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SAFE NURSING CARE SAVES LIVES

Smile Train Training Handout

Rona Breese, RGN BASarah Hodges MB ChB FRCA

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TABLE OF CONTENTS

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The Role of the Nurse in care of children

with Cleft Lip/Palate Surgery

4Overview of Clefts

6Pre-Operative Nursing Care for Cleft Lip/Palate Surgery

8Post-Operative Nursing Care for a child following cleft surgery

10Monitoring vital signs and nursing assessment in children 15Post-operative complications19Pediatric basic life support24Psychological Care

25Feeding children with cleft lip and or palate

28Pediatric pain assessment and management

32Training your team

30Discharge preparation

31Documentation

33What Next?

34Action Plan

36Key Concepts

39Glossary of Cleft Terms

Appendix A: Sample Post-Operative Care Plan

Appendix B: Sample Nursing Care Pathway

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THE ROLE OF THE NURSE IN CARE OF CHILDREN WITH CLEFT LIP/PALATESmile Train takes quality of care very seriously and recognizes that nurses have a vital role to play in achieving this, alongside surgeons, anesthesiologists and other health care personnel

Nursing care should never be considered to be routine. Nurses must always be prepared, know what to do and be ready to act quickly if a child’s condition changes.

In many hospitals nurses complete a series of tasks as part of their job, including:• Administering drugs• Giving treatments• Following doctors instructions• Recording vital signs• Taking patients to and from the operating theater• Discharge• Providing education, comfort & support for patients and families• Documenting patient information

All of these tasks are important parts of nursing care, however if they are carried out in isolation from each other, then quality, holistic care is not delivered. Holistic nursing care takes into account all of the needs of the child and their caregivers.

Also beyond completing routine tasks and carrying out instructions, to deliver safe and effective care nurses must be competent and confident to make assessments and interventions without advice from medical staff. Nurses may also plan the patient’s path through the hospital stay, navigating their journey from admission to discharge. However there are many variables that prevent care being provided as planned and much of nursing is about dealing with the unpredictable. It is a combination of the constant observation and assessment that nurses undertake, and the interventions they perform when things don’t go according to plan that make the difference in patient outcomes.

Nurses are best placed to detect early changes in a child’s condition which may indicate potentially life threatening complications. The appropriate response to such changes has the capacity to save lives.

The following are essential nursing skills

ASSESSING

DECIDING

REACTING

Appropriate, prompt nursing action saves lives

TABLE OF CONTENTS

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OVERVIEW OF CLEFTS

Cleft lip and/or palate is a relatively common, congenital abnormality causing facial and oral malformations. Cleft lip and/or palate arises very early in embryonic development.

Embryology:

At the end of the fourth week of conception the facial prominences begin to appear.

During the 5th week the nasal pits form from the frontonasal prominence which is mesenchyme ventral to the brain vesicles. These nasal pits become the nostrils and on either side are the medial and lateral nasal prominences. During the next 2 weeks of development the maxillary prominences (see diagram 1& 2 below) increase in size and grow medially pushing the medial nasal prominences to the midline. The cleft between these prominences fuses and these become the upper lip. The lateral nasal prominences form the nasal alae.

The lower lip and jaw form the mandibular prominences that merge across the midline.The two medial nasal prominences merge not just on the surface of the face but deeper as well. On the surface they form the philtrum (central portion) of the upper lip and the upper jaw with 4 incisor teeth. Deeper they form the triangular primary palate. The secondary palate is formed from two shelf-like out-growths of the maxillary prominences. These appear at 6 weeks and grow obliquely downwards either side of the tongue. In the 7th week these shelves move up as the tongue moves down and they fuse to form the secondary palate and they also fuse with the primary palate. At the same time the nasal septum grows

down and joins the top of the cephalic part of the newly formed palate. By 10-12 weeks the development of the face is complete.

Incidence:

Cleft lip/palate is the second most common birth defect after club foot. There are varying opinions on the actual incidence of clefts but most experts agree that it in part depends on ethnicity. Some experts say that the highest cleft incidences are among Asians (at approximately 1 in 500 births). Caucasians have an average incidence of 1 in 700 births and individuals of African descent have the lowest incidence of approximately 1 in 1200 births.

Cleft lip occurs when there is a partial or complete lack of fusion of the maxillary prominence with the medial nasal prominence on one or both sides. Cleft palate results when the palatine shelves fail to fuse.

Clefts can vary in severity from a small defect in the vermillion of the upper lip to a complete cleft of the face extending beyond the nose and up to the eye.

Causes:

Experts agree that the causes of cleft lip/palate are multifactorial and may include a genetic predisposition as well as environmental issues such as drug and alcohol use, smoking, maternal illness, infections or lack of Vitamin B folic acid. A woman is at a higher risk for having a baby with a cleft if she is a teenager or over 35 years old and if she is exposed to certain medications, chemicals, infectious diseases and environmental agents (called teratogens) that can disrupt the normal development of a fetus. Examples of teratogens include alcohol, cocaine, cigarettes, seizure medications, thalidomide, chemotherapy, radiation, lithium, organic solvents, chemicals, lead, anesthetic gases and organic mercury. Additional examples are certain diseases and infectious agents such as genital herpes, diabetes and hyperthermia.

Diagram 1 Diagram 2

Mandibular Prominence

Maxillary Prominences

Lateral Nasal Prominences

Medial Nasal Prominences

Mandibular Prominence

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The duration and frequency that the fetus is exposed to teratogens can influence the severity and impact of a birth defect.The crucial time for head and face development in a fetus is between the 3rd and 12th weeks of pregnancy. A lip typically fuses within 8 to 10 weeks after conception and a palate usually fuses within 10 to 12 weeks. The palatal shelves fuse one week later in females as compared to males, which may explain why isolated cleft palate occurs more frequently in females as compared to males.

Types of Clefts:

There are 2 major types of clefts:• Cleft lip with or without cleft palate• Isolated cleft palate

Cleft lips can be unilateral or bilateral. Cleft palates can involve the soft palate or both the hard and soft palate.

Clefts and Syndromes:Cleft lip/palate is often part of a syndrome and way be associated with cardiac defects and other birth defects.

The most common syndromes with cleft association are Pierre Robin sequence, Treacher-Collins syndrome, Goldenhar’s syndrome and Patau’s syndrome. Pierre Robin sequence is also often accompanied by respiratory challenges that may make surgery and anesthesia very difficult.

Health and survival challenges:

Children born with a cleft lip and or palate face many challenges. These challenges include:

Feeding – an infant or child with a cleft palate will likely have feeding difficulties and may not be able to breastfeed easily or at all. A child with a cleft lip (and no associated cleft palate) may also experience feeding difficulties but breastfeeding is usually possible.

Swallowing – an infant or child with a cleft palate may have difficulty swallowing and may be prone to aspiration and recurrent chest infections.

Speech – children with cleft lip and palate will likely have speech difficulties and need access to surgery and speech therapy to speak normally

Hearing – many children with cleft lip and palate have difficulty hearing

Dental – children with clefts may require an alveolar bone graft and/or orthodonticsfollowing surgery.

Facial growth – due to developmental problems and the surgery there may be reduced midface growth

Cosmetic – without surgery a child with a cleft will look very different from other children and may face associated challenges such as teasing, lack of inclusion and abandonment

Emotional development – sometimes parents have difficulty bonding with babies that have a cleft lip and/or palate and the child may grow up feeling unwanted and have trouble relating to peers, achieving educational milestones and having normal emotional development.

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PRE-OPERATIVE NURSING CARE FOR CLEFT LIP/PALATE SURGERY

The nurse plays a vital role in preparing a child and their caregivers for cleft lip and/or palate surgery. Pre- operative care includes both physical and psychological preparation.

Optimizing nutritional status

Pre-operative nursing care includes optimizing a child’s nutritional status by supporting and monitoring feeding. The goal is to ensure that the child will achieve the minimum required weight for surgery. There are various techniques for supporting the feeding of a child with a cleft lip and palate that are covered in these training materials.

Pre-operative physical preparation is intended to prevent or reduce peri- and post-operative complications

Goals for pre-operative care:1.Safe preparation of the child for surgery2.The child will not demonstrate distress pre-operatively3.Caregivers will demonstrate an understanding of the surgery and post-operative care4.Caregivers will receive adequate support and reassurance

Pre-operatively, nurses should work to optimize the child’s nutritional status, physically prepare them for surgery, and psychologically prepare the child and caregivers for surgery.

Physical preparation for the surgical procedure

Pre-operative physical preparation of a child before surgery reduces the likelihood of complicationsfollowing surgery and peri-operative injury.

Physical pre-operative preparation includes:• Documentation of weight and height• Documentation of any allergies• Nil by mouth• Checking for fever• Observing for signs of upper

respiratory tract infections• Checking name label• Check consent has been signed by a doctor• Complete pre-operative investigations

If height and weight are not accurately recorded injury may be caused by inappropriate drug dosage. Known allergies must also be clearly documented to prevent severe reactions. Smile Train’s nil by mouth (NBM) recommendations are:• 2 hours for clear liquids (water,

black tea, apple juice) • 4 hours for breast milk• 6 hours for solids, non-clear liquids

(including formula and cows milk)

The timing and nature of the last oral intake should be recorded. It is essential that the patient’s caregivers understand the importance of NBM recommendations. If parents do not understand these recommendations and why they are important they may try and provide food or liquid to their child which can lead to serious complications or adverse outcomes during surgery.

