MANAGEMENT

OF CRITICALLY
ILL CHILD

ANUMOL PR
II YEAR MSC NURSING
 REMEMBER THAT
Children are not young adults
Adults are big children
Different age group
Age specific norms
Remember important differences
between adult and kids
NORMAL CHILDREN
RR : upper limit
 < 2 mo 60
c/min
 2-12 mo 50 c/min
 1-5 years 40 c/min
 CONT…

BP
 0 to 28 days 60 mm Hg in term
neonates
 1 -12 mo 70 mm Hg in infants
 1 to 10 years 70 mm Hg + (2 x age
in years)
 >10 years 90 mm Hg in
children
 CONT…

 HR

 Newborn to 3 mo: 85: 205

3 months to 2yrs: 100—190
 2yrs to 10 yrs: 60—140
> 10yrs: 60—100
APPEARENCE
Tone

Interactiveness

Consolability

Look/Gaze

Speech/Cry
WORK OF BREATHING

Abnormal airway sounds

Abnormal positioning
Retractions

Nasal flaring
Head bobbing
 CONT…

 Work of breathing is a more accurate

immediate indicator of oxygenation
and ventilation than conventional
measures, such as counting RR or
chest auscultation.
 Work of breathing reflects the child’s
physiologic compensatory response to
cardiopulmonary stress.
 Assessing work of breathing entails careful
listening for abnormal airway sounds and
observing for specific visual information
about breathing effort. characteristics of work
of breathing.
 Combining assessment of
appearance and work of breathing
can establish severity.
A child with normal appearance and
increased work of breathing is in
respiratory distress.
 Abnormal appearance and increased
work of breathing means early
respiratory failure.
 Abnormal appearance and abnormally
decreased work of breathing is late
respiratory failure.
CIRCULATION TO SKIN
 Pallor

 Mottling

 Cyanosis
 An important indicator of core perfusion is
circulation to skin.
 When cardiac output is inadequate, the body
shuts down circulation to non-essential
anatomic areas such as the skin in order to
preserve blood supply to vital end organs
(e.g. brain, heart and kidney).
 Therefore, circulation to skin reflects
the overall status of circulation to the
body’s important end organs. Pallor,
mottling and cyanosis are key visual
indicators of reduced circulation to
skin.
 USING THE PAT TO EVALUATE SEVERITY
ANDILLNESS OR INJURY CATEGORIES

 The three elements of the PAT are

interdependent and together allow rapid
assessment of the child’s overall physiologic
stability. For example:
 If a child is alert and interactive, pink, but has
mild retractions, one can take time to
approach the child in a developmentally
appropriate manner to complete the physical
 On the other hand, if the child is poorly
responsive, with unlabored rapid
respirations, and has pale or mottled skin,
one should move rapidly through the
pediatric primary survey, and initiate
resuscitation.
 Abnormal appearance and decreased
circulation to skin means shock.
MANAGEMENT OF
CRITICALLY ILL CHILD

 Supportive care
 Nutrition

 Prevention of complications
SUPPORTIVE CARE
 Eye care
 Oral hygiene
 Prevention and treatment of pressure
sores
 Care of IV lines, central lines and chest
tubes
 Prevention of stress ulcers
 Thromboembolic prophylaxis
EYE CARE
Lubricating ointments
Artificial tears
ORAL HYGIENE

 Ventilator associated pneumonia

 Chlorhexidine based oral care
PRESSURE SORES
 Pediatric hospital population – 7%
 ICU patients – 26%

Most common sites

 Occipital region
 Nose

 Chin or neck
 Heel

 Sacral
RISK FACTORS
 Mechanical ventilation
 Hypotension

 Malnutrition

 Sensory loss
 Dependent edema
 Central line access
 >96 hrs stay
 PREVENTION
 Regular checking and
repositioning if necessary
 Use of pressure alternating
mattress
CARE OF
INTRAVENOUS LINES

 Ideal- once per shift for signs of

infusion phlebitis
 Visual Infusion Phlebitis (VIP)
scale
CENTRAL LINES
 Displacement

 Bleeding

 Patency

 Infection

 Hematoma formation
CHEST DRAINS
 Movement of fluid column
 Amount of drainage and its
nature
 Displacements

 Breath sounds
 Subcutaneous emphysema
STRESS ULCERS
Risk factors
 Thrombocytopenia
 Coagulopathy
 Organ failure
 Mechanical ventilation and high
pressure ventilator setting
 Higher severity of illness
 Shock
 Prolonged surgery
 Steroid administration
Risk factors
 Central venous catheter
 Age <1yr and >14 yr
 Recent surgical procedure
 Complex medical conditions
 Prolonged hospitalization
 Inherited
or acquired thrombophilia
Thromboembolic prophylaxis
 Heparin

 Thrombolytic therapy
NUTRITION
Causes of malnutrition in ICU
Metabolic stress response
Assessment of energy
expenditure
Nutrient delivery
Assessment of nutritional status
 Medical history
 Diet history
 Weight, height, head circumference at
admission
 Signs of malnutrition
Factors that may increase energy
needs
• Fever
• Sepsis
• Burns
• Trauma
• Cardiac or Pulmonary Disease.
Factors that may decrease energy
needs
 Sedation

 Pentobarbital Coma
 Mechanical Ventilation
 Starvation

 Paralysis
 PREVENTION OF
COMPLICATIONS

Ventilator associated
pneumonia
Blood stream infections
Urinary tract infections
 GENERAL MEASURES
 Hand washing
 Sterilization of medical devices
 Aseptic precautions
 Appropriate and rational use of
antibiotics
 Surveillance of nosocomial infections