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Student Information and Induction Workbook
Paediatric Critical Care Unit
Queens Medical Centre Nottingham
Reviewed C Whittaker/K Broom Aug 2014
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Dear ____________________
On behalf of all the staff in the children’s critical care unit we would like to welcome you to
Paediatric Critical Care Unit (PCCU)
Your first day on the unit will be an informal induction day between 8-3. We look forward to seeing
you.
During your placement you will have at least two mentors.
Your mentors are _____________________________
____________________________
Shifts / Off Duty
Our shift times are as follows:Long day 07.00 – 20.00
Early 07.00 – 13.30
Late 13.30 – 20.00
Night 19.30 – 07.30.
Off duty is allocated by the student coordinators. You will be required to work these shifts unless
requested prior to your placement or negotiated with the student link nurses. All off duty changes
to be done by the student coordinators only.
Contact
Direct phone number for PCCU 0115 9709232.
Your student link nurses are Carli Whittaker (Critical Care Educator) Kirstin Broom (Junior Sister),
Beth Broughton (Junior Sister) and Joanne Bernardini (Staff Nurse).
Location
We are located on E floor, East block at Queens Medical Centre campus.
We are located adjacent to the lifts.
Notice board
There is a student Notice board located in the staff room which holds lots of useful information.
Sickness/absence
If you are late for shift or need to go off sick, please speak to the nurse in charge as soon as
possible. It is also your responsibility to inform the school of nursing of any absence.
Uniform/Presentation
You must always comply in full to the uniform policy with your university/hospital identification
clearly on display. If you do not comply, you will not be allowed to work.
Health and Safety
Emergency number for cardiac arrest / Fire etc 2222.
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Paediatric Intensive Care Unit
Philosophy of care
Our aim is to provide all children with individualised holistic care. We believe in acknowledging all
cultural, religious and spiritual values and to encourage family participation in their child’s care.
We try to provide a relaxed friendly atmosphere, encouraging an open and honest relationship
between family and carers. We offer educational information boards and leaflets in various
languages and scripts.
We aim to practise named nursing, delegating to each family a nurse responsible for planning,
implementing and evaluating their child’s care. We aim to provide continuity of care to allow the
child and family to develop trusting partnerships with a few familiar nurses.
We aim to have experienced, knowledgeable nursing staff and we encourage all staff to undertake
further training. We strive to offer research based care and to offer nursing care of the highest
standard.
The Unit
The Paediatric Critical Care Care Unit (PCCU) at QMC campus of Nottingham University Hospitals
Trust is expanding to a capacity of 14 critical care beds with a combination of 8 PICU and 6 PHDU
beds. The combined units have an 8-bedded open area and 2 cubicles that are used for isolation
or to provide the family with privacy on PICU then 3 2 bedded bays and 2 cubicles on PHDU.
Admissions to PCCU arrive from various sources; paediatric A&E, the wards, theatres (routine or
emergency), and retrievals from referring hospitals. Nottingham University Hospitals Trust are the
regional centres for oncology, neurosurgery, renal, spinal surgery, tracheostomy surgery and
therefore the critical care unit admits many children from other regional hospitals for treatment. We
offer care to children from the ages of 0 to 16 years.
Their individual needs will vary depending on the nature of their admission. Each bed space is
equipped in the same way. Daily safety checks are carried out to ensure the safety of staff and
patients. You will be expected to be involved in these checks at the beginning of each shift.
Handover starts at 0830 and Ward round starts at around 1000. Each patient is discussed in detail
and parents are asked to leave the ward during this period for confidentiality reasons.
During your placement you will come into close contact with the patients on
the unit. In accordance with NMC guidance your activities should always be
under the supervision of a registered nurse. You will be observing care that is
given, helping provide care and later, fully participating in providing care and
managing your own work load. At all times you should work only within your
level of understanding and competence, asking appropriate questions to
clarify uncertainty.
