Interventions based on Priority System
Respiratory System
Priorities:
- Oxygen Delivery
- Positioning
- Blood gas
- Pharmacological help- beta 2 antagonists, antimuscarinic bronchodilators, methyxanthines
- Reposition sats probe- ear probe
Goals:
- CXray
- Wean off O2
Cardiovascular System
Priorities
- ECG
- Maximise oxygen delivery if needed, minimise oxygen demand
- Treat underlying ie heart attack, shock, dehydration
- Aspirin
- Blood markers: troponin, creatinine
- Blood gases- lactate, hyperkalaemia
- Fluid resuscitation for hypotension
- Diuretics for oedema, left heart failure
- Ace inhibitors, beta blockers
- Sepsis 6/ paediatric sepsis 6
- Morphine for pain- uncontrolled pain can have detrimental effects on the cardiovascularly compromised child (RCN, 2017)
- Anti emetics
Goals
- CXray
- Echocardiograph
- Angiograph/ cath lab
Renal
Priorities
- Fluid resuscitation
- Urine dipstick
- Blood gas
- Question meds ie diuretic, ace inhibitor, metformin, NSAIDS- NHS Eng 2016 Think Kidney guideline- at risk for AKI
- Blood glucose monitoring- hyperglycaemia causes high GFR
- eGFR- creat level x age x ethnicity x sex
- Bladder scan
- Catheter- bladder vol of 300ml< justifies catheterisation
- Check meds- for potassium
- Some chemotherapeutic drugs are nephrotoxic
- Bloods for infection
Goals
- medical review, poss dialysis for kidney failure
- Fluid resuscitation
Post Operative Surgical Care
Priorities
- Airway management- suctioning- post op atelectasis
- AVPU/ GCS/ Neuro obs
-Pain management- morphine, oxycodone, poss a Patient controlled analgesia
- DVT- compression socks, positioning
- Infection prevention- ANTT
- Assess surgical site
- MUST tool for eating/ drinking after surgery
- Appendicitis- open bowels, pass wind, pass urine
- Manage post op bleeds
- SBAR for transfer of acutely ill patient
- Dehydration?
- Drains for evacuating blood?
- Post adenotonsillectomy bleeds- sit upright, encourage spitting and suction, IV access for TXA and fluid resus, apply adrenaline soaked gauze to bleeding site with forceps, may need further surgery for cautery, start antibiotics (GWACAHS2023)
- For ileus post appy= gut rest and TPN, PICC line inserted, NG for gut asp/drainage, treat infection if there is one
Goal
- Regain conciousness
- Eat and drink
- Wound healing?
- Bowel, bladder movements
- Discharge
Endocrine
Priorities
- Blood glucose
- Urine dipstick- proteins
- ABG check electrolyte imbalance
- Poss analgesia
- Anti emetics
- Isotonic saline- fluid to give with high blood glucose
- Patent airway
- HypOthyroidism- levothyroxine sodium IV
- Glucose IV
- Glucagel
- Reverse any present shock, restore blood circulation
- Antibiotics if infection present
- Insulin
- Fluid balance chart
Goals
- Restore blood sugar to normal levels
- Restore hydration status
- Potassium replacement (lost in hyperglycaemia)
Sepsis
Priorities
Sepsis 6
- Take bloods
- Take urine
- Take lactate 30ml p/kg over first 3 hours (SSC, 2021)
- Give antibiotics
- Give fluids
- Give oxygen
Paediatric sepsis 6
- give high flow oxygen
- obtain IV access and take bood cultures, glucose and lactate
- give IV antibiotics
if shocked give:
- fluid resuscitation
- inotropic support ie adrenaline (increase strength of muscular contraction, increases blood pressure)
- involve senior clinicians/ specialists early, discuss w PICU if inotropes commenced
15 mins ideal, 1 hour acceptable
(Sepsis trust paediatric group, 2015)
- AVPU/ GCS
- Sepsis Trust guidelines (2022) say temp is natural response- not recommended to treat
- Escalate to doctor, medical review
- If acute coronary syndrome not present, but troponin levels elevated, increases mortality rate (BCS, 2019)
Goals:
- Escalate to doctor
- Restore circulation
- Treat main source of infection/ early administration of antibiotics
- Haemodynamic stabilisation
- Fluid resus
- Inotropic/ vasopressor support
Neurological
Priorities
- Neuro observations
- GCS over AVPU
- FAST assessment for stroke
- Check for cushings response (tachycardia, bradpnea, hypertension)
- Airway management- elevate head of bed 20-30 degree. to decrease ICP, Semi-fowlers position
- U and Es- for electrolytes- hyponatraemia neuro deterioration
- Full blood count- infection
- Anti coagulant- check no clotting in blood
- Escalate for MRI or CT
- Give oxygen if needed, if GCS 8> they may need intubation
- Seizure management, buccal medazolam, recovery position
-ABG to check if shes acidotic
Goals
- MRI or CT
- Gain consciousness
- Find cause of deteroration
- Stable neuro obs
- Refer to specialist
Major Trauma
primary survey
- establish IV access- consider IO, use gauze, saline and clingfilm to prevent bone from drying out
- bloods and blood gas
- may need fluid bolus
- may need blood
- manage major wounds
- x rays and ct scans
- accompanied by qualified nurse and poss dr for scans
secondary survey
- hypothermia- bear hugger
- member of staff assigned to support family
- support and explanations