Pre-operative observations

The nurse needs to check the general health of the child by observing the child and recording baseline observations. This information will identify what is normal for the child as well as indicate pre-operative infections or conditions. It is a nurse’s responsibility to ensure that all ordered pre-operative investigations take place and are recorded in the patient’s chart.

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It is important that the nurse communicates any abnormal pre-operative results to medical staff as these may necessitate delaying the child’s surgery

Physical preparation includes ensuring that all documentation and checklists are complete before the child leaves the ward. The nurse should ensure that the patient has a name label to prevent mistaken identity in the operating theater which could lead to the wrong procedure being carried out.

Consent

Medical staff are responsible for providing carers with an explanation of the intended cleft surgery and anyassociated risks before a consent form is signed.

Informed consent should be obtained by the surgeon after discussing potential risks and complications with the child’s parents. Signing consent is NOT a nursing responsibility, but the nurse should check pre-operatively to ensure signed consent has been obtained.

Psychological Preparation

It is important that nurses understand the potential for distress that hospitalization and surgery can have on a child. Similarly, it is important that nurses prepare caregivers for the pre-operative period, the surgery itself, and the post-operative period. Nurses should also reinforce information given to caregivers by other medical staff.

Psychological care of a baby or young child focuses on limiting painful procedures and the anxiety that can be caused by separation from caregivers. If hospital policy allows, the child should be taken to the operating theater by the patient’s caregiver. The presence of a caregiver in the anesthetic room or operating theater during induction may be helpful in reducing distress. However, this would require discussion with the caregiver beforehand to ensure that they are comfortable doing this.

Pre-operative teaching goals for caregivers:• Caregiver will demonstrate an understanding

of the surgery and post-operative care• Caregivers will receive adequate

support and reassurance

Nurses should explain the need for pre-operative investigations, timing of surgery and explanation of the surgery that will take place. Caregivers should understand the expected length of time the child will be away from the ward as well as what to expect when the child returns. Explanations should include information about patient monitoring that will take place after surgery, discussions on how the caregiver can comfort the child, pain relief, and information on feeding the child.

It may be helpful to introduce the patient’s caregivers to another family whose child is recovering from the same surgery. This will help the caregivers understand the changes that they can expect to see in the early post- operative period. Caregivers should be advised that following cleft lip or palate surgery it is normal for the child to be puffy and swollen around the nose, lip or eyes. This is normal and will reduce in a few days. Slight bleeding from the nose or mouth is also normal. The child’s voice may also sound hoarse for a few days following anesthetic induction during surgery. The nurse should allocate time to answer any questions the caregivers might have.

Preparing the caregivers psychologically helps them to cope with and participate in the child’s post-operative recovery.

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POST-OPERATIVE NURSING CARE FOR A CHILD FOLLOWING CLEFT SURGERY

The role that nurses play during the post-operative period cannot be undervalued.

No matter how proficiently the surgeon repairs the cleft lip or palate, nursing care on the ward following surgery is vital for a successful outcome and the child’s safety.

Nursing Care Saves Lives

If nurses monitor the children in their care effectively and frequently they will quickly detect changes which require interventions. These interventions will save lives.

On many occasions, recovery following surgery will be routine and uneventful. However it is essential that this does NOT lead to complacency in nursing care.

Nurses must be constantly vigilant in case the child’s post-operative recovery includes unanticipated events.

Always be prepared and ready to act!

The Nursing Process is a way of delivering nursing care which is holistic and patient centered. The focus is on meeting the physical as well as psychological needs of the child and their caregiver.

The Nursing Process is based on:• Assessing needs• Planning interventions• Understanding the rationale for interventions• Implementation• Evaluating if the care had the desired effect

The Nursing Process begins on admission and ends which the child is discharged.

Key stages of Post-Operative Nursing Care:• Preparing the ward for the child’s return• Safely collecting the child from recovery• Monitoring the child• Identifying and responding to post-

operative complications

• Promoting comfort• Recommencing fluids and diet• Documenting care• Preparing for discharge.

Preparing the Ward for the Child’s Return

Before collecting a child from recovery it is essential that the nurse ensures that the bed space the child willoccupy is prepared. Any equipment which will OR may be required in the post-operative period must be at hand. It is essential that the following equipment is available for post-operative cleft care:• Oxygen• Stethoscope• Oxygen saturation monitor• Ambu bag

It is desirable that a Suction machine is available, but it should be used with extreme caution after cleft surgery.

Collecting a Child from Recovery

The nurse in the recovery room must check the patient’s condition to ensure that he or she is safe to return to theward. If the patient is not meeting the criteria listed on the recovery checklist, the ward nurse should not remove the child from recovery. Instead, the child should remain in recovery until the criteria are met.

Before Retrieving a Child from Recovery they must be:• Protecting their airway• Awake/easily awakened• Not in obvious discomfort• Not bleeding• Not vomiting• Observations must be stable• Documentation must be complete/ and

post-operative instructions clearly written

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Recovery is a safe, controlled, well- staffed and equipped environment.

DO NOT take a child out of recovery UNLESS it is safe to do so

If it is safe to return to the ward with the child, nurses should accompany the child while visually monitoring their condition during transfer.On the ward the child should be placed in a bed space close to the nurse station or in an area where they can be easily monitored.

Priorities on Return to the Ward:

AIRWAY

BREATHING

CIRCULATION

Post-Operative Care on the Ward

Once back on the ward the nurse should begin post- operative vital signs monitoring for 24 hours. Post-Operative Vital Signs Monitoring Following Cleft Lip or Palate Surgery should include:• 1 hourly Heart Rate, Respirations,

Oxygen saturation and AVPU for 24 hours

• 4 hourly Temperature for 24 hours (BUT 1 hourly temperature if abnormally high or low)

Undergoing cleft surgery has the potential to affect the child in many ways. The nurse must be aware of potential effects and actions to be taken if they arise.

Post-Operative Nursing Intervention Plan

The Post-Operative Nursing Intervention Plan is a nurse’s guide to interventions which may be requireddependent upon nursing observations and assessment.

A copy of a sample intervention plan can be found in Appendix B

Post-Operative Nursing Care Plan

The Post-Operative Nursing Care Plan is based upon identified actual/potential problems and needs following cleft surgery. It documents appropriate nursing interventions which aim to resolve problems, meet needs, and prevent potential problems from being actual problems. It provides prompts for the nursing care of children following cleft lip or palate surgery as well as rationale for the recommended actions. A copy of a Post-Operative Nursing Care Plan for Cleft Children can be found in Appendix A

Potential Post-Operative Problems/Needs Include:

1.Risk of respiratory compromise2.Risk of bleeding3.Risk of pain/discomfort4.Risk of inadequate hydration/nutrition5.Risk of cardiovascular/neurological instability6.Risk of infection7.Risk of altered temperature8.Risk of trauma to wound site9.Need to prepare child/caregiver for discharge

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MONITORING VITAL SIGNS AND NURSING ASSESSMENT IN CHILDREN

Vital Signs

Monitoring vital signs is an essential part of nursing assessment and essential for the early detection of post- operative complications.

Once on the ward, the patient should be nursed in a high visibility bed and frequently observed. Observations should be recorded 1 hourly for the first 24 hours and then reduced to 4 hourly.

The purposes of monitoring vital signs is to:• Determine a baseline• Monitor changes in condition• Monitor responses to therapy

Vital signs that should be measured routinely for cleft surgery patients include:• Respiration• Oxygen saturation• Heart rate• Temperature• AVPU (responsiveness check)• Capillary refill time (if

hypovolemia is suspected)

Oxygen saturation monitoring has been included as an important supplement to respiratory monitoring. Equipment to monitor oxygen saturation should be available at all Smile Train partner hospitals, usually in the form of a pulse oximeter. Accurate blood pressure measurement requires the use of an appropriately sized blood pressure cuff. Infants and children require different sized cuffs depending on the circumference and length of their arm. In children blood pressure is a late vital sign to change when the child deteriorates. For these reasons, blood pressure is not included in routine post-operative monitoring in children after cleft surgery.

It is essential for nurses to know the normal vital sign ranges based on the age of the child.

Nurses need to understand the possible causes of alterations in vital signs. This will enable them to

make informed decisions as to nursing interventions which may be required. Vital signs monitoring provides nurses with pieces of information, but it is only part of the bigger picture.

Nursing Assessment

The Nursing assessment when paired with the patient’s vital signs helps to build a complete picture of the child’s condition.

Nursing assessment involves:• Looking• Listening• Touching• Asking• Analyzing information

Thorough nursing assessment will provide essential information about respiratory, cardiovascular and neurological function.

Monitoring Respiration

Respiration is the most undervalued and important vital sign.

Respiration is usually the first vital sign to change when a patient deteriorates.

Infants and children under the age of 6 years are predominantly abdominal breathers. For this reason, when monitoring respiration in patients under 6 years old abdominal movements of chest movements should be counted. This will require removing bedding and possibly opening clothing.