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As a pre-registered student you are never professionally accountable in the
way that would later affect an application to the NMC. As far as the NMC is
concerned it is the registered practitioners with whom you are working, who
are professionally responsible for the consequences of your actions or
omissions. This is why you must always work under direct supervision of a
registered nurse. This does not mean however, that you can never be called
to account by your university or by the law, for the consequences of your
actions or omissions.
Mentorship
As a team we take student learning very seriously and aim to support you as
well as we can.
The aim of this Critical Care placement is to provide an environment in
which you can learn and practically apply transferable acute care skills.
In this placement you will need to be able to apply theoretical knowledge to
the practice of assessment, planning, implementation and evaluation of
nursing care. It will be helpful for you to revise the basic anatomy and
physiology of the main body systems so you can observe and understand the
effects illness and disease have on all the systems of the body and on the
individual as a whole.
We are aware that you will have several skills assessments to complete
during this placement and that it is important for you to achieve a number of
them. From experience however, we feel you will get the most of this
placement if you also try and consider other learning opportunities.
In addition to your skills, suggested Learning outcomes include:
Be part of the morning ward round, both medical and with the
physiotherapists (as appropriate).
Understand infection control issues in the acute care environment.
Ensure that you are familiar with Trust policies.
Understand how to communicate effectively with members of this large MDT, the patients
and the families.
Understand principles of IV therapies including blood transfusions.
You
will
get
many opportunities to become familiar with handling IV
medications, so use them.
Become confident in the use of the observation charts, recording the
observations, balancing fluids and checking the bed space at the start
of each shift.
Be familiar with managing your own patient workload.
Observe on a crash call if the opportunity arises.
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Expectations of learners:
To contact the clinical area 2 weeks prior to commencing your
placement.
Adhere to our philosophy of care.
To identify your learning needs at the start of your placement and
discuss how they will be met during your first interview with your mentor.
To be receptive to the learning opportunities available and be proactive in engaging in
activities designed to meet your learning needs.
To utilise the mid- and end-interview to jointly reflect on your own
progress.
Flexibility in the shift pattern in order to maximise contact time with your mentor and
experience the 24 hour care of the NHS. If you
change your off duty it is your
responsibility to ensure that you work the
minimum number of shifts with your mentors.
To notify your mentor and/or other members of the team if you have a
concern about this placement.
If not able to discuss concerns with your mentor then please find
another member of staff whom you feel comfortable with, or raise it with your university
link lecturer.
Evaluate the placement by giving constructive feedback.
Expectations of Placement
All students should receive as a minimum:
You will be allocated at least two mentors for the duration of your placement
and will be allocated to work with them as often as possible.
A tour of the unit, placement area.
An explanation of relevant policies procedures and guidelines.
A copy of the unit student information pack.
You should have your preliminary interview within the first 2 shifts of
working with your mentor.
You and your mentor should arrange provisional dates for intermediate
and
interviews.
You will be welcomed onto the ward and be treated as a valued
member of staff by all of the MDT.
Learning opportunities will be made available to students by all staff
members where appropriate. All staff are responsible for student
learning.
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The Team
There are four Consultant Paediatric Intensivists, who rotate on a weekly basis to manage the unit.
Lead Consultant: Dr Patrick Davies
Dr Shri Alurkar
Dr Dusan Raffaj
Dr Haris Kotsonis
Paediatric registrars and senior house officers also support the unit.
Sue Mager leads the nursing staff on PCCU.
There are approximately 80 members of nursing staff on the unit, many of which hold the
Specialist Paediatric Intensive Care Nursing Course.
The unit employs a:PCCU Assistant/Housekeepers – Linda Benson, Jane Inger , Paul Wainwright
PCCU Clinical Development Nurse - Rachel Bower
PCCU Educator– Carli Whittaker
PCCU Foundation Programme Educator- Louise Brown
PCCU Receptionists–Sue Clarke, Lisa Smith, Pat McGrath and Hannah Scutter.
