Alfie Negative Effects On Children

Following the Nursing and Midwifery Code of Conduct and ensuring confidentiality, dignity and respect is maintained throughout this essay, I will be changing the child’s name to Alfie (NMC, 2015). Alfie was a 3 year old who my mentor and I triaged and assessed in the early hours of the morning in A and E. He presented with a barking cough, temperature of 40°C and very irritable. These are all common signs and symptoms of croup.
The National Institute for Health and Care Excellence (2012) defines croup as “a common childhood disease”. It affects the trachea, bronchi and larynx, causing respiratory distress and a bark like cough accompanied by a stridor commonly on inspiration. All of these factors are present due to an upper air way obstruction.
Croups can either be Viral or bacterial. Human Parainfluenza virus (Viral croup) accounts for about 80% of all cases (Nichols and Webberley, 2016). It starts by infecting the nasal cavity and the pharynx, spreading along the respiratory tract and to the larynx and trachea. This causes the top of the trachea to become swollen reducing the space available for air to pass (Nichols and Webberley, 2016). Children with the symptoms of croup may compensate by breathing quickly and deeply. Many children may become anxious and restless as the swelling in the trachea increases. This can lead to the child becoming exhausted and unable to breathe on their own needing outside help. As a health care professionals following the NMC code of conduct it was essential that my mentor and I observed and intervened when necessary to promote wellbeing and prevent deterioration (Nursing and Midwifery Council, 2015). Research suggests (BMJ Journals, 1996, and Mersch and FAAP, 2016) that croup can be a very stressful time for the patient and their family so I ensured Alfie was as content as possible throughout our care whilst looking for signs and symptoms of distress and discomposure. My mentor and I provided Alfie with the robot TV in order to distract him. When communicating with Alfie we ensured that we communicated with Alfie’s Parents to guarantee that they were happy with the care we were providing and also to educate them as they were not familiar with croup and its symptoms (Silverman, Kurtz, and Draper, 2005). Under the supervision of my mentor I ask Alfie’s parents if he had any medical condition or prevision admissions to hospital; it is important to find this out as it could have an effect on future treatment. We explain to mum that croup is a contagious infection and excellent hand hygiene is a must. It is our roles as Health Care Professionals to ensure that “Health Care Associated Infection” (HCAI) didn’t occur throughout Alfie’s stay.

Hospitalization can have both a positive and negative effect on children.
For many children going to hospital is a very intimidating experience (Kids Health, 2014). Not only are they brought into a new environment but also pushed out of their comfort zone with a fear of the unknown. It was vital that I ensured Alfie was comfortable and felt secure while he was under mine and my mentor’s supervision. Further-more, ensuring family centred care was present was equally as important. Multi-disciplinary teams need to realise that parents are the experts when I comes to their children and gaining knowledge and skills from them is invaluable; (Davis, Day, and Bidmead, 2002) agrees as the partnership model of care identifies that families are the specialists. Excellent communication between the multidisciplinary teams and the families is essential for a successful partnership (Coad and Glasper, 2014). My mentor and I also needed to be aware of any social, religious and culture beliefs Alfie and his family may have which could affect his treatment (Bussey-Jones and Genao,
2003).

Like many infections and diseases, the severity of croup can differ from child to child. Its symptoms are grouped into four different categories; these are, mild, moderate, severe and impending respiratory failure (NICE, 2012). According to the NICE guidelines Alfie was presenting with severe symptoms of croup as he had a recurrent barking cough with an audible inspiratory and intermittent expiratory stridor at rest along with intercostal, subcostal and sternal recession (NICE, 2012). Due to this it was vital that my mentor and I carried about an initial systematic, structured assessment of Alfie (Berman et al. 2010) followed by regular observations using a paediatric early warning signs chart (PEWS) as well as a croup score chart. We also ensured that within the assessment we were looking for signs of improvement through effective treatment, deterioration and failure to meet his needs. According to the NICE guidelines for croup it was essential that a child with moderate or severe croup is admitted to the ward (Bishop, Enriquez, et al., 2015, NICE, 2012). We approached this situation using the A, B, C, D, E assessment tool to assess Alfie. According to the Resuscitation Council (2015) this approach is used to carry out a complete head to toe, personalise assessment and to re-assess regularly; they state that all needs and interventions should be completed before moving onto the next step, therefore ensuring effective treatment and care is carried out (Govender, 2014).

When Alfie presented in triage, I knew that he had a patient airway as he was giggling and communicating with his parents, despite working incredibly hard. It was important that my mentor and I first established that his airway was patient as an untreated airway obstruction causes lower oxygen levels in the body, increasing the risks of hypoxia to the “brain, kidneys and heart”; these can then lead to a cardiac arrest and even death (Govender, 2014). The next stage of the systematic, structured assessment was focused primarily on Alfie’s breathing; I was looking to assess the rate, rhythm, depth and efficiency (NP and NP & Jongen, 2009). As I had seen a few children in A and E presenting with croup I knew the symptoms that I should be looking for when assessing Alfie. I expected to see some signs of troubled breathing, recession, stridor, hoarse voice and the distinctive barking cough (National Institute for Health and Care Excellence, 2012). Due to seeing the symptoms prior, I was aware that croup is caused by inflammation of the upper airway, therefore, wasn’t looking for symptoms such as a dry cough, a slight pause in between breaths, grunting and a wheeze (Brough and Nataraja, 2010); These are signs and symptoms associated with bronchiolitis which is a lower respiratory infection affecting the lungs and the airway (Knott, 2013).

