The Great Ormond Street Manual of Clinical Nursing Practices

Sue Macqueen is now retired but was a Clinical Nurse Specialist in Infection Control at Great Ormond Street. Elizabeth Bruce is a Clinical Nurse Specialist in Pain Control Service at Great Ormond Street. Faith Gibson is a Clinical Professor of Children and Young People's Cancer Care at Great Ormond Street

Foreword ix Acknowledgements x List of contributors xi Introduction xvii 1 Assessment 1 Introduction 2 Measuring vital signs, height and weight 6 Review of systems 13 Blood pressure 21 References 35 2 Allergy and anaphylaxis 38 Introduction 39 Allergy and the immune response 39 Diagnosis and management of allergy 40 Management of anaphylaxis 41 Food allergy 43 Respiratory allergy 46 Allergens in the healthcare setting 48 Conclusion 51 Key texts 51 References 51 Useful websites 52 3 Biopsies 53 Introduction 54 Liver biopsy 54 Punch skin biopsy 60 Renal biopsy 66 Bone marrow aspirate and trephine 69 References 72 4 Administration of blood components and products 74 Introduction 75 An overview of blood transfusion 75 Administration of red cells 76 Administration of platelets 76 Administration of fresh frozen plasma (FFP) 76 Administration of cryoprecipitate 76 Administration of albumin 80 Administration of immunoglobulin 80 Administration of coagulation factors 86 Conclusion 86 References 86 5 Bowel care 87 Introduction 88 Constipation 88 Treatment of constipation 89 Diarrhoea 91 Transanal colonic irrigation 95 Stoma care 97 References 101 6 Burns and scalds 103 Introduction 104 Common causes of burns in children 104 Overview of anatomy of the skin 104 Classifi cation of burns 104 First aid following a burn 105 Fluid resuscitation for major burns 108 Wound healing and wound care 108 Which dressing? 111 Nutrition 112 Psychological care following a burn 112 References 115 7 Child protection 117 Introduction 118 The hospital setting 118 An individual and corporate responsibility 118 Defining child abuse and neglect 119 The effects of abuse and neglect 120 Sources of stress for families 120 Children with disabilities 121 Difference and culture 122 The legal framework, national and political infl uences 122 Learning from serious case reviews 123 A safeguarding culture 125 Implications for nursing practice 126 The Common Assessment Framework (CAF) 126 Practice guidance for the children s nurse 127 Professional responsibilities of staff at Great Ormond Street Hospital 127 Procedures for children attending A&E 128 Procedures for children admitted to hospital 129 Fabricated or induced illness: concerns or suspicion 130 Pre-discharge planning procedure 130 A final word communication with other agencies 131 Acknowledgements 131 References 131 8 Cytotoxic drugs 134 Chemotherapy administration 135 Legislation 135 Consent 135 Safe handling 135 Reconstitution and preparation of chemotherapeutic agents 135 Personal protective equipment 136 Work practices 136 Safe administration of chemotherapy 136 Routes of administration 138 Intrathecal route 140 References 141 9 Fluid balance 142 Introduction 143 Fluid balance in the ill child 143 Vascular access 149 Haemofi ltration 151 Peritoneal dialysis 158 Interventions 163 References 164 Further reading 165 10 Personal hygiene and pressure ulcer prevention 166 Introduction 167 Bathing 167 Toileting 174 Nappy care 180 Nail care 187 Oral hygiene 189 Eye care 202 Ear care 206 Pressure ulcer prevention 208 Conclusion 216 References 217 Useful websites 220 11 Immunisations 222 Introduction 223 Routine childhood immunisation schedule in UK 2010 223 Special risk groups 224 Immunity 224 Types of vaccine 225 General considerations 225 Specific diseases and the vaccines 227 Storage and administration of vaccines 231 Ensuring good uptake 231 Vaccine safety scares 233 Immunisation of healthcare professionals 233 Conclusion 234 References 234 Further resources 235 12 Infection prevention and control 236 Introduction 237 Financial burden of hospital acquired infection 237 Freedom of information 238 Bioterrorism 238 The chain of infection 238 Standard precautions 240 Hand hygiene and skin protection 241 Personal protective equipment 245 Isolation nursing 249 Aseptic non-touch technique 257 Management of exposure to blood and body fluids 259 Reporting of injuries, diseases and dangerous occurences regulations 260 Blood spillage 260 Decontamination of equipment and the environment 261 Laundry management 262 Waste disposal 263 Pest control 264 References 264 Further reading 266 13 Intravenous and intra-arterial access 267 Intravenous access 268 Peripheral venous catheters 268 Peripherally inserted central catheters 290 Non-tunnelled short-term percutaneous central venous catheters 292 Tunnelled central venous catheters: Hickman and Broviac lines 292 Implantable ports 293 Removal of central venous catheters: possible complications 309 Arterial lines 310 References 321 Appendix 13.1 Suppliers of stickers and certifi cates 324 14 Investigations 325 General introduction 326 Introduction to radiology 326 General radiology 330 Fluoroscopy 330 Intravenous urography 331 Micturating cystourethrogram 332 Dysphagia swallow using videofl uoroscopy 333 Upper gastrointestinal series 333 Tube oesophagram 334 Barium follow through 335 Barium enema 335 Contrast enema (and Gastrografi n enema) 335 Air enema 336 Tracheobronchography 337 Linogram 338 Ultrasound 339 Computed tomography 339 Nuclear Medicine 340 Magnetic resonance imaging 342 Interventional radiology 342 Collection of microbiological specimens 344 Blood samples 346 Biopsy material 347 Cerebro-spinal fl uid 347 Taking swabs 347 Faeces 350 Fungal samples of hair, nail and skin 351 Gastric washings 351 Naso-pharyngeal aspirate 352 Sputum 352 Urine 353 Vesicular fluid for herpes polymerase chain reaction (PCR) 354 References 355 15 Administration of medicines 357 Introduction 358 Child development considerations 359 Drug calculations 360 Oral administration 364 Enteral tube administration 366 Buccal and sublingual administration 369 Intranasal administration 370 Inhalation administration 372 Rectal administration 376 Injections 378 Intradermal administration 380 Subcutaneous administration 382 Intramuscular administration 384 Intravenous administration 387 Intraosseous administration 387 Intrathecal administration 389 Epidural administration 393 Skin patches administration 393 Acknowledgements 394 References 394 Further reading 395 16 Moving and handling 397 Introduction 398 Legislation 398 Risk assessment 399 Injury 400 Documentation 405 Equipment 406 Restraint and therapeutic holding 412 References 415 17 Neonatal care 416 Introduction 417 Neonatal thermoregulation 417 Vitamin K administration 424 Umbilical care 426 Newborn blood spot screening (formerly Guthrie testing) 428 Phototherapy neonatal jaundice 431 References 434 18 Neurological care 436 Introduction 437 Neurological observations 437 Seizures 443 External ventricular drainage 447 Lumbar puncture 462 References 464 Bibliography 465 Appendix 18.1 The GOSH Coma Chart 466 Appendix 18.2 Types of painful stimuli 470 Appendix 18.3 Examples of motor responses 470 Appendix 18.4 An example of an algorithm for a convulsing child 471 19 Nutrition and feeding 473 Introduction 474 Nutritional requirements 474 Nutrition from preterm to adolescence 474 Breast feeding 480 Enteral feeding 485 Parenteral nutrition 499 Sham feeding 506 References 509 Supporting breast feeding some useful addresses 511 20 Orthopaedic care 512 Introduction 513 Neurovascular observations 513 Plaster care 519 Crutches 526 Care of a child in traction 530 Key texts 538 References 538 21 Pain management 539 Introduction 540 General principles of pain management 540 Pain assessment 542 Administration of Entonox 548 Epidural analgesia 554 Patient and nurse controlled analgesia (PCA/NCA) 566 Prevention and management of opioid related complications 570 Sucrose 573 Key