PCCU Retrieval Co-ordinator – Abi Hill
PCCU Sisters- Sarah Johnson, Anita Jarvis, Amanda Griffiths
RETRIEVAL SERVICE
We have an active 24-hour retrieval service. The team will retrieve children from hospitals where
specialised intensive care for children is unavailable.
Retrieval nurses under take specialist
training and must fulfil certain criteria prior to becoming a team member. Please take the
opportunity to go out with the team if space is available. Training nurses and doctors take priority.
RESEARCH
PCCU has a strong commitment to research and nursing staff are greatly encouraged to
participate and contribute their views. We are currently undertaking several studies; please feel
free to speak with link nurses or research nurse for more information.
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Workbook
Airway and Breathing
Assessment
How would you perform a respiratory assessment?
______________________________________________________________________________
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__________________________________________________________________________
What adjuncts can be used to support airway and breathing?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________________
Signs of respiratory distress
*
*
*
*
*
*
*
*
*
*
*
*
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The above picture shows the equipment needed for Intubation.
Where would this equipment be located on PICU?
Can you name all the equipment in this picture?
The above picture shows a patient being intubated orally. You could research
the procedure used for intubation and what things are done/assessed to
ensure that intubation has been successful.
Reviewed C Whittaker/K Broom Aug 2014
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Tracheostomy
Often on PCCU you may be caring for a patient with a tracheostomy, often this is due to
respiratory and / or cardiac conditions. These patients sometimes require Long Term Ventilation.
To enhance their lung capacity, gaseous exchange and optimise their breaths with this ventilatory
support. This can be provided via a face or nasal mask, however on PCCU we specialise in
patient with LTV via a tracheostomy.
In most respects the care required for these children is no different to that of any other child you
will care for. It may be necessary to suction the child through the tracheostomy fairly regularly to
prevent a blockage that would inhibit their breathing. Nebulisers are also often required to loosen
secretions. The tapes securing the tracheostomy need to be changed daily and the tracheostomy
tube is changed weekly along with the circuits if they are receiving ventilation. Children with a
tracheostomy will have an emergency box in case of a blockage that requires an emergency
tracheostomy change. It is important that this is checked with your normal safety checks at the
beginning of the shift to ensure all equipment required is present.
Many of these children will go home with their tracheostomy with or without ventilation depending
on the child’s condition. An important part of the care of these children therefore is discharge
planning and working with parents and professional teams within the community to allow the child
to return home as soon as possible.
Great Ormond Street Hospital (2007)
Reviewed C Whittaker/K Broom Aug 2014
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Types of Ventilation on PICU
On PICU we use a variety of different types of ventilation Modes and settings.
The most common ventilator used on PICU is the Evita XL. Along side this there is the Sensor
Medics HFOV 3100A/3100B and the SIPAP infant ventilator.
Whilst on PICU you may see these machines used. Take some time researching the following
types of ventilation, what they mean and how they work.
BiPAP_________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________
SIMV__________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________________________________________________
CPAP_________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________________________
HFOV_________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________________________
NIV/SIPAP_____________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________________________
ST____________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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Please name the following machines
1.
2.
3.
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4.
5.
Calculating Endotracheal tube (ETT) size and length.
ETT Size Age (yrs) +4
4
Length Oral: Age(yrs)+12
Nasal: Age(yrs)+15
2
2
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Ventilator Observations.
Fio2- ____________________________________________________
Frequency- _______________________________________________
PIP-_____________________________________________________
PEEP-. __________________________________________________
Minute Volume_____________________________________________
Minute Volume Leak-________________________________________
VTi and VTe- ______________________________________________
Slope/Ramp_______________________________________________
Example; 10kg patient. What would the expected TV be: The expected tidal volume range is._____________________________
T insp ____________________________________________________
PASB ____________________________________________________
Trigger- __________________________________________________
Reviewed C Whittaker/K Broom Aug 2014
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Blood Gases
Terminology:
ABG - Arterial blood gas
VBG - Venous blood gas
CBG - Capillary blood gas
ABG
PH 7.35 – 7.45
PCO₂ 4.5 – 6
PO₂ 10 – 14
HCO₃ 22- 26
BE ±2
SpO₂ 96 – 100
There are no reference values for VBGs and CBGs. Both have lower pO2 and
are unreliable measurements, however they are good for monitoring the
pCO2. When measuring pCO2 the reference values are the same as an ABG.
