Nurse Practitioner Clinical Practice Guideline for the Respiratory Assessment of Children

All NP clinical guidelines on this site have been developed for use in a particular Area Health Service and for specific Nurse Practitioner positions in that AHS, and therefore reflect the specific scope of practice of the position and the operation of the AHS. Therefore, prior to use by Nurse Practitioners in other positions, the guidelines will need to be reviewed and adapted as necessary to address local scope of practice and Area Health Service needs. The adapted guidelines must also be approved in writing by the AHS CE, as required by the Nurse/Midwife Practitioner Policy Directive 2005_556 prior to use.

This Guideline has been developed under Section 78A of the Nurses Act 1991. It covers the care of patients aged 4 months to 16 years

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November 2004
Area: Classification:

Wentworth Area Health Service

Subject:

NP Guideline

CLINICAL PRACTICE GUIDELINES FOR THE RESPIRATORY ASSESSMENT OF

CHILDREN

Contents:
Purpose Guideline Development Group Notes for Use of Guideline 1.Introduction 2. Assessment 3. Management 4. References

page 3 3 4 5 5 7 9

Symbols used in this document - Special Note - Item to note

- Opinion of Guideline Development Team

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Area:

Classification:

Wentworth Area Health Service

Subject:

NP Guideline

CLINICAL PRACTICE GUIDELINES FOR THE RESPIRATORY ASSESSMENT OF

CHILDREN

Purpose
The guideline is implemented post assessment with a robust triage system designed to identify the critically ill patient. The guideline is intended for use by Nurse Practitioners working in Principal Referral Hospital Emergency Departments, along side senior medical officers. The Nurse Practitioner has been Registered by the NSW Registration Board, thus has demonstrated advanced knowledge and clinical skills in the assessment and therapeutic management of Emergency Department Patients. This guideline is to be used for the management of patients aged 4 months to 16 year who present with respiratory illness.

Guideline Development and Specialist ReviewersGroup

This guideline was collaboratively reviewed by a team of Expert Clinicians and Health Managers. The development and review team consisted of: Arlene Bannon BA, Grad Dip Critical Care Nursing, MN Nurse Practitioner Nepean Emergency Department. Dr Paul Mcmurray, MBChb (Otago New Zealand) Emergency Registrar Dr Mary Samaan, B: Med (New); FRACGP; DRACOG. Emergency Registrar Cate Salter, BHSC (Nursing), MCN (ED) Area Emergency Clinical Nurse Consultant, Wentworth Area Health Service Cathy Crowe, BHSC (Nursing), Grad Dip Emergency Nursing Emergency Department Nursing Unit Manager Craig Webb, Dip App. Sc. MRT (New) Head Radiographer Nepean Hospital Trish Boss, DipApSci (nursing); Paeds Cert(RAHC); GradDip(AdClinNurs); GradDip(Clin Teach); FMI(CertIV); MRCNA. Paediatric Clinical Nurse Consultant, Wentworth Area Health Service. Specialist Approval Professor Ralph Nanan, Director of Area Paediatric Services - WAHS (November 2003) Nurse Practitioner Guideline 4/6/03 Page 3 of 10

Dr Jason Hort Staff Specialist Department of Paediatrics - WAHS (November 2003) Dr Rod Bishop Director of Area Emergency Services - WAHS (November 2003) Nepean Hopsital Drugs & Therapeutics Committee WAHS Nurse Practitioner Steering Committee WAHS
Area: Classification:

Wentworth Area Health Service

Subject:

NP Guideline

CLINICAL PRACTICE GUIDELINES FOR THE RESPIRATORY ASSESSMENT OF

CHILDREN

Notes for Guideline use

Local implementation of the Guideline This guideline was adapted for use by Nurse practitioners working at Nepean Emergency Department. The guideline was developed by WCH, approved by the Director General of Health NSW and reviewed by clinical experts and health managers at Nepean hospital. Statement of intent This guideline is not intended to be construed or to serve as a standard of care. Standards of Care is determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge and technology advance and patterns of care evolve. These parameters of practice should be considered guidelines only. Adherence to them will not ensure a successful outcome in every case, nor should they be construed as including all proper methods of care or excluding other acceptable methods of care aimed at the same results. The ultimate judgment regarding a particular clinical procedure or treatment plan must be made by the nurse practitioner in light of the clinical data presented by the patient and the diagnostic and treatment options available. In making clinical decisions the nurse practitioner should remain cognizant of their level of expertise and take advantage of the expertise of all members of the treating team.

