Download retrieval service - Nottingham University Hospitals NHS Trust

Student Information and Induction Workbook
PICU
Queens Medical Centre Nottingham
Reviewed C Whittaker/K Broom 08/2012
1
Dear ____________________
On behalf of all the staff in the children’s critical care unit we would like to
welcome you to PICU and PHDU
Your first day on the unit will be an informal induction day between 8-4. 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 links. 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 link nurses only.
Contact
Direct phone number for PICU 0115 9709232.
Your student link nurses are Carli Whittaker (Critical Care Educator) Kirstin
Broom (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 on the main bay of the unit 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.
Reviewed C Whittaker/K Broom 08/2012
2
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 Intensive Care Unit (PICU) at QMC campus of Nottingham
University Hospitals Trust has the capacity for 10 beds with 6 beds currently
funded for PICU admissions. The unit has an 8-bedded open area and 2
cubicles that are used for isolation or to provide the family with privacy.
Admissions to PICU 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.
Reviewed C Whittaker/K Broom 08/2012
3
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 Intensive 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.
Reviewed C Whittaker/K Broom 08/2012
4
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 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 final 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.
Reviewed C Whittaker/K Broom 08/2012
5
The Team
There are five Consultant Paediatric Intensivists, who rotate on a weekly basis
to manage the unit.
Dr Harish Vyas
Dr Simona Lampariello
Dr Patrick Davies
Dr Shri Alurkar
Dr Dusan Raffaq
Paediatric registrars and senior house officers also support the unit.
Sue Mager leads the nursing staff on PICU.
There are approximately 40 members if nursing staff on the unit, many of
which hold the Specialist Paediatric Intensive Care Nursing Course.
The unit employs a:Retrieval Co-ordinator – Rachel Bower
PICU Educator – Carli Whittaker
PICU Research Nurse- Daniel Walsh
Receptionists PICU–Sue Clarke and Hannah Scutter.
PICU Assistant – Linda Benson, Mick Thorpe
RETRIEVAL SERVICE
We have an active 24-hour retrieval service. The Retrieval Nurse Co-ordinator
Rachel Bower manages the 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
PICU/PHDU 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.
Reviewed C Whittaker/K Broom 08/2012
6
Workbook
Airway and Breathing
Assessment
How would you perform a respiratory assessment?
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
What adjuncts can be used to support airway and breathing?
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Signs of respiratory distress
*
*
*
*
*
*
*
*
*
*
*
*
Reviewed C Whittaker/K Broom 08/2012
7
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 08/2012
8
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_____________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Reviewed C Whittaker/K Broom 08/2012
9
Please name the following machines
1.
2.
3.
Reviewed C Whittaker/K Broom 08/2012
10
Calculating Endotracheal tube (ETT) size and length.
ETT Size Age (yrs) +4
4
Length Oral: Age(yrs)+12
Nasal: Age(yrs)+15
2
2
Ventilator Observations.
Fio2- ____________________________________________________
Frequency- _______________________________________________
PIP-_____________________________________________________
PEEP-. __________________________________________________
Minute Volume_____________________________________________
Minute Volume Leak-________________________________________
VTi and VTe- ______________________________________________
Example; 10kg patient. What would the expected TV be: -
The expected tidal volume range is._____________________________
T insp ____________________________________________________
PASB ____________________________________________________
Trigger- __________________________________________________
Reviewed C Whittaker/K Broom 08/2012
11
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.
Reviewed C Whittaker/K Broom 08/2012
12
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 08/2012
13
Cardiovascular
Assessment
How would you perform a cardiovascular assessment?
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
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
Reviewed C Whittaker/K Broom 08/2012
14
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.
Reviewed C Whittaker/K Broom 08/2012
15
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.
Reviewed C Whittaker/K Broom 08/2012
16
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 08/2012
17
DISABILITY
How would you assess the neurological status?
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Reviewed C Whittaker/K Broom 08/2012
18
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
Reviewed C Whittaker/K Broom 08/2012
19
PICU 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 PICU. 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
Reviewed C Whittaker/K Broom 08/2012
Midazolam
Milronone
Morphine
Noradrenaline
Pancuronium
Paracetamol
Penicillin
Phenobarbitone
Phenytoin
Salbutamol
Spironolactone
Vancomycin
20
Paralysing agents
Analgesics
Sedatives
Anti-convulsant drugs
Respiratory drugs
Antibiotics
Inotropes
Diuretics
Cardiac drugs (include for heart failure, anti arrhythmias)
Other
Reviewed C Whittaker/K Broom 08/2012
21
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________________________________________________________.
Reviewed C Whittaker/K Broom 08/2012
22
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. ________________________________________________________
Reviewed C Whittaker/K Broom 08/2012
23
Infusions
Refer to the PICU 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_________________________________________________________
Reviewed C Whittaker/K Broom 08/2012
24
PICU Floor plan
Back
door
Blood
Linen
gas
room
Drugs
Sluice
Room
Reception
Resource Room
Retrieval Parent’s
toilet
Room
Staff
toilet
Equipment
Room
Parents
Sitting
room
Managers
Office
Doctors
office
Staff Room
Reviewed C Whittaker/K Broom 08/2012
Quiet Room
25