Respirations should be counted for a full minute. When monitoring respiratory rate it is important to know the normal rates for the age of a child and understand the potential causes of an increase or decrease.

Age (years) Respiratory rate

<1 30-40

1-2 25-35

2-5 25-30

5-12 20-25

>12 15-20

Normal Respiratory Rate

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Traditionally, nurses have only recorded respiratory rates by counting breaths. Respiratory assessment is SO MUCH MORE than counting breaths.

Respiratory assessment includes observing:• Pattern and effort of breathing• Signs of respiratory distress• Skin color, pallor and cyanosis• Sounds of breathing

Accessory Muscle Use and Retractions

Infants and young children predominately breathe using their diaphragm and do not have well developed accessory muscles. Consequently, increased respiratory effort involves more rapid and forceful contraction of the diaphragm. The ribs are soft and tend to flex with soft tissue movement. This leads to costal and sternal recession with each breath. Tracheal tug is a form of recession. When this is severe it may be appear as “head bobbing.”

It is important that nurses listen for changes in respiratory effort:Sounds of Breathing• Wheezing: a high pitched whistling

most noticeable on expiration. Indicates obstructed lower airway airflow

• Stridor: a harsh rasping sound usually on inspiration but may be on expiration. Indicates limitation of airflow at upper airway level.

• Grunting: a deep or low pitched sound at the end of each breath.

• Gurgling: a bubbling sound in upper airways• Cough: this should be noted if it is dry,

hacking, barking, moist or paroxysmal

Cyanosis is visible when oxygen saturation is 85% or lessCyanosis is a LATE sign of Hypoxia

Early signs are:• Increased respiratory rate• Increased heart rate• Agitation• Restlessness• Confusion

Respiratory Distress and Respiratory Failure

Thorough respiratory assessment provides vital information and enables nurses to distinguish between a child who is working hard to breathe (respiratory distress) from one who is deteriorating towards respiratory arrest (respiratory failure).

Potential changes in respiratory rate after cleft surgery

Increase Decrease

Respiratory distress Anesthetic agents

Bleeding Opioids

Pain Pain

Pyrexia Cardio/respiratory failure

Fluid volume excess

Signs of respiratory distress in a child

Signs of respiratory failure in a child

Alert but tired Decreased level of consciousness

Tachypnea Apnea/reduced respiratory rate

Increased work breathing

Increased/decreased work breathing

Tachycardia Bradycardia

Cyanosis (late sign) Cyanosis

Decreasing Sp02 Low Sp02

Respiratory Distress vs. Respiratory Failure

Retractions are a CARDINAL SIGN of respiratory distress in infants and children.

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Prompt nurse-led interventions for a child in respiratory distress may prevent deterioration into respiratory failure andimprove the child’s chance of survival. Questions to ask when monitoring respiratory rate:• What is the respiratory rate?• What was the previous respiratory rate?• What is the patient’s effort of breathing?• Is there any noise with breathing?• What do they look like?• What is the oxygen saturation?• Does the patient require oxygen?• What is the temperature?

Oxygen SaturationOxygen saturation monitoring gives information about the concentration of oxygen in the hemoglobin in a patient’s blood. It is recorded using pulse oximetry, which uses an infrared light source to measure oxygenation data. Oxygen saturation is a useful observation alongside respiratory assessment.

The oxygen saturation probe can be placed on the thumb or big toe of a young child or the finger of a larger child. The tongue can only be used in an emergency.

A healthy child with normal lungs, breathing air will have an arterial oxygen saturation of 95-100%. A reading above 94% is considered acceptable. Oxygen delivery to the tissues falls rapidly if saturation <90%. It is also important to note that if a child is severely anemic they will have less hemoglobin, therefore they may have normal oxygen saturation levels even though oxygenation of tissues is inadequate.

Oxygen Saturation should be >94% Set Oxygen Saturation Alarms at 94%

Accurate oxygen saturation recording requires a still child and a good pulse signal. Inadequate perfusion at the pulse oximetry probe site will lead to inaccurate readings. Additionally, if a child is peripherally cool, poorly perfused or agitated it will not be possible to obtain an accurate reading. See Appendix B (Nurse Intervention Plan) for nursing actions when Oxygen Saturation is <94%

If a monitor does not seem to be working try to check:• Is the monitor plugged in or

the battery charged?• Is the infrared sensor emitting light?• Check your own oxygen saturation

for a baseline reading?• Is there warmth and perfusion to the

area where the probe is applied?• Is something impeding blood flow to the area• Is light escaping from the edge of the probe• Is good waveform displayed?

If poor, use new site• Does the heart rate match

the apical heart rate?• Are the alarms silenced?

If the reading is low, reposition and recheck 3 times over 5 minutes while checking airway is open and other vital signs

Monitoring Heart Rate

Heart rate in children of less than two years of age should be counted using a stethoscope to auscultate the apex of the heart. In a child more than two years of age a radial or brachial pulse can be recorded. In bothsituations heart rate should be recorded for a full minute.

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Questions to ask when measuring heart rate:• What is the heart rate?• What was the previous heart rate?• How does the child look and

what are they doing?• Is the child warm or cool peripherally?• Is the child well perfused?• What is the capillary refill time?• Is the heart rate regular or irregular?• If the pulse is palpitated, is it easily palpitated

(strong) or easily obliterated with pressure?• Is there bleeding?

Capillary Refill Time

Capillary refill time (CRT) is a quick test performed on the nail beds to assess perfusion, or the time it takes for blood to reach the capillary bed.

To conduct the CRT apply pressure to the nail bed by squeezing until it turns white, indicating that the blood has been forced from the tissue. Then stop squeezing and note the time that it takes for color to return to the nail bed.Normal CRT is less than 2 seconds. An increased CRT may indicate reduced peripheral perfusion due to hypovolemia. CRT is a useful tool in comprehensive nursing assessment. It should not be used in isolation but considered alongside other assessment.

Monitoring Temperature

It is important to record temperatures pre-operatively to identify infections which may require surgery to be delayed. Record temperature under the axilla. Oral and rectal measurements should not be used routinely in children under five years old.Measure temperature four hourly post-operatively. If the reading is elevated, or low repeat after one hour. Also measure a child’s temperature if they ever feel warm or cold to the touch, even if the previous recording was recent and normal.

Increase Decrease

Early respiratory distress Late respiratory distress

Pain Hypoxia

Bleeding Cardio/respiratory failure

Pyrexia

Medications (atropine adrenaline)

Potential changes in heart rate after cleft surgery

Age (years) Beats per minute (BPM)

<1 110-160

1-2 100-150

2-5 95-140

5-12 80-120

>12 60-100

Normal Resting Heart Rates

Potential changes in temperature after cleft surgery.

Increase Decrease

Infection Enviroment/exposure

Enviroment Muscle Relaxants

Excessive clothing/ bleeding

Infusion cool fluid/blood

Malignant hyperthermia Vasodilators

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Level of Response

A child’s level of response is an indication of level of consciousness and can be quickly assessed using AVPU score. A change in level of response may indicate a significant change in the child’s condition. AVPU should be recorded hourly alongside other observations.The scale is:A – AwakeV – Responds to Voice P – Responds to Pain U – Unresponsive

If a child responds to you at their bedside, they score an A for awake. If they are not awake but respond to you talking, they score a V. If they do not respond to voice, try gently squeezing the nail bed or rubbing the sternum as a painful stimuli; if they respond, they score a P. If they do not respond they score U for unresponsive.

Summary• Recording vital signs is one element

of nursing assessment. • Thorough nursing assessment is a

vital aspect of good nursing care. • Careful attention to assessment will alert

the nurse to changes in a child’s condition. • Intervention at an early stage will help

prevent or avert consequences which could be potentially life threatening if left untreated.

• Nursing assessment is a continuous process.

Always Remember

AIRWAY BREATHING CIRCULATION

ASSESS DECIDE REACT

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POST-OPERATIVE COMPLICATIONS

Post-Operative Complications Summary

All patients who have had an operation under either regional or general anesthesia are in a potentially unstable cardio-respiratory state. Many potentially devastating complications can occur during emergence and recovery from anesthesia.

Nurses are responsible for their patients.

After cleft surgery, children are at risk from various complications. Many of these can cause airway obstruction as the surgery takes place in the mouth near the airway. Monitoring is essential for the early detection of post- operative complications. Initially, children in recovery should be observed constantly and observations recorded every 15 minutes. Once on the ward, the patient should be nursed in a high visibility bed and frequently observed. Observations should be recorded 1 hourly for the first 24 hours and then reduced to 4 hourly.

After a general anesthetic has been administered, patients return to normal function occurs in 3 stages:

• Stage 1 – rapid return of airway reflexes starts in the operating room

• Stage 2 – the child becomes fully conscious but may still be sleepy (this occurs in the recovery room)

• Stage 3 – over the next 1-4 days the child’s other functions return to pre-surgical levels

Recovery rooms and Post-Anesthesia Care Units (PACU) were developed to provide an area of high level monitoring for patients during the potentially high-risk period as they emerge from anesthesia.

