NURSING

CARE
OF THE
CRITICALLY ILL
CHILDREN Prepared by:
Gita Tamang
Ward: PSICU
 CONTENT

Critically ill children

▪ Introduction

▪ Classification

▪ Pediatric Assessment Triangle(PAT) followed by ABCDE

approach.

▪ Nursing care
 INTRODUCTION

➢ “Critically ill children are those who are at risk for actual
or potential life threatening health problems. The more
critically ill the child is the more likely he or she is to be
highly vulnerable, unstable and complex thereby
requiring intense and vigilant nursing care.”

- American Association of Critical Care Nurses

CONDITION CONSIDERED AS
CRITICAL?
o Any patient with life threatening condition

- Acute respiratory failure(Pneumonia/

Asthma/Bronchitis )

- Cardiac arrest

- Heart block
 CONTD………

- Cardiac tamponade

- Acute renal failure

- Multiple organ failure

- Severe burn
 CONTD………

- Seizures

- Severe shock etc.

CLASSIFICATION OF CRITICAL ILL
CHILDREN
Level 0: Normal ward care

Level 1: at risk of deteriorating, support from critical care

team
CLASSIFICATION CONTD……

Level 2: more observation and intervention, single failing

organ or post operative care

Level 3: advanced respiratory support or basic respiratory

support, multi-organ failure
PAEDIATRIC ASSESSMENT TRIANGLE(PAT)
MOTTLING
 PAEDIATRIC ASSESSMENT

A: Airway

B: Breathing

C: Circulation

D: Disability

E : Environment-Exposure
 1. A: Airway

Airway patency: Look, Listen and Feel.

- If any obstruction;

▪ Back blow or chest thrust for <1year

▪ Abdominal thrust for patient >1year

Suctioning:
 2. B: Breathing

Respiratory rate: higher than adults due to higher

metabolic rate and oxygen consumption.

Oxygen saturation: desaturation will happen much faster

due to less respiratory reserve.
 3. C: Circulation

 Assess 5’p’:
I. Pulse
II. pulse volume
III. preload,
IV. peripheral perfusion(capillary refill time, temperature,
moisture, lactate level)
V. blood pressure.
 CONTD…..
Bleeding
• Bleeding is considered to be severe post cardiac surgery when drain
exceed;

- 4ml/kg/hour in the first hour

- 2ml/kg/hour in the second hour

- 1ml/kg/hour in the subsequent hours associated with

haemodynamically unstable.
 CONTD…..

 Sudden stoppage of drain loss should also be concern and

alert the nursing and medical team to possible developing
“Tamponade.”

Beck’s Triad:
‘hypotension, distention of jugular veins and muffled heart
sounds.’
 4. D: Disability

Level of consciousness can be assess by using the score of

AVPU(subjective), Pediatric Glasgow Coma Scale and
Mini-mental state Examination(MMSE).
AVPU SCORE
E: Environment-Exposure

Evaluate any signs or nearness of trauma, fever, injury,

skin rashes, unseen hemorrhage and wound leakage.
NURSING CARE IN CRITICALLY ILL
CHILD
A. Continuous monitoring

B. Respiratory care

C. Cardiovascular care

D. Gastrointestinal

E. Nutritional care
 CONTD…..

F. Neuromuscular

G. Comfort and reassurance

H. Communication

I. Infection control

J. Fluid and electrolytes

CONTD…..

K. Bowel and bladder care

L. Glucose balance
GASTROINTESTINAL/NUTRITIONAL CARE

Nutritional support means to ensure adequate nutrition

to avoid over and under malnutrition.

Under malnutrition leads to impaired muscle strength,

reduced wound healing and increased rate of sepsis.
 CONTD…….

Over nutrition leads to increased carbon dioxide

production resulting in difficulties in weaning from
ventilator support as well as lipogenesis causing
increased fat deposits in the liver.
Early(24-48hrs) enteral feeding reduces infection, stress
ulceration and GI bleeding.
 CONTD…….

In babies with cardiac defects the initiation time, rate and
feed type has shown to have impact on the incidence of
Necrotizing enterocolitis.

Breast milk is the first line feed in less than 1year of age if
not then infant formula to be used.
CONTD…….

2hourly bolus feeds to be initiated as first line feeding

regime.

Bolus feeds achieve fast enteral requirements significantly

faster than continuous feeds and risk of infection is also
less.
CONTD…….

 Nasojejunal feeding can reduce the frequency of pneumonia.

 NJ feeds are preferred over Parental nutrition(takes 3-4days to

fulfill requirement) with lower risk of sepsis and
complications. If feed tolerance is poor with noted vomiting
and absorption is repeatedly poor it is appropriate to use
prokinetic medications.
Special instruction for intubated patient

N/G feeding is not indicated in patients where extubation

is anticipated but if extubation is not expected for a
couple of days then start feeding.

In patient with coarctation repair N/G feeding should be

delayed for 12hours post operatively.
Special instruction cont.….

Post extubation, oral feeding should be commenced as

soon as possible if the patient remains well cardiovascular
and respiratory wise.

In all patient, N/G feeding is discontinued at least 4 hours

prior to planned extubation.
 COMFORT AND REASSURANCE

 Anxiety, discomfort and pain must be recognized and relieved

with assurance, physical measures, analgesia and sedatives.

 Simple analgesia: Paracetamol is prescribed regularly.

 First line: morphine sulphate commenced at a rate of 10-

40mcg/kg/hour depending on the surgery performed.
 CONTD….

 Morphine sulphate is also preferred analgesia for ECMO

patients due to high fentanly absorption to the circuit.

 Fentanyl infusions are preferred for some patients eg; those

patients with pulmonary hypertention or neuroprotection
where rapid or deep sedation is required. ( fentanyl dose
0.5mcg/kg for analgesia and 1mcg/kg for sedation).
 SEDATION

Benzodiazepines (midazolam): 50-250mcg/kg/hour

infusion

Muscle relaxants are rarely indicated, Vecuronium is the

agent of choice, but should be used with caution in
neonates and in patient with renal dysfunction.
 INFECTION CONTROL

Low grade (38˚C) fever during immediate post operative

period in common and may be present for 3-4 days.
VAP bundle(oral care by Chlorhexidine 0.2% child above
6years age)
CAUTI bundle
CLABSI bundle
SSI bundle
FLUID AND ELECTROLYTES BALANCE

Calculate fluid based on the SEGAR HOLIDAY formula

where 100% intake is;

- 100ml/kg for the first 10kg

- 50ml/kg for the second 10kg

- 20ml/kg for the subsequent kg

max. 2500ml for male and 2000ml for female.

 Maintenance fluids

 Weight <10kg(neonates):
= Dextrose 10% or 1/5 NS+D10%
 Weight >10kg(infants and older children)
= Dextrose 5% or DNS

Some infants may need a higher infusion to maintain glucose

homeostasis. This can be achieved by addition of a 50% dextrose
to achieve a desired glucose.
GLUCOSE BALANCE

Limited glycogen and glucose stores

Target Glucose: 80-200mg/dl

Persistent elevation in serum glucose >300mg/dl is

indication for Insulin therapy.
GLUCOSE BALANCE cont…

Hypoglycemia

-Newborn: blood sugar<55mg/dl

-Above newborn: blood sugar <45mg/dl

Neuroglycopenic syndrome: dizziness, weakness,

drowsiness, delirium, confusion, seizure and coma.
 Area to be concern during care of
critically ill child
 Developmental need of child

 Psychological dimension of child- separation anxiety, parental

visiting, divertional therapy

 Socioeconomic factor

 Long term care and rehabilitation dimension

 Terminally ill child management.