General care issues for Paediatric Critical Care: nursing procedure

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Objectives

Children are entirely dependent upon their adult carers to provide for all their physical and emotional needs. There are a number of specific nursing care guidelines the nurse may use when caring for the acutely and critically ill child. However, it is important that the nurse is aware of some general care issues when caring for the infant/child in Paediatric Critical Care. 

Scope

This nursing procedural guideline is intended to be followed by nurses involved in caring for the highly dependent or critically ill infant or child within the Paediatric Critical Care Unit at the Royal Hospital for Children (Glasgow). 

Audience

All nursing staff involved in caring for infants or children in Paediatric Critical Care should be familiar with this nursing care guideline.

Essential equipment (for each bed space and in each cubicle or 4 bed-bay):
  • Re-breathing set or ambubag & face mask – appropriate size
  • Wall oxygen, suction & tubing 
  • Oxygen/air blender – where indicated
  • Suction catheters – correct sizes & Yankeurs                                  
  • Spare portable oxygen cylinder (at least 1/2 full to full)
  • Disposable aprons                                                              
  • Disposable sterile & non-sterile gloves            
  • Alcohol hand gel/rub
  • Stethoscope
  • Patient trolley–stocked with items for all care and medicine administration and sharps bin    
  • Patient monitor(s) -with appropriate leads & disposables      
  • Ventilator & humidifier (where required) – check correct tubing & filter attached         
  • Fluid infusion pumps and syringe pumps                     
  • C.I.S. bed side computer or appropriate paperwork for documentation 
  • Laminated care signage - MOVE, W.A.I.T, Tracheostomy checklist (if required) & Ward round checklist
Procedure

PROCEDURE

RATIONALE

Handover & communication:

Each nurse should receive a full patient(s) handover from the nurse on previous shift. This should be carried out using a structured framework.

Information should include:

-Current condition using ABC approach

-Reason for admission & overview of medical history

-Significant events & planned interventions

Group handover & communication:

After individual handover, each 4BB should also have an initial ‘huddle’ with a brief update on each patient in the area & key care points highlighted (E.g. planned procedures, discharge, MRI, Grade 2 intubation or above)

Bedspace & Equipment:

Each bed space must have functioning wall oxygen, air and suction equipment. This must be checked at beginning  of each shift and documented by the nurse.

The bedspace area should be kept clean, dry and free from clutter.

Equipment should be in good working order and any broken items should be removed, cleaned, labelled and set aside for uplift to medical physics for review/repair.

The handover involves transfer of care and accountability from one nurse or nurses to the next.

 

At this time, critical patient information is given in a defined period of time and inconsistencies in this transfer of information could result in errors, near misses or harm to the patient.

 

 

Using a structured approach to information giving can improve the flow of information & reduce the likelihood of missed or inaccurate information on patient condition and care needs.

 

 

 

To ensure working oxygen, air and suction equipment available for either routine or emergency airway care.

 

 

To help maintain a safe environment and reduce risks to the patient, family and staff.

Patient assessment:

In Paediatric Critical Care each clinical nurse should perform a comprehensive, systematic assessment of his/her patient(s) at the start of each shift. E.g. aware of safety of ETT, airway issues/grade of intubation, IV access etc.

Assessment of findings and patient status should be documented in care plan evaluation on Clinical Information System (CIS) or on appropriate paperwork as soon as possible. Document safety & equipment checks

Assessment of the patient(s) following nursing handover is of critical importance in ensuring the nurse has effective knowledge about patients’ baseline and current vital signs and in identifying patient need and priorities.

Safety issues:
In principle, no infant or child’s bed side or cubicle should be left unattended.

However, the nurse will have to leave the child’s bed side or cubicle at times throughout the shift (E.g. to assist in the care of another patient or during breaks).

At this point the nurse MUST ensure that another nurse is able to observe the child.

If not carrying out a procedure at the bed side, the nurse must ensure that the cot sides or incubator safety shields are used. In specific patients ensure top & bottom of cots or beds are on.