In children under 1 year of age the most common post-operative complications are respiratory complications

• Most Common: Hypoxemia• Second: Laryngospasm

These complications will occur even more frequently in children undergoing cleft surgery since the surgery takes place in the mouth and near the airway.

Timing of Post-Operative Complications

Post-Operative complications can occur in the recovery room AND/OR on the ward.

Where Complications Usually Occur

Identification and Management of Post-Operative ComplicationsMany post-operative complications following cleft surgery can lead to airway obstruction.

AIRWAY OBSTRUCTION

Always remember: A B C

Airway, Breathing, Circulation

Recovery Room Recovery Room OR Ward

Ward

Residual Sedation Bleeding Aspiration

Fotgotten Pack Laryngeal edema

Laryngospasm Bronchospasm

Hypothermia Fever

Shivering Agitation

Nausea/Vomiting

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Signs and symptoms of airway obstruction:• Tachypnoea• Difficulty breathing or unable to breathe• Obstructed breathing pattern• Tracheal tug• Low SpO2• Tachycardia or bradycardia if hypoxic• Stridor or no noise• Distressed but maybe no crying• Possibly gagging

MANAGEMENT OF FORGOTTEN PACK

• Call for help: inform surgeon or anesthetist immediately

• Airway: support the airway• Breathing: Give high flow oxygen• Place in recovery position• Remove pack if just sitting in mouth,

if not wait for the surgeon.• Suction very gently if required

During surgery a pack may be inserted into the throat to protect the airway from blood trickling past the endotracheal tube and into the trachea. This pack should be removed before the child is fully awake in the operating room. If the pack is forgotten, the child will have difficulty breathing, and will eventually go into respiratory arrest. It is important to diagnose this problem rapidly and remove the pack if this can be done easily. If not the anesthetist must be called immediately while the nurse supports the airway and gives oxygen with a face mask. Forgotten packs will almost always be identified before a patient reaches the ward. MANAGEMENT OF LARYNGOSPASM

• Call for help: call the aneasthetist• Airway: Jaw thrust chin lift• Breathing: Give high flow oxygen,

holding Hudson mask firmly or using anaesthetic face mask and Ambu bag

• If it doesn’t resolve the child may need re-intubating.

Laryngospasm occurs when the vocal cords close and obstruct the airway. This should occur only rarely outside of the operating

theater. In laryngospasm the patient will rapidly become hypoxemic and may have stridor or silent breathing (in severe cases).

MANAGEMENT OF LARYNGEAL EDEMA

• Call for help: Call anesthetist• Airway: Support the airway• Breathing: Give high flow oxygen• Consider: Nebulized Adrenaline (0.5mg

in 3 mls NS over 10 minutes).• Consider: Dexamethasone IV 0.25mg/

kg if not given in theatre• May need re-intubating

Laryngeal edema occurs when the true or false vocal cords become swollen. Swelling reduces the size of the airway and the child develops an obstructed breathing pattern, with or without noises, and becomes hypoxic. It may happen if the intubation was difficult or if the endotracheal tube was too big. This is an emergency and needs the assistance of the anesthetist immediately.

MANAGEMENT OF RESIDUAL SEDATION

• Call for Help• Airway: Support- recovery

position, chin lift or jaw thrust• Breathing: Give oxygen• Stay close and monitor this should resolve• If concerned call anesthetist

Patients who have had a general anesthetic may metabolize the drugs more slowly than expected. This will result in prolonged sedation after surgery has finished. Consequently, the patient will be unconscious longer and may not be protecting their airway sufficiently. MANAGEMENT OF ASPIRATION

• Call for help• Airway: Open the airway• Breathing: Give high flow oxygen• Consider careful suctioning• Stop all feeding• Give antibiotics• Consider respiratory support

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A baby with a cleft palate has an abnormal swallowing mechanism and they are susceptible to aspirating saliva, blood and feeds, especially post-operatively. Patients with cleft lip can also aspirate. Risk of aspiration is the reason that the first post-operative feed must be given when assessed safe and by a nurse not a carer. Aspiration will make patients prone to developing a chest infection. They may have noisy breathing, with audible crackles and low oxygen saturation on air. Ensure antibiotics have been prescribed and continue to monitor the patient closely for any deterioration. If the patient is not improving and becomes pyrexial, it may be safer to continue intravenous fluids and wait to start oral fluids.

MANAGEMENT OF BRONCHOSPASM

• Call for help• Airway: Check airway• Breathing: Give oxygen via a face mask• Consider: nebuliazed salbutamol

2.5mg in 3ml normal slaine• Consider: Dexamethasone 0.1-0.25mg/

kg IV if not already given in theater

Bronchospasm is due to constriction of the muscles around the bronchioles. Certain drugs can cause this, but children with an upper respiratory infection are also much more susceptible to post-operative bronchospasm. Bronchospasm may settle spontaneously with oxygen via a face mask. However, if the patient develops an audible wheeze, tracheal tug or subcostal recession and is becoming listless then it is important to treat with nebulized salbutamol 2.5mg in 3 ml normal saline. You can give dexamethasone 0.1-0.25 mg/kg intravenously if this was not already given in the theater.

MANAGEMENT OF BLEEDING

• Call for help: Call surgeon and anaesthetist• Airway: Put child in lateral position to

prevent aspiration, if airway obstructed Jaw thrust chin lift. Consider very gentle suction

• Breathing: Give high flow oxygen• Circulation: Start fluid resuscitation 10-

20ml/kg of Ringers Lactate or 0.9% Saline

• Use sterile gauze to apply very gentle pressure on bleeding area if possible

• Check if blood was cross matched and send to recovery

After surgery if the bleeding has not been adequately controlled, continued bleeding may obstruct the airway. Look for any continuous dribbling of blood or frequent swallowing. If bleeding becomes very severe, the child will become tachycardic, tachypnoeic and may have a reduced level of consciousness. Capillary refill time will also be prolonged beyond 2 seconds.

Calculating Blood Volume

When assessing bleeding remember that the blood volume of a child under 3 is only 80-85 mls/kg. A 6kg child would have a blood volume of 480-510 mls. Therefore, the loss of 51mls in a 6kg baby is 10% loss of blood volume.

Categorizing Bleeding and Shock in Children

Mild Bleeding – Compensated Shock• Heart Rate UP• Respiratory Rate UP• CRT > 2 seconds• Cool peripheries• Neurological – Irritable

Moderate Bleeding – Decompensated Shock• Heart Rate WAY UP• Respiratory Rate WAY UP• CRT > 3 seconds• Cool peripheries/pallor• Neurological – agitated/lethargic

Severe Bleeding – Cardiopulmonary Failure• Heart Rate WAY UP or very low/bradycardia• Respiratory Rate WAY UP or

gasping/irregular and low• CRT > 5 seconds• Cold peripheries, cyanosis• Neurological – responds to pain or• unresponsive.

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REMEMBER!!!Bradycardia, reduced respiratory rate and unresponsiveness are all VERY late signs of shock

MANAGEMENT OF OTHER POSTOPERATIVE COMPLICATIONS

Hypothermia and Shivering

When a child or adult is anesthetized they lose the ability to conserve their body temperature and they will often emerge from the operating theater feeling cold. Before the age of 3 months a baby cannot shiver and therefore is more likely to become hypothermic. Give oxygen, wrap the child with a blanket and avoid giving cold fluids.

Nausea/vomiting

Post-operative vomiting in children can be distressing and difficult to manage. Try to stop them from moving around and administer oxygen, which will often relieve nausea in the post-operative period. Delay oral intake of fluids and continue intravenous fluids. If nausea or vomiting becomes very severe ask the doctor to prescribe an antiemetic.

Fever

Many children develop a fever post-operatively and this may be due to intro-operative drugs like atropine. Fever usually resolves spontaneously, but excess bedding and clothing should be removed. If the fever persists start tepid sponging, give paracetamol or ibuprofen (as prescribed) and check the blood smear and white cell count. If the blood smear is positive for malaria, start anti-malarial treatment. If the white cell count alone is raised and the child is not improving, then it is important to inform the doctor so the appropriate antibiotics can be commenced, if required.

Agitation

Agitation can be caused by a number of factors. If a child went to sleep distressed, then he or she is likely to wake up distressed. Additionally, some patients react to drugs like morphine with agitation and in some children separation from the parents can cause anxiety and anguish.

Always exclude hypoxia first when looking for causes in an agitated child. Hypoxia can cause agitation so it is essential to fully assess the child and exclude hypoxia and airway obstruction before bringing the caregiver in to soothe the baby. Make sure the child is not in pain and administer prescribed analgesia, if required.

Summary

Nurses are best placed to detect early changes in a child’s condition which may indicate potentially life threatening complications. If nurses are informed, competent and confident to carry out interventions – nursing care saves lives.

Remember the most common causes of post-operative airway obstruction: Aspiration, Bleeding, Forgotten pack, Laryngospasm, Laryngeal Edema, Residual sedation. Even if you are unsure of the cause of any post-operative complication

DON’T PANIC – REMEMBER A.B.C – GET HELP

• Airway: - Jaw thrust, chin lift, recovery position

• Breathing: - Look, listen and feel - Oxygen by nasal prongs, mask or Ambu bag

• Circulation: Consider fluid resuscitation 20ml/kg N/Saline or R/lactate if bleeding (stat)

NURSING CARE SAVES LIVES

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PEDIATRIC BASIC LIFE SUPPORTBASED ON RESUSCITATION COUNCIL GUIDELINES (UK) 2015

For this section:• An infant is a child under 1 year• A child is between 1 year and puberty

What is Basic Life Support?