Analysing blood gases allows you to see how well the respiratory system and
metabolic systems are working. It shows the interaction between the lungs,
blood and kidneys.
Guide to Interpreting Blood Gases:
Look at pH to determine alkalosis or acidosis
Look at pCO₂ to determine if it is a respiratory disorder
Look at HCO₃ and BE to determine if it is a metabolic disorder
Remember they can have components of both. Is there a
compensatory mechanism happening?
Now try and interpret the examples given below and list the common causes
for these derangements.
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Examples
1.
2.
3.
4.
pH 7.24
pCO₂ 9.8
Description: __________________
________________________
p0₂ 12
Causes: _______________________
HCO₃ 42 ‫־‬
BE +0.5
________________________
_________________________
pH 7.53
pCO₂ 3.2
Description:_____________________
_________________________
pO₂ 11
Cause: _________________________
HCO₃ 24
BE +1
_________________________
_________________________
pH 7.22
pCO₂ 5.3
Description:_____________________
_________________________
pO₂ 12
Cause: _________________________
HCO₃ 14
BE –8
_________________________
_________________________
pH 7.5
pCO₂ 5.5
Description_____________________
_________________________
PO₂ 14.9
Cause: ________________________
HCO₃ 32
BE +5
_________________________
_________________________
Reviewed C Whittaker/K Broom Aug 2014
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Cardiovascular
Assessment
How would you perform a cardiovascular assessment?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Estimated Weight Calculator
0-12 Months (0.5 x age in months) +4
1-5 years (2x age in years) +8
6-12 years (3x age in years)+ 7
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Fluid Management
Fluid management is an essential part in a patients care. Calculating that your
patient is receiving the correct amount of fluid is part of your daily safety
checks. There are complete guidelines that can be found on the ward.
Normal maintenance fluid requirements apply as they would typical, however
in some circumstances restrictions or additions may be a made.
Example
A child might be restricted to 80% fluid.
The child weights 8kg
Normal 100% allowance
8 x 100 = 800mls per 24hrs
80% restrictions
8 x 80 = 640mls per 24 hours
Now try this example
A child has a 90% restriction in place
The child weights 12kg
______________________________________________________________
______________________________________________________________
______________________________________________________________
The Intravenous fluid of choice is currently 0.9% NaCl and 5% Dextrose
however this does not apply to all patients. From the Fluid Management
guidelines what fluid is recommended for Head Injury patients?
_____________________________________________________________
The PICU chart allows you to keep an accurate record of a patient’s fluid
balance. You will be part in calculating the overall balance of your patient
and changing your plan of care accordingly.
Some patients require additional fluid, three reasons are show below
Fluid Resuscitation for Shock
Bolus of 10-20ml/kg is given and can be repeated if necessary. This is normally 0.9% NaCl, 4.5%
Human Albumin Solution or commercial colloid ie Gelofusin.
Replacement of Pre-existing Fluid Losses
To calculate fluid deficit,
Fluid deficit (ml) = weight (kg) x % dehydration x 10
This fluid should be replaced over the next 24 hours
Replacement of Ongoing Fluid Losses.
Fluid losses should be replaced ml for ml, usually with 0.9% NaCl +/- KCL.
If there is significant blood loss, packed cells may be used.
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Inotropes.
Inotropic drugs or catecholamines are widely used for a range of problems, these include: Cardiac arrest
Myocardial failure
Acute and chronic cardiac failure
Renal dysfunction
Septic and cardiogenic shock.
The role of an inotrope is to maximise cardiac output and optimize its distribution.