 

Critically and acutely ill infants and children can deteriorate rapidly and may have life threatening changes in their condition, may remove invasive lines or may extubate themselves if left unattended.

 

 

To ensure patient safety and prevent accidental fall from bed or cot.

Responsibilities, documentation & organisation of care:

The nurse allocated each shift to care for an infant or child is responsible for the entire care of their patient, or patients, and acts to coordinate care with other health care professionals.

Any breaks will be arranged according to the needs of the child, unit need and safe coverage by mutual agreement between each nurse and their co-workers.

The nurse must give an extended report from huddle to another staff nurse prior to leaving for a break.

The second nurse assumes responsibility for the infant or child and interacts with the family and other health team members in the principle nurse’s absence.

 

The caregiver, by assuming full responsibility for monitoring the infant or child’s condition and care, can detect changes promptly.

When many people are involved in the care, a principle caregiver reduces the assumption that someone else did or did not complete a task, and helps to maximise resources.

To ensure the second nurse is aware of child’s condition and treatment prior to assuming temporary responsibility for their care.

Communication:

The staff nurse will report any deterioration in their patient’s condition directly to the nurse-in-charge and the Paediatric Critical Care medical fellow.

The staff nurse will also ensure that the nurse-in-charge is kept informed of all laboratory report findings and of any ongoing changes in their patient’s condition.

 

The staff nurse (principle caregiver) caring for the infant/child is the one person who has current and detailed information on the infant or child’s condition and observed changes.

The nurse-in-charge has overall responsibility for the care given to all patients in the Paediatric Critical Care Unit. They may be able to support the staff nurse in patient care, especially with regard to any appropriate procedure, policy or physician interaction required.

Monitoring:

All monitors and monitor alarm limits must be checked at least once each shift by the staff nurse caring for the infant or child. This must be documented.

Specific monitoring: E.g. ECG, SpO2, temperature, please refer to separate specific monitoring guideline(s).

Specific nursing procedures & care: E.g. Mouth, skin & pressure area care, chest drain.

Unless specifically directed all acutely and critically ill infants and children will require some form of monitoring of their overall condition.

Checking and setting appropriate alarm limits can help detect changes in child’s condition.

Refer to separate specific monitoring competencies & guideline(s).

 

Refer to separate specific competencies & care guideline(s).

 

Review

This nursing procedural guideline should be reviewed every two years from date of approval.

References

Morgan, B (2017) General care routines for all patientsStandards for Nursing Care. Critical Care Trauma Centre, London Health Sciences, Canada. 

NHS Greater Glasgow and Clyde (2018) Prevention and Control of Infection Manual: Hand hygiene - 5 moments and 6 steps. Standard Operating Procedures, Core Prevention Policies NHS Greater Glasgow Control of Infection Committee, Glasgow.  

NQB (2018) Safe, sustainable and productive staffing:  An improvement resource for children and young people’s inpatient wards in acute hospitals. NHS Improvement, London.

Paediatric Intensive Care Society (2015) Quality Standards for the Care of Critically Ill Children (5th edition). London, PICS. 

Royal College of Nursing (2013) Defining staffing levels for children and young people’s services. RCN standards for clinical professionals and service managers. RCN Publishing, February 2013, London.

Ream, RS Mackey, K Leet, T Green, C Andreone, TL Loftis, LL Lynch, RE (2007) Association of nursing workload and unplanned extubations in a pediatric intensive care unit. Pediatric Critical Care Medicine, Vol. 8 (4), pp 366 – 371.

Tibby, SM Correa-West, J Durward, A Ferguson, L Murdoch, IA (2004) Adverse events in a paediatric intensive care unit: relationship to workload, skill mix and staff. Intensive Care Medicine, Vol. 30 (6), pp 1160-1166. 

Editorial Information

Last reviewed: 01 October 2018

Next review: 31 October 2021

Author(s): Jeanette Grady, Clinical Nurse Educator

Approved By: PICU Clinical Guideline Group