Basic Life Support (BLS) is the immediate treatment for an unresponsive child who is not breathing normally. Following cardio-respiratory arrest, BLS is the maintenance of Airway, Breathing and Circulation.

The goal of BLS is to prevent hypoxic cerebral damage by maintaining oxygenation of vital organs, notably the brain. This is achieved by artificially forcing air into the lungs and compressing the chest wall.

Seconds Count! In order to prevent hypoxic cerebral damage, resuscitation must begin immediately after respiratory or cardiac arrest. Following a cardio- respiratory arrest a child’s survival depends upon prompt and effective basic life support. Nurses have a responsibility to immediately commence basic life support while waiting for medical help to arrive.

Cardio-respiratory arrest will be an infrequent event on the ward, however it is essential that basic emergency equipment, including an Ambu bag and oxygen, is available at all times. A child’s survival following cardio-pulmonary arrest depends on immediately re-establishing oxygenation to vital organs. If a nurse needs to leave the child in search of basic equipment, vital minutes will be lost.

In children (unlike adults) cardiac arrest is usually preceded by respiratory arrest. Respiratory arrest is caused by respiratory insufficiency. Cardio-respiratory arrest in children is a predictable event. It is extremely important that nurses are aware of and react to pre- arrest changes in the patient’s condition.

If following a respiratory arrest a child has a cardiac arrest the prognosis is very poor. In pediatric life support, prevention and recognition of the impending event is a major factor in overall survival.

Pediatric Basic Life Support Sequence

Follow this sequence to perform BLS on a child.

UNRESPONSIVE

Shout for help

Open airway

NOT BREATHING NORMALLY

5 rescue breaths

NO SIGNS OF LIFE

15 chest compressions

2 rescue breaths, 15 chest compressions

CALL DOCTOR

• Respiratory insufficiency Respiratory Arrest

Cardiopulmonary Arrest in Children

• Respiratory arrest Cardiac Arrest

• Hypoxia Bradycardia

• Bradycardia Asystole

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Check responsiveness:

• Gently, stimulate the child and ask loudly “Are you all right?”

• Stimulate by tickling the feet or gently rubbing the shoulder

If the child responds by answering or moving:• Leave the child in the position you found him,

check his condition and get help if needed• Reassess the child regularly

If the child does not respond:• Shout for help• Turn the child onto his back and open

the airway using head tilt and chin lift

The tongue is the most common cause of airway obstruction in children. A simple head tilt and chin lift or jaw thrust maneuver should open the pediatric airway.

The jaw thrust may be the most effective method for opening the airway following cleftpalate surgery, especially in cases of Pierre Robin Sequence.

Opening the Airway

Infant

Opening the Airway in an InfantTo open the airway in an infant, the head must be in a neutral position (eyes looking straight up to the ceiling).An infant’s large occiput will cause the head to flex whenlaying supine, placing a small towel under the shoulder can aid achieving a neutral head position.

Child

To open the airway in a child, place your hand on their forehead and gently tilt their head back. With yourfingertip(s) under the point of the child’s chin, lift chin.Do not push on the soft tissues under the chin as this may block the airway.

In an older child, the head should be placed in a ‘sniffing’ position to open the airway.

Jaw Thrust

If you still have difficulty opening the airway, try the jaw thrust method: place the first two fingers of each hand behind each side of the child’s jaw bone and push the jaw forward.

Check for Breathing

After opening the airway, make sure to keep the airway open and look, listen and feel for normal breathingby putting your face close to the child’s face and lookingat the chest.• Look for chest movements• Listen for breath sounds at the

child’s nose and mouth• Feel for air movement on your cheek

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In the first few minutes after cardiac arrest a child may be taking infrequent, noisy gasps.Do NOT confuse this with normal breathing!

Look, listen and feel for no more than 10 seconds before deciding how to proceed.

If you have ANY doubts whether breathing is normal, act as if it is NOT normal.

Recovery Position

If the child’s breathing is normal after opening the airway, turn the child into recovery position – that is a lateral position with their mouth in a position to enable free drainage of fluid. The patient should be stable in this position. In an infant, this may require the support of a small pillow or rolled-up blanked behind his back to maintain the position.

Rescue Breaths

If breathing is not normal or is absent after opening the airway first clear the airway. Carefully remove any obvious airway obstruction. Do not blindly sweep your fingers inside the child’s mouth as this may push an obstruction further into the airway.

Remember, potential causes of airway obstruction following cleft surgery include:• Forgotten pack• Blood/vomit• Tongue• Laryngospasm• Laryngeal edema

To give rescue breaths follow this sequence:• Maintain open airway!• Give 5 initial rescue breaths using an

Ambu bag (attach oxygen if its available), make sure to cover the mouth and nose to ensure a good seal around the mask

• Check if the chest rises and falls with each breath

• While performing the rescue breaths note any gag or cough response to your action

If you have any difficulty making the chest rise and fall, the airway may be obstructed. Try to:

• Open the child’s mouth and remove any visible obstruction. Do not perform a blind finger sweep.

• Ensure that there is adequate head tilt and chin lift, but also that the neck is not over extended.

• If the head tilt and chin lift have not opened the airway, try the jaw thrust method.

• Make up to 5 attempts to achieve effective breaths. If still unsuccessful, move on to chest compression.

Child

To open the airway in a child, place your hand on their forehead and gently tilt their head back. With yourfingertip(s) under the point of the child’s chin, lift chin.Do not push on the soft tissues under the chin as this may block the airway.

In an older child, the head should be placed in a ‘sniffing’ position to open the airway.

Jaw Thrust

If you still have difficulty opening the airway, try the jaw thrust method: place the first two fingers of each hand behind each side of the child’s jaw bone and push the jaw forward.

Check for Breathing

After opening the airway, make sure to keep the airway open and look, listen and feel for normal breathingby putting your face close to the child’s face and lookingat the chest.• Look for chest movements• Listen for breath sounds at the

child’s nose and mouth• Feel for air movement on your cheek

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Assess for Signs of Life Take no more than 10 seconds to look for signs of life. These include:• Any movement• Coughing• Normal breathing (not abnormal

gasps or infrequent, irregular breaths)

If there are no obvious signs of life, take no more than 10 seconds to check for a pulse/signs of circulation.• In an infant – feel for the brachial pulse

on the inner aspect of the upper arm.• In a child over 1 year – feel for the

carotid pulse in the neck• For both infants and children, the femoral

pulse in the groin can also be used

If you are confident that you can detect signs of circulation within 10 seconds:

• Continue rescue breathing, if necessary, until the child starts breathing effectively on their own

• Turn the child onto their side in the recovery position IF they start breathing effectively but remain unconscious

• Re-assess the child frequently• Call for help

Start Chest Compressions

If there are no signs of life and unless you are CERTAIN that you can feel a definite pulse of morethan 60 beats per minute within 10 seconds, startchest compressions.Chest compressions should be performed by:

• Compressing the lower-half of the sternum (locate the lower-half of the sternum by finding the angle where the lowest ribs join in the middle and compress one finger’s breath above this)

• Compression should be sufficient to depress 1/3 of the depth of the chest• Don’t be afraid to push too hard

• Push hard and fast

• Release the pressure completely, then repeat at a rate of 100-120 per minute

• After 15 compressions, tilt the head and give 2 effective breaths

• Continue the compressions and breaths at a ratio of 15:2

Chest Compression in Infants:

One RescuerIf there is only one rescuer, the rescuer should compress the sternum with the tips of two fingers andsupplement with breaths, as described.

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Two RescuersIf there are two or more rescuers, the encircling technique should be used:• One rescuer should place both thumbs flat,

side by side on the lower half of the sternum, with tips pointing towards the infant’s head

• The hands should be spread with the fingers together to encircle the lower part of the infant’s rib cage with the tips of the fingers supporting the infant’s back

• Press down on the lower sternum with your two thumbs to depress it at least 1/3 of the depth of the infants chest

• A second rescuer should perform breaths

Chest Compression in Children Older Than 1 YearIn children older than 1 year old:• Place the heel of one hand over

the lower half of the sternum• Lift the fingers to ensure pressuer is

not applied over the child’s ribs• Position yourself vertically above the child’s

chest and, with your arm straight, compress• the sternum at least 1/3 the depth of the chest

Chest Compression in larger childrenIn larger children use both hands with the fingers interlocked

CONTINUE RESUSCITATION: 2 breaths for every 15 compressions until the child shows signs of life (normal breathing, cough, movement or definite pulse greater than 60 bpm), or further medical help arrives.

REMEMBER – in Pediatric Cardiopulmonary Arrest

SECONDS COUNT!Always be prepared, expect the unexpected

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PSYCHOLOGICAL CARE

Holistic nursing care of a child who has been admitted for cleft lip or palate surgery and their family includes psychological care.