Children who require Inotropic therapy also require continuous cardiac, blood pressure, respiration
and saturation monitoring. The measurement of central venous pressure is also desirable.
The most commonly used inotropes used on PICU are: Adrenaline, Noradrenaline, Dopamine, Dobutamine and Milrinone
Inotropic Action is _______________________________________
Chronotropic Action is ____________________________________
Vasoconstriction is _______________________________________
Vasodilation is __________________________________________
Nursing Implications for Inotropes.
-Continuous monitoring of heart rate, arterial blood pressure, respiration rate and oxygen
saturations are essential.
-Central venous access is required for administration of medication- can easily cause
extravasations and lead to necrosis.
-Interruptions in the infusion may result in an alteration of the blood pressure/ heart rate. This
means that they must not be stopped. 3 way tapes are inserted into the inotrope lines to enable
double pumping.
-An inadvertent flush may result in a large increase in heart rate and blood pressure.
-Can run with other Inotropic drugs, but nil else.
-Patient requires accurate fluids balance for duration of administration
-Weaning of drug required to prevent rapid decrease/increase of heart rate and blood pressure,
while keeping the drugs within a therapeutic range.
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Receptors and Sites
Receptor Site
Peripheral vascular beds.
1
Myocardium
2
Presynaptic
Central
1
Myocardium
2
Airway smooth muscle.
Myocardium
Peripheral Vascular beds
DA1
Renal and splanchnic beds
Myocardium
Peripheral vascular beds
DA2
Presynaptic neural endings
Clinical actions of Catecholamines
Drug
Adrenaline
Receptor
1
2
1
Noradrenaline 1
1
Dopamine
Dobutamine
DA1
DA2
1
Actions
Inotropic and chronotropic.
Peripheral vasodilation.
Peripheral vasoconstriction
At high doses
Peripheral vasoconstriction
Inotropic and chronotropic
2
Renal and splanchnic vasodilator.
Renal and splanchnic vasodilator.
Peripheral vasoconstriction
At high doses
Inotropic and chronotropic at high doses.
1
2
1
Inotropic and minimal chronotropic.
Peripheral vasodilation
Minimal peripheral vasoconstriction.
Reviewed C Whittaker/K Broom Aug 2014
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DISABILITY
How would you assess the neurological status?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
INFECTION PREVENTION & CONTROL
Infection Control Link Professionals
We currently have several link nurses, try to find out who they are and put their names here
_____________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Infection Control is high on the Trust’s agenda
- MRSA ~ less than 4 new bacteraemia cases per month
- C.Diff ~ 5% reduction in new cases each month
Apron & gloves for ALL patient contact
- Familiarise yourself with apron colour coding
Weekly hand washing audits (Mondays)
MRSA screening of all PICU patients
- Routinely screen ALL patients every Tuesday
- Screen all admissions regardless of where they are from
- Screen all pts with previous MRSA colonisation
- All patients MSRA status to be checked and documented on
care plans.
Ongoing monthly audit of invasive lines:
PVC
CVC – CVL days
Renal dialysis catheters
Urinary Catheters
Ventilators
…as part of DoH “Saving Lives” initiative (2007) Matching Michigan
Infection Control Policies kept in wardrobes behind desk and online
Results of Audits displayed in staff room
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PCCU Drug Calculations
On the ward you will find a variety of Paediatric medication formularies, and it
is good to get into the habit of checking the doses of the medications
prescribed for your patient. You can also find out information from the bedside
folders.
We also use a Drug Infusion Calculator on PCCU. Every patient will have one
printed out on admission and one of the bedside safety checks is to ensure
that it is present.