Review of Guideline This Guideline was developed in November 2003. It should be viewed as an initial guide and a dynamic document that should be reviewed and revised by those who use it as the basis of there Local Guidelines.

Signature___________________ Date____________________________ The guideline should be signed and dated by the Chairperson of the WAHS NP steering Committee prior to its implementation.

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Review date: January 2006

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Area:

Classification:

Wentworth Area Health Service

Subject:

NP Guideline

CLINICAL PRACTICE GUIDELINES FOR THE RESPIRATORY ASSESSMENT OF

CHILDREN

1. Introduction
This assessment guideline has been designed to sit in front of a group of guidelines associated with respiratory presentations of children to emergency departments. These guidelines include: The Management of a Child with Asthma. The Management of a Child with Bronchiolitis. The Management of a Child with Croup. Section 3 provides a flow diagram for referral to other guidelines. Respiratory disease accounts for approximately 50% of illness in infants, children and adolescence. The most common problems are infections (particularly viral) and asthma, which remain the most frequent reasons for admission to hospital 1,3.

2. Assessment
In addition to immediate visual observation of the child, a rapid but thorough assessment is undertaken to determine the nature and severity of the problem and whether immediate and urgent intervention is required. The need for supplemental oxygen is assessed as well as the level of observation required.

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Area:

Classification:

Wentworth Area Health Service

Subject:

NP Guideline

CLINICAL PRACTICE GUIDELINES FOR THE RESPIRATORY ASSESSMENT OF

CHILDREN

Clinical Feature
Respiratory rate

Infants
Respiratory rate outside the normal ranges of :0-6 months 30-60 respirations/Min 6-12 months 25-40 respirations/Min4 Nasal flaring Substernal retractions Abdominal breathing Subcostal retractions

Children
Respiratory rate outside the following normal ranges: Toddler: 20-35 respirations/Min School age & Adolescent: 14-25 Nasal flaring Substernal retractions Supraclavicular retractions Intercostal/subcostal retractions

Respiratory observations

Expiratory grunt Expiratory grunt Inspiratory stridor Inspiratory stridor Inspiratory or expiratory Inspiratory or expiratory wheezes wheezes Diminished breath sounds Diminished breath sounds Pallor , cyanosis, mottled, dusky Pallor, cyanosis, dusky Colour Behaviour Irritability Irritability Lethargy Lethargy Refusal to drink fluids Refusal to eat or drink Weak cry Following this initial examination a full history should be gathered from the Breath sounds

child and parents and/or caregivers accompanying the child. This history should include: The reason for the presentation; A history of the illness from the child if possible and the parent or Caregiver including any treatment received prior to presentation; Other medical conditions or recent illnesses; Immunization history; Routine or recent medications; Allergies; A full family history - including exposure to tobacco, history of Asthma.1,3.

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Area:

Classification:

Wentworth Area Health Service

Subject:

NP Guideline

CLINICAL PRACTICE GUIDELINES FOR THE RESPIRATORY ASSESSMENT OF

CHILDREN

In addition to the respiratory and cardiovascular assessment undertaken, A further physical examination should occur in conjunction with, or immediately following the patient history. This assessment will assist in establishing a provisional diagnosis and determining investigations and treatment. The examination will require assessment of: Behavior and level of consciousness; General appearance, paying attention to positioning and posture; Temperature and colour of extremities 2,3. Neurological status;

3. Management of Respiratory Illness

Refer to the flowchart on page 8 3.

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Area:

Classification:

Wentworth Area Health Service

Subject:

NP Guideline

CLINICAL PRACTICE GUIDELINES FOR THE RESPIRATORY ASSESSMENT OF

CHILDREN

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Area:

Classification:

Wentworth Area Health Service

Subject:

NP Guideline

CLINICAL PRACTICE GUIDELINES FOR THE RESPIRATORY ASSESSMENT OF

CHILDREN

6. REFERENCES

1. Kilham, H. & Isaacs, D.(Ed) (2004) The Childrens Hopsital Handbook 2004. http://www.chw.edu.au 2. Sheedy,S.B., Lenehan, G.P., (1999) Manual of Emergency Care. (5th Edition). Mosby 3. Westmead Childrens Hospital -Nurse practitioner guidelines [Homepage Office of the Chief Nursing Officer] [online] 20th May 2003 last updated. Available: http://internal.health.nsw.gov.au/nursing/index.html. [Accessed 28th May 2003] 4. Emergency Nurses Assosciation (1998) Emergency Nursing Paediatric Course Provider Manual (2nd edition). ENA:NSW

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