The birth of a child with a cleft lip or palate may have a profound impact upon the family. Each individual in the family will likely respond slightly differently and their reaction will be affected by many factors, including the type of cleft, the individual’s beliefs, and the social support that is in place.

The emotional response of delivering a child with a facial deformity may be much more intense than the reaction to a more life-threatening but hidden disorder such as a heart defect.

The birth of a child with a cleft lip/palate may evoke the same psychological reactions as the death of a child, since the family will often grieve for the child they had expected or idealized. As well as coping with their own emotions, the family has to cope with reactions from their extended family, friends and the community.

Possible emotional responses following the birth of a child with

a cleft lip or palate Include:

Shock Anger

Disbelief Denial Guilt

Anxiety Sadness

The responses and reactions of family, friends and the community may affect the way that a family cares for their child both consciously and subconsciously.

When caring for a child who has been admitted for cleft lip or palate surgery, it may be helpful for the nurse to consider the following question: “What does the family believe caused their child to be born with a cleft lip or palate?”

There are many commonly held misconceptions regarding the causes of cleft including:• Witchcraft• Punishment from god for past actions• Sexual intercourse outside of marriage• Inappropriate antenatal practices

If the nurse caring for the family understands the family’s beliefs she/he can provide information to help correct misconceptions with information about the actual causes of birth defects.

Effective pre- and post-operative psychological support is a key component of nursing families with a cleft child. Nurses should demonstrate empathy and understanding as they teach and support families.

Psychological Nursing Care Includes:

• Make time to understand the family’s beliefs

• Correct Misconceptions• Provide support and understanding

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FEEDING CHILDREN WITH CLEFT LIP AND/OR PALATE

Supporting feeding both pre- and post-operatively is a nursing responsibility. Nutrition can at times be a neglected aspect of nursing care but it is essential, especially for children with cleft, that nurses treat nutrition as an important component of care.

Children with cleft palate (with or without cleft lip) will have more significant feeding difficulties than those with cleft lip alone. Many children with cleft palate are at risk of malnutrition and death due to feeding difficulties.

Pre-operatively, the goal of nursing interventions is to promote optimum nutrition and ensure that the minimum pre-operative weight is achieved to enable surgery. Nursing interventions may include:• Supporting or teaching caregivers in

feeding techniques for cleft lip and/or palate• Follow prescribed feeding and supplement

program if feeding is inadequate• Record oral and nasal-gastric (NG) intake daily• Record weight daily• Assess hydration status

Feeding difficulties for children with cleft lip and/or palate

Children with cleft lip may have difficulty creating the suction required to successfully breastfeed. It may help for the mother to gently squeeze the breast to increase the flow of milk.

Children with cleft palate will frequently choke and regurgitate milk through the nose. Caregivers should be told not to panic when this occurs. Feeing these children in an upright position may help with feeding difficulties.

Children with cleft may also swallow excessive amounts of air during feeding and need to be burped more frequently.

Feeding a child with a cleft is time consuming and the child may tire during feeding before being satisfied due to poor suction and possibly a non-rhythmic sucking action. Caregivers of children with cleft palate need encouragement, advice and support in the early post- natal period to prevent malnutrition.

Goals in Supportive Feeding

• To ensure the child’s nutritional needs are met, and this is demonstrated in appropriate weight gain

• To promote breast feeding, where possible• To identify a feeding position which

maximizes suction and reduces regurgitation

Strategies for feeding: unilateral cleft lip• Feed with the affected side down• Cradle hold on one side and

football hold on the other• Use the fingers or breast tissue to seal the lip• Ensure as much tissue as possible

is in the baby’s mouth• Position the nipple to the side

that is not affected

“football hold”

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Strategies for feeding: bilateral cleft lip• Feed upright with one leg on either

side of the mother’s leg• Feed in semi-upright football hold position

Strategies for feeding: cleft palate or cleft lip and palate• Feed semi-upright or with a football hold• Gently squeeze the breast to increase

the flow of milk or express breast milk into the baby’s mouth

• Position the breast toward the side of the palate which is the most intact

• Tip the breast downwards• Support the baby’s chin and the

breast to maintain position

Summary Pre-Operative Feeding:

Surgery is the only way to repair a cleft lip and palate. Without it, children with clefts will continue to face numerous health, survival and development challenges. It is essential that children with clefts receive proper nutrition to be fit for surgery. Poor nutritional status is linked to an increase in surgical and post-surgical complications.

Breast milk is best for all children. Mother of babies with cleft should try to feed their children directly from the breast using the strategies described in this training. If that is not possible, expressed milk, fed using a spoon, cup or bottle may be successful. If using a bottle the teat hole could be enlarged into a slit, but care must be taken to avoid feeding too quickly. If the mother is unable to express breast milk, formula or cows milk may be an option It is essential that any feeding devices are thoroughly cleaned and sterilized and that any cow’s milk or water used for feeding is boiled and cooled.

Post-Operative Feeding

Following surgery, feeding should be commenced in a safe way and should follow local-policies and the instructions of the anesthetist and/or surgeon.

Before Post-Operative Feeding Begins, A Child MUST be:

• Fully awake• Responsive• Protecting their airway

Premature feeding can lead to life- threatening aspiration.

The first post-operative feeding MUST be supervised by a nurse!

The patient is usually restricted to liquids only for the first 24 hours following cleft surgery. Liquids can be given with a spoon or a cup, but the baby or child must be fed sitting upright. The first few feedings must be done under the direct supervision of the nurse to avoid accidental aspiration. The nurse should discuss this with caregivers before and after surgery and ensure that caregivers understand the reasons for supervised feeding and comply.

Additionally, children feeding post-operatively:• Will need to adjust to their altered

oral cavity and breathing patterns• May require post-operative analgesia

to ensure comfort during feeding• May initially find it easier to be spoon fed milk

or thickened milk as an alternative to sucking• May require gentle syringe feeding (in

this case it is important for the syringe to be placed at the child’s lip to prevent possible trauma to the operation site)

When fluids have been tolerated, soft food can be reintroduced depending on the patient’s age and local policy. Feeding in an upright position continues to be important.

Following cleft palate surgery, a soft, semi-solid diet is recommended for three weeks. Caregivers should be advised to continue this diet at home.

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Post-Operative Cleft Palate Feeding Advice

• Soft, sloppy diet for 3 weeks• Avoid hard, rough foods• Feed small quantities (initially)• Feed propped upright

Caregivers of children with cleft palates should be encouraged to feed their child small quantities as they adjust to their newly repaired palates. This does not mean food intake should be reduced, just that food should be fed in smaller quantities. Straws and comforters/dummies/pacifiers should be avoided initially after cleft palate surgery. Caregivers should make sure that spoons do not touch the palate during feeding.

Nurses should assess the patient’s ability to feed following surgery and inform medical staff of any difficulties before discharge. Prior to discharge nurses should reiterate feeding advice and answer any concerns or questions raised by the caregivers.

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PEDIATRIC PAIN ASSESSMENT AND MANAGEMENT

Summary Post-Operative Pain Management:

Post-Operative pain is a normal response following surgery. It is self-limiting and reduces as tissue damage resolves. The severity of pain reflects the degree of tissue damage but it is not the only factor. Fear and anxiety increase pain and produce a poor response to drugs.

Pain has a sensory component (sharp, stabbing, aching sensations) and an affective component making the patient irritable, anxious or afraid which will exacerbate suffering. The contribution of these components will vary from patient to patient.

There are many misconceptions about pain perception in infants, notably that neonates and infants are physiologically unable to feel pain. This is NOT true.

Pain management is important. Not treating pain will delay a patient’s recovery and discharge.

Physiological signs of pain in children:• Increased heart rate• Shallow respirations and possible drop in SpO2• Shrill, prolonged cry• Flushing• Diaphoresis, palmar sweating

Behavioral changes associated with pain:• Agitation and unconsolability• Swiping or thrashing• Rigidity or flaccidity• Clenching of fists• Facial expressions or resignation

Pain Assessment

Pain is the 5th vital sign. There is no ideal assessment technique in children, especially children who are preverbal and cannot express pain in words.Nurses and caregivers need to be aware of the child’s behavior and openly communicate their impressions and observations.

The FLACC (Face, Legs, Activity, Cry, Consolability) Scale is one example of an assessment tool that can be used in preverbal children. It has been validated in children from 2 months of age to 7 years of age

No particular expression or smile 0

Occasional grimace or frown, withdrawn, disinterested

1

Frequent to constant quivering chin, clenched jaw

2

Normal position or relaxed 0

Uneasy, restless, tense 1

Kicking, or legs drawn up 2

Lying quietly, normal position, moves easily

0

Squirming, shifting back & forth, tense

1

Arched, rigid or jerking 2

No cry (awake or asleep) 0

Moans or whimpers, occasional complaint

1

Crying steadily, screams or sobs, frequent complaints

2

Content, relaxed 0

Reassured by occasional touching, hugging or being talked to or distracted

1

Difficult to console or comfort 2

Face

Legs

Activity

Cry

Consolability

FLACC Scale

Total the scores to assess the patient’s level of pain:Score 0 No Pain

Score 1-3 Mild discomfort or pain

Score 4-6 Moderate pain

Score 7-10 Severe pain

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Pain Management

Generally, the post-operative pain experience by most children, infants and babies after cleft lip and/or palate surgery is not severe. However, post-operatively the nurse should look for signs of pain. The nurse should also encourage the caregiver to touch, hold and comfort the child following surgery. Both pharmacological and non-pharmacological methods can be used to relieve distress and pain in patients post-operatively.

