthcare professional
are judgement free.  It is important that
her culture is taken into account when creating her care plan. It is
important to consider the ethical