It was very clear that Alfie was presenting with general signs of respiratory distress as he was using his accessory muscles, had central cyanosis and had signs of recession. Alfie was presenting with an increased respiratory rate of 60 breaths per minute, which is, according to research (Southampton University Hospitals NHS Trust, 2008, NICE, 2012), above the normal, safe ranges; Due to this Alfie was presenting with increased effort showing signs of intercostal, subcostal and sternal recession (NICE, 2012). Under the supervision of my mentor I assessed the depth of each breath and could clearly see he was equally using both sides of his chest, meaning that his lungs are working equally and correctly. His oxygen levels were recorded showing a rate of 84% in air. My mentor and I decided that it was essential he was prescribed humidified oxygen, given a single dose of prescribed oral dexamethasone and after re-assessing possibly given a nebulizer (National Institute for Health and Care Excellence, 2012). Under the supervision of my mentor, I gave Alfie 15 litres of oxygen until he was no longer hypoxic (WHO, Department of Child Health, 2000). We then gave Alfie Oral Dexamethasone. This medication reduces the swelling in the trachea and will help to ease his breathing. My mentor explained to me and Alfie’s parents that normally only one does of dexamethasone is needed but if no signs of improvement occur he may need another dose. We then explained to Alfie and his family that it will start to work with-in an hour of being given but could take up for hours for Alfie’s breathing to return to its normal rate, rhythm, depth and efficiency (Medicines for children, 2014). Alfie started to show signs of distress when we presented with the medication; we then explained to him that mum could give it to him he automatically calmed down. I knew it was essential to keep Alfie calm, as a distressed child breathes faster and harder constricting their airways making it harder to breathe (Spock and Needlman, 2012). We told mum that distraction through play, music and television are good ways of keeping children calm (Keene, 2015, P60). If Interventions didn’t occur at this stage of the care, Alfie would have shown signs of deterioration. We would have seen him become dyspnoea and exhausted (Williams and Wilkins, 2009, p 110) which may cause respiratory arrest, therefore, needing to be ventilated (Defendi, 2015). We reassessed Alfie before moving on to assessing his circulation to ensure that his breathing rate, rhythm, depth and efficiency was decreasing effectively (NP and NP & Jongen, 2009).

My mentor and I continued to assess Alfie using the Resuscitation Council (2015) A, B, C, D, E approach.
Moving onto C for circulation, I was looking at signs of cardiovascular failure. I started by taking Alfie’s heart rate using the monitor as well as finding his radial pulse point. I believed it was important to take a manual pulse as it enables me to feel for the rate, rhythm and amplitude of each beat (Merrifield and Ford, 2005). According to (Pritchard and Mallett, 2001) Alfie was presenting with tachycardia as his heart rate was 150 beats per minute, outside the normal, safe ranges for a 3 year old. The rhythm of his heart was normal showing that there wasn’t a disruption of the hearts normal conductive system and the amplitude was “strong and bounding” (Trim, 2005). I was expecting Alfie’s heart rate to be high due to his increased respiratory efforts. We observed Alfie regularly to insure that our interventions were effective and decreasing his signs of discomfort. I took Alfie’s temperate to see that it was 40°C but he was not showing any signs of being distressed. Research (Choices, 2014, Coad and Glasper, 2014, p169) suggests that antipyretics shouldn’t be given to a child who is comfortable with a temperature but my mentor, Alfie’s parents and I decided that due to his raised vital signs it would be beneficial for Alfie to have some paracetamol to bring the vital signs back to their normal ranges. Alfie was observed frequently after to ensure the medication was
working effectively, decreasing his temperature and in time bring his heart rate and respiratory rate down. His skin was slightly mottled, warm peripheries with a central capillary refill time (CRT) of less than two seconds. This ensured us that Alfie was not suffering from dehydration (Cockett and Day, 2009, p166). We communicated with Alfie’s parents about our concerns but they reassured us that he always had slightly mottled skin. Never the less we continued to observe Alfie to ensure his CRT wasn’t decreasing and that he wasn’t deteriorating. We decided that taking Alfie’s blood pressure wasn’t essential at that present moment as it was important to keep him calm and prevent distressing him. We continued to reassess Alfie to ensure treatment was effective and also to ensure his family were happy with the treatment given. If interventions hadn’t occurred at this point Alfie may have suffered from compensated or decompensated shock. This is when there is insufficient blood flow and oxygen supply to “meet the metabolic demands” (American Heart Association, 2005). Shock tends to progress from compensated to a decompensated state. Signs of compensated shock ranges from tachycardia, extended CRT and weak peripheral pulses whereas decompensated shock ranges from a low mental state, the production of metabolic acidosis and weak central pulses. It is important to recognise these signs and symptoms to react and deliver effective life-saving care (American Heart Association, 2005).

We continued to assess using the systematic, structured assessment. After C, we moved onto D, which is disability. We knew from communicating with Alfie’s parents that he didn’t have a disability and was normally a fit and well child, however is there were any concerns with his level of consciousness we would use AVPU or the Glasgow Coma Scale. After completing and managing “D” we would have moved onto “E”, Exposure, it is vital that elements are not missed and full exposure of the body is a necessity but in doing so respecting the patients’ rights and dignity (Nursing and Midwifery Council, 2015).

Therefore the evidence provided in this essay demonstrates without medical intervention Alfie would have deteriorated dramatically, causing compensating and decompensating shock to occur putting his life in danger.