Non-pharmacological means may be effective for the first 6 hours post-operatively if good intra-operative analgesia was given. For most of the babies who have been starved per-operatively in accordance with anesthesia guidelines and protocols, their main concern is feeding. The post-operative feeding regimen will depend on the type of operation and the surgeon’s instructions. Many surgeons are happy for babies to breastfeed soon after a cleft lip repair. However, it is important to know if the anesthesiologist has given an infraorbital nerve block, as this will make the upper lip numb and cause the baby to have difficulty sucking. Additionally, a mixture of sugar and slightly warm water will often be sufficient to soothe a disgruntled baby in the first few hours post-operatively.

Multimodal analgesia uses the different types of drugs and methods of administration to provide superior pain relief with reduced dosage and side effects. The World Health Organization has described an analgesic ladder to help with administering pain relief. Always start at the bottom and work your way up towards the top, as necessary, without stopping the drug on the step below.

Continued on page 30

Paracetamol/Acetaminophen

Loading dose: 30-40mg/kg PR or 20mg/kg orally Maintenance dose 15-20mg/kg (PR or oral)Maximum dose 24 hours 90mg/kg PR or oral)

Ibuprofen Dose: 5mg/kg/6 Hourly Maximum single dose: 200mgMaximum dose: 800mg/day Do not give in babies < 6 months

Diclofenac Dose: 1mg/kg 8 hourly (same dose oral or rectal) Maximum single dose: 50mg Maximum dose: 150 mg/day Do not give babies < 6 months

Tramadol Dose: 1-2mg/kg 6-8 hourly Can be given orally or IV Avoid in children < 1 year

Morphine Dose (IV): 0.1 mg/kg; usually giv-en in theater Dose (oral): 0.2-0.4 mg/kg 4-6 hourly Nurses must monitor respiration and treat any respiratory depres-sion with naxolone

Analgesic LadderBottom

Top

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First step: Paracetamol (also known as Acetaminophen or APAP) and/or non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or diclofenac.

Paracetamol is a very safe drug in children and can be given every 6 hours, usually in syrup form for babies.

NSAIDs cannot be given to babies under 6 months of age and must be used with caution in children with coexisting brittle asthma. NSAIDs can cause increased bleeding. This is unlikely to be a problem in a cleft lip patient but the nurse should check with the surgeon before giving it to a cleft palate child.

Second step: Weak opioids. Worldwide, the most commonly used weak opioid is codeine. This can be given orally, rectally or intramuscularly – but NEVER intravenously. Tramadol is another weak opiate which is increasing being used in children. The opiate effect is similar to codeine and it also has some inflammatory action.

Final step: Strong opioids. The final step is strong opiates like morphine. These need to be used cautiously in babies and neonates as they have an increased effect. Strong opioids can cause respiratory depression, nausea, vomiting and pruritus. Morphine can be given intravenously and orally. Intramuscular use should be avoided, if possible. REMEMBER

A baby can experience pain.

Assess pain it is a vital sign

Use multimodal analgesia which includes non-pharmacological methods first.

Communicate closely with caregivers.

Reassess

Discharge Preparation

Preparing the child and their family for discharge is the final element of nursing care.The goal of discharge preparation is to ensure that the patient’s family is confident to continue to care for their child at home. To do this, it is essential that nurses ensure that the family is given all necessary information.

Preparation for discharge begins on admission and continues until discharge. The day of discharge is time to reinforce previous information and give final information and confirm that the family understands the information they are given.

Discharge preparation includes advice on:• Feeding• Preventing trauma to the operation site• Analgesia after discharge• Signs of post-operative complications• What to do if complications arise• Further treatment, if required

Feeding – caregivers should be reminded to continue a soft, sloppy diet following cleft palate repair for 3 weeks. Nurses should discuss suitable foods and foods to be avoided.

Preventing trauma to the operation site – nurses should ensure that caregivers understand how to keep the lip suture line clean without disturbing the sutures. They should remind caregivers to avoid using straws and dummies/pacifiers and to feed very carefully ensuring spoons don’t touch a repaired palate.Analgesia after discharge – discuss suitable analgesia and dosages.

Post-operative complications – complications after discharge do not occur frequently but it is important that caregivers know how to recognize them and what to do if they occur. They need to know when and where to seek help if problems arise. Complications may include infection or wound breakdown.

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Further treatment if required – it is important to discuss with caregivers if a child has a cleft lip and palate that may be repaired separately. Nurses must stress the importance of returning for a later palate repair and reminding caregivers of the implications if they fail to do so

DOCUMENTATION

Nursing documentation is an essential part of nursing care. Nursing documentation is a written record of the care which has been provided. It should include a complete summary of the nursing care delivered.

High standards of documentation promote continuity of care between nurses across shifts. Documentation of changes in the patient’s condition enable the early detection of problems and ensures that information is shared among the nursing team. Documentation also improves communication and the dissemination of information between the interdisciplinary cleft team.

Documentation is an essential part of nursing care and the use of standardized nursing documentation such as a care pathway improves the quality and consistency of care that nurses provide to patients. If an unexpected event occurs following surgery, nursing documentation is a vital part of the complete multidisciplinary record of the child’s progress. Documentation is an accurate account of what occurred and when it occurred.

Nursing care pathway for cleft surgery – this is a nursing tool that can be used to deliver consistent quality care, from admission to discharge. A sample can be found in Appendix B. It follows the child’s progress, includes prompts to guide care, reduces the time required to document care and reduces inconsistencies in care.

The Nursing Care Pathway has 4 components:• Prompts for pre- and post-operative

care and safety checklists• Nursing observation chart• Nursing intervention plan• Evaluation

Prompts and checklists – promote standardization and consistency and are easy to check to ensure care has been given.

Nursing observation chart – indicates frequency of monitoring, includes a shaded grid to approximate abnormal readings.

Nursing intervention plan – includes nurse initiated interventions based on observations, clear guidance for nurses and a flow diagram to determine appropriate interventions.

Evaluation – includes a record of interventions and an evaluation of the effect.

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TRAINING YOUR TEAM

The purpose of this section is to give you the knowledge and skills you need to effectively teach what you have learned to nurses in your hospital.

If you keep your learning to yourself, the impact will be limited, if nursing practices are to improve you need to teach others what you have learnt.

There are many challenges you may face when training your peers – these include time constraints, workload pressures, shifts and unwillingness to consider new ideas.

Adult LearningAdults learn in different ways from children and these differences need to be considered when planningtraining.

Principles of adult learning include:• Learning by doing• Explaining the purpose – answering

why do I need to know this?• Recognize prior knowledge• Define expected outcomes• Learning must be relevant

Learning StylesPeople have different learning styles. Some learn better from listening, others from seeing, and others from experiencing or doing. Additionally, the amount of information the learner retains likely varies by activity. Learners that engage in discussion groups or practice by doing learn more than learners who only read or listen to lectures.

Based on research, these are the average level of learning retention based on different learning activities:

Planning to trainWhen you are planning to train other nurses you must:• Identify needs• Plan how to meet needs• Carry out training• Assess learning• Evaluate

Before the training begins and as part of the training process you need to identify needs. Ask – what does your team know already? What do you want them to know? Once you have decided this you can set targets or outcomes, such as: “By the end of the training participants will be able to…”

Once you know what to teach you need to decide how you will bridge the gap between what trainees know and what you want them to know. Plan how to meet needs by considering how you will deliver the information required and what resources you will need to do so. Think about how you will involve those you are teaching and how to facilitate learning (not just lecture).

It is also important for you to know if the participants are learning everything you wanted them to. You need to assess their learning during and at the end of training. This can be done in a number of ways including: asking questions, organizing a skills test or practical demonstration, giving a written test, or observing practices on the ward. After assessing learning, evaluate how the training has gone and consider strategies for improvement in future training.REMEMBER – we are ALL life-long learners. Training is a skill that requires planning and practice – but has the potential to make a significant impact in many lives.

Lecture 5%

Reading 10%

Audio-Visual 20%

Demonstration 30%

Discussion Group 50%

Practice by Doing 75%

Teaching Others 90%

ActivityAverage Learning

Retention Rate

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WHAT NEXT?

What are you taking away from this course?

The purpose of this training is to improve your knowledge, understanding and competence in the care of children undergoing cleft lip/palate surgery. We hope that you will use this training to raise standards of nursing care in your hospital and improve patient outcomes.

Learning without meaningful follow-up and application is largely forgotten and wasted.

How can cleft care improve in your hospital?

Make a list of the three most important changes to nursing practice that you would like to see in yourhospital following this course

1.

2.

3.

Make a plan for changeIt is important to plan what you are going to change and how you are going to implement the change. Unplanned changes usually fail. Consider:• When will the changes start?• Who needs to know• Who will the changes affect?• Who needs training?• What resources are needed?

Don’t be too ambitious at first. It is better to plan a small change and be successful than to plan a large one that fails. Consider breaking the changes into manageable steps which can be implemented one at a time. Remember that change must be achievable while not conflicting with your current work demands.

Communicate the planCommunicate the plan to you whole team. Be ready to repeat and answer questions.

Give clear directionMake sure that all nurses who will be affected by changes know what to expect and what will be expect of them.

Share your new skillsPlan training sessions using course materials to share your new skills with your team.

Make the reasons for change clearBe ready to explain why change is necessary; don’t expect everyone to agree with you immediately.

Be prepared for resistanceResistance to change is part of the process. Anticipate it and be prepared to calmly repeat explanations andencouragement. Don’t be discouraged.

Lead by exampleAct as a role model to make change. Don’t expect others to do things if you don’t do them.

Encourage everyoneEncourage those who are embracing the change, support those who are struggling or unwilling. The more people who join, the easier change will be.

Keep communicatingBe prepared to repeat explanations throughout the process.

Celebrate improvementsAs you notice positive changes and improvements in care (even small ones)celebrate the success to helpmaintain momentum.

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ACTION PLAN

Select ONE area within your nursing practice which you would like to change or improve after this training. You may want to make many changes but it is easiest to use a different action plan for each change. Answering each of the questions below will help you implement that plan.

An action plan should be:• Simple and straightforward• Clear and time bound• Contain items that you can implement

with or without support• Achievable in the context of

your work demands

1.What would you like to change/improve/introduce or teach?

2.Why do you want to do this?

3.How will you implement the change?

4.What barriers might make implementation difficult?

5. How will you avoid or overcome these barriers?

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6.Who needs to be involved in the change?

7. How will you measure progress?

8. Timing: When do you intend to start implementing the item?

9. Resources: What resources/training will be needed?

10. Benefits: What benefits do you hope will result from your actions?

11. Commitment: What will you do in the next 21 days?

12. When do you plan to meet your manager to discuss your ideas?

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KEY CONCEPTS

These key concepts are found throughout your training.

Remember Them!!

The following are essential nursing skills:

Assessing

Deciding

Reacting

Appropriate, prompt nursing action saves lives

Pre-operative physical preparation is intended to prevent or reduce peri- and post-operative complications

Smile Train’s nil by mouth (NBM) recommendations are:

2 hours for clear liquids (water, black tea, apple juice)

4 hours for breast milk6 hours for solids and non-clear

liquids (including formula and cows milk)

Pre-Operative Preparation Includes:• Document weight and height• Document any allergies• Nil by mouth• Check for fever• Observe for signs of upper

respiratory tract infections• Name label• Consent signed by doctor• Complete pre-operative investigations

Recovery is a safe, controlled, staffed, equipped environment.

Do NOT take a child out of recovery unless it is safe to do so.

Essential equipment for post-operative cleft care. Prepare bed space BEFORE collecting the child from recovery. Make sure you have:Oxygen StethoscopeOxygen saturation monitor Ambu bag Suction (desirable)

Retrieving from recovery

Before collecting a child from recoverycheck that:

√ Child is protecting his/her airway √ Child is awake/easily rousable √ Child is not in obvious discomfort √ Child is not bleeding √ Child is not vomiting √ Observations are stable √ Documentation/complete post- operative instructions written

Post-Operative Nursing Care Priorities

Airway Breathing Circulation

Role of the Nurse

Pre-Operative Nursing Care

Post-Operative Nursing Care

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Potential Post-Operative Problems/Needs

Nurses must be constantly vigilant in case the child’s post-operative recovery

includes unanticipated events.

Always be prepared and ready to act!

Post-Operative Vital Signs Monitoring AfterCleft Lip/Palate Surgery

1 hourly heart rate, respirations, AVPU & oxygen sat, 4 hourly temperature (or 1 hourly

temperature if high or low) for 24 hours.4 hourly vital signs thereafter

Montioring Respiration is the most undervalued and important vital sign.

Respiration is usually the first vital sign to alter when a patient deteriorates

Monitoring & Nursing Assessment

Respiratory Distress vs. Respiratory Failure

Cyanosis is a late sign of Hypoxia

Early signs: tachypnea and tachycardia Agitation, Restlessness and ConfusionCyanosis = Oxygen Saturation < 85%

Oxygen Saturation should be > 94%Set alarm limits at 94%Potential changes in respiratory rate

after cleft surgery

Increase Decrease

Respiratory distress Anesthetic agents

Bleeding Opioids

Pain Pain

Pyrexia Cardio/respiratory failure

Fluid volume excess

Hypothermia

Age (years) Respiratory rate

<1 30-40

1-2 25-35

2-5 25-30

5-12 20-25

>12 15-20

Normal Respiratory Rate

Prompt nurse led interventions for a child in respiratory distress may prevent deterioration into respiratory failure and improve the child’s chances of survival.

Signs of respiratory distress in a child

Signs of respiratory failure in a child

Alert but tired Decreased level of consciousness

Tachypnea Apnea/reduced respiratory rate

Increased work breathing

Increased/Decreased work breathing

Tachycardia Bradycardia

Cyanosis (late sign) Cyanosis

Decreasing Sp02 Low Sp02

Normal Resting Heart Rates

Age (years) Beats per minute (BPM)

<1 110-160

1-2 100-150

2-5 95-140

5-12 80-120

>12 60-100

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Feeding

Post-Operative Complication

Pediatric Basic Life Support

Basic Life Support sequence

Even if you are unsure of the cause of a post- operative complication…DON’T PANIC! REMEMBER ABC

Airway (Jaw thrust, chin lift)Breathing (Look, listen, feel and Oxygen by nasal prongs, face mask or AMBU bag)Circulation (20ml/kg N/Saline or Ringers lactate)

Calculating blood volume in children < 3 years

80-85 ml per kg(e.g. 6kg child has blood volume of 480- 510mls)

FLUID RESUSCITATION

20 mls per kg body weight of Ringers Lactate or normal saline (stat)Repeat

Before a post-operative feeding begins a child must be:

Fully awake ResponsiveProtecting their airway

Premature feeding can lead to life- threatening aspiration!

First post-operative feeding MUST be supervised by a nurse!

If you suspect airway obstruction…

Open airway, Give oxygen, Stay with the child, Call for help!

Post-Operative Cleft Palate Feeding Advice:• Soft, sloppy diet for 3 weeks• Avoid hard, rough foods• Feed small quantities initially• Feed propped upright

• Respiratory insufficiency Respiratory Arrest

Cardiopulmonary Arrest in Children

• Respiratory arrest Cardiac Arrest

• Hypoxia Bradycardia

• Bradycardia Asystole

UNRESPONSIVE

Shout for helpOpen airway

NOT BREATHING NORMALLY

5 rescue breaths

NO SIGNS OF LIFE 15 chest compressions

2 rescue breaths, 15 chest compressions

CALL DOCTOR

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GLOSSARY OF CLEFT TERMS

Alveolar bone grafting: The alveolar ridge can be incomplete in cleft lip/palate. The defect is repaired with a bone graft, usually taken from the hip.

Alveolar ridge: The bony ridge of the gum line containing the teeth.

Cleft: “Split” or “Separation”

Columella: The central, lower portion of the nose which divides the nostrils into right and left.

Eustachian Tube: The air duct which connects the nasopharynx with the middle ear; usually closed at one end, opens with yawning and swallowing; allows ventilation of the middle ear cavity and equalization of pressure on two sides of the eardrum.

Fistula: An abnormal opening, usually referring to a hole in the palate after repair.

Glue ear: A condition where the middle ear fills with glue-like fluid instead of air, cuasing dulled hearing due to poor Eustachian tube function. Common in cleft palates even after repair.

Grommet: A tube which is placed in the ear drum to allow air into the middle ear in the treatment of glue ear.

Hard Palate: The front part of the roof of the mouth containing bone covered by mucosa.

Malocclusion: Incorrect positioning of the upper teeth in relation to the lower teeth.

Mandible: The lower jaw

Maxilla: The upper jaw.

Nasal Septum: The “wall” that divides the nose into right and left halves. It normally joins the roof of the hard palate like an inverted “7”.

Palatal Insufficiency: A lack or shortness of tissue preventing the soft palate from contacting the back of the throat (pharynx).

Palate: The roof of the mouth including the front portion (or hard palate) and the back portion (or soft palate).

Philtral Columns: Normal ridges in the skin of the central upper lip connecting the peaks of the Cupid’s bow to the base of the nose.

Pierre Robin Sequence: A condition existing at birth, presenting with cleft palate, micrognathia (a small lower jaw) and macroglossia (relatively large tongue). PBS often leads to breathing and feeding difficulties.

Soft Palate: The mobile soft tissue attached to the back of the hard part of the palate, crucial to swallowing and speech. It contains muscles whose function results in the closure of the mouth cavity from the nose cavity.

Submucous clefts: When the mucosa of the palate is intact but the palatal muscles are not intact.

Uvula: Small, cone-shaped muscular process hanging at the back of the soft palate.

Velopharyngeal Incompetence: Inability to achieve adequate velopharyngeal closure.

Velum: The soft palate