Group these drugs into the appropriate categories found on the following page
inotropes, analgesics, sedation, paralysis etc
Adenosine
Adrenaline
Aminophylline
Amoxicillin
Atenolol
Atrovent
Captopril
Cefotaxime
Chloral Hydrate
Ranitidine
Clonidine
Dexamethasone
Dnase
Dobutamine
Dopamine
Erythromicin
Fentanyl
Frusemide
Gentamicin
Ibruprofen
Lorazepam
Mannitol
Midazolam
Milronone
Morphine
Noradrenaline
Pancuronium
Paracetamol
Penicillin
Phenobarbitone
Phenytoin
Salbutamol
Spironolactone
Vancomycin
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Paralysing agents
Analgesics
Sedatives
Anti-convulsant drugs
Respiratory drugs
Antibiotics
Inotropes
Diuretics
Cardiac drugs (include for heart failure, anti arrhythmias)
Other
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Now calculate the following, show your workings out at the side.
Paracetamol (120mg in 5 mls)
210mg________________________________________________________
45mg ________________________________________________________
80mg________________________________________________________
100mg________________________________________________________
240mg________________________________________________________
Ibuprofen (100mg in 5 mls)
40mg, ________________________________________________________
60mg, ________________________________________________________
35mg, ________________________________________________________
90mg, ________________________________________________________
160mg.________________________________________________________
Chloral hydrate (500mg in 5 mls)
100mg________________________________________________________,
60mg________________________________________________________,
350mg________________________________________________________,
75mg________________________________________________________,
40mg________________________________________________________.
Phenytoin (oral 30mg in 5 mls)
20mg________________________________________________________,
70mg________________________________________________________,
50mg________________________________________________________,
45mg________________________________________________________.
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Phenytoin (IV 250mg in 5 mls)
20mg________________________________________________________,
45mg________________________________________________________,
100mg________________________________________________________,
125mg________________________________________________________
225mg________________________________________________________.
Metronidazole (500mg in 100mls).
70mg________________________________________________________,
100mg________________________________________________________,
350mg________________________________________________________,
165mg________________________________________________________.
Gentamycin (80 mg in 2 mls)
50mg________________________________________________________,
20mg________________________________________________________,
35mg________________________________________________________.
100mg________________________________________________________.
Ranitidine (50mg in 2mls)
22mg________________________________________________________
14mg________________________________________________________
36mg________________________________________________________
42mg________________________________________________________
45mg. ________________________________________________________
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Infusions
Refer to the PCCU infusion prescription sheet to calculate the dose and diluting fluid.
Conversion for micrograms/kg/hr
Amount of drug x1000
Divide by patients weight
Divide by volume in syringe
Conversion for micrograms/kg/min
Amount of drug x1000
Divide by patients weight
Divide by volume in syringe
Divide by 60 ( minutes in 1hr)
Morphine Sulphate
Two strengths- 10mg in 1 ml and 60mg in 2 ml.
Calculate dose to be added to a 50ml syringe for the following.
Calculate how many mcg/kg/hr = 1 ml for each weight
9kg__________________________________________________________
28kg_________________________________________________________
Midazolam
Strength 10 mg in 2 ml
Calculate dose to be added to 50mls .
Calculate how many mcg/kg/hr = 1 ml for each weight.
9kg__________________________________________________________
28kg_________________________________________________________
Noradrenaline
Strength 1mg in 1 ml
Calculate dose to be added to 50mls
Calculate how many mcg/kg/min = 1 ml for each weight.
9kg__________________________________________________________
28kg_________________________________________________________
Dopamine
Strength 200 mg in 5 ml
Calculate dose to be added to 50mls.
Calculate how many mcg/kg/min = 1 ml for each weight.
9kg__________________________________________________________
28kg_________________________________________________________
Rocuronium
Strength 200mg in 20 ml
Calculate how many mcg/kg/hr = 1 ml for each weight.
9kg__________________________________________________________
28kg_________________________________________________________
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PCCU Floor plan
Back
door
Blood
gas Drugs Linen
Sluice room Room
Reception
Retrieval
Room
Resource Room
Staff
toilet
Equipment
Room
Parent’s
toilet
Parents
Sitting
room
Managers
Office
Quiet
Office
Staff Room
Quiet Room
S
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