pediatric routine care

1. Routine Care in PICU

2. Objectives
• Outline the importance of routine care of children in
PICU
• Describe the elements of routine care and other care in
PICU

3. Team work is important

4. • What are the importance of routine
care in PICU?

5. Routine care of children in PICU
Importance:
• Facilitates identification of clinical issues
• Encourages patient centered care
• Prevents hospital acquired infections
• Ensures hygiene and comfort
• Reminds clinicians to ensure routine care and
treatment is applied to every patient

6. Elements of Care
FASTHUGS BID

7. Elements- FASTHUGS BID
• Feeding
• Analgesia
• Sedation
• Thromboembolic
prevention
• Head of bed
elevation
• Ulcer prevention
• Glucose control
• Spontaneous
Breathing Trial
• Bowel care
• Invasive device and
catheter
• De-escalation of
Drug

8. Feeding
• Malnutrition is linked to poor outcome
• Should start within 24-72 hrs
• Enteral feeding is preferred but parenteral feeding
as an alternative
• Monitor for intolerance to feeding
• Carbohydrate: 50-60%, (e.g. 38–120 kcal/kg/day)
• Protein: 1.5-3 gm/kg/day (15-30% lipids)

9. Analgesia

10. • Child should be monitored for:
– common signs of pain by using validated pain
assessment tool
• Use analgesic agents:
–to provide pain relief
–i.e. Paracetamol, Ibuprofen, Opioids
(fentanyl, morphine) etc.
• Reassess effect

11. Sedation
• Goal: patient to be awake and comfortable
• Sedative medications:
– midazolam, ketamine, propofol, opioids
• Level of sedation should be assessed using a
validated scoring tool
Thrombolytic Therapy
• Some ICU children are at an increased risk for
Thrombosis
• Consider pharmacological and non-pharmacological
methods of prophylaxis

12. Head of Bed Elevation
• Elevate HOB to 30-45 degree
• Reduce the incidence of:
- gastro-esophageal reflux (aspiration)
- ventilator acquired pneumonia (VAP)
Ulcer prophylaxis
• Risk of developing stress-related mucosal damage
• leads to increased mortality
• Consider H2 antagonists and PPI’s

13. Glycemic Control
 Blood sugar must be kept within normal range (60-
140mg/dl)
 Decreases rate of infection and minimizes the
hospital stay
Spontaneous Breathing Trial
• Should be performed everyday as child’s condition
improves

14. Bowel Care
• Defecation
Indwelling Catheters and Lines
Intravenous line, CVP line, A- line
• Inspect all invasive line insertion sites for:
- patency
- signs of infection
- security
- pressure areas
• Lines and dressings should be changed according to
hospital protocol or if soiled/damaged
• Catheter care

15. De-escalation of Antibiotic
• Does the child need antibiotic?
• Duration of antibiotic?

16. Other Nursing Care
• Mouth care
• Eye care
• Pressure Area Care
• Patient sponging
• Sleep promotion
• Tracheostomy care
• Care of children under mechanical ventilator
• Handover

17. Mouth care
• Clinically proven to reduce VAP
• Use chlorehexidine 0.12% especially for intubated
child
• Tooth brushing at least twice a day if child is able
to do

18. Eye care
• Perform 4 hourly
• Clean outer eye with normal saline and
gauze
• Use eye drops and/or ointment:
– to lubricate the eyes and to reduce the risk of
corneal abrasions as needed
• If patient cannot close eyelids properly:
– consider using barrier to promote eye closing

19. Pressure area care
• level of risk should be assessed using a validated
tool
• Patients should be repositioned and their skin
assessed at least 3 hourly
• Consider:
- pressure relieving mattress
- adequacy of nutrition/hydration
- mobilization

20. Sponge bathing
• Once a day or when required
• Reduces risk of infection and promotes comfort
• Use either water bath or disposable wipes
• Use clean to dirty approach (infection control)

21. Sleep promotion
• Limit visiting hours and promote rest periods
• Reduce stimuli (i.e. noise, lights)
– if needed use aids such as eye mask and ear
plugs
• Encourage a day/night routine

22. Tracheostomy care
• Stoma should be inspected for infection and wound
breakdown
• Clean daily/PRN with NaCl 0.9% soaked
gauze/cotton swab
• Use tapes to ensure security
• Make emergency airway management equipment
readily available

23. Care of Children Under Mechanical
Ventilation

24. Adequate oxygenation, ventilation and support for
work of breathing
• Assessment of the child receiving MV
• General observation: comfort of child, chest expansion,
color and consciousness
• Auscultation: breath sound
• Work of breathing
• Document cuff pressure every shift
• Volume and quality of secretions
• Continue monitoring
• Monitor gastric insufflation and remove air from
stomach

25. Correct position and patency of artificial airways
• Chest radiograph
• Auscultation for breath sounds
• ETCO2 monitoring
• Ensure artificial airway is secured and stabilized
• Suction only as needed: not according to a schedule
• Use close suction if available
• Hyper oxygenate the child before and after suctioning

26. Contd…
• Do not instill normal saline while suctioning
• Limit suction pressure to the lowest level to remove
secretions
– (60-100 in preterms and neonates, 80-120 mm of Hg in
children)
• Suction for the shortest duration

27. Maintenance of fluid and electrolyte balance
• Calculation and monitoring of all fluid intake
• Monitor urine output:1-2 ml/kg/hr
• Evaluation of lab value
• Daily weight
• Optimize nutrition through early initiation of
feeding via OG/NG tube

28. Child should remain free of nosocomial infection
• Minimize ventilator source of infection (VAP) by
emptying condensation in tubing
• Keep head of bed elevated at 30 degree unless
contraindicated
• Mobilize patient as far as possible
• Maintenance of oral hygiene
• Consider removal of additional potential source of
hospital acquired infection as a daily basis

29. Maintenance of skin integrity
• Asses skin integrity every 2-4 hrs
• Keep skin clean and dry
• Reposition child every 3 hourly
• Prone positioning for all ventilated children as far
as possible
• Maintenance of oral hygiene
• Moisture the lips every 2-4 hrs or as required

30. Acceptable level of comfort
• Assess child’s pain and sedation level
• Titrate pain and sedation medication as per
protocol
• Provide non-invasive comfort measure
• Parental presence
• Favorite blanket or toy
• Ear plug to reduce the noise level
• Dim lights
• Distraction technique

31. Points to be considered before handover
• Infusions refilled and lines correctly labeled
• Ensure patient is clean and comfortable
• Empty drainage bags emptied
• Ensure dressings intact and lines secured
• Check that room re-stocked, neat and tidy
• Ensure documentation completed

32. Handover of children

34. Summary
• Why routine care is important in PICU?
• What are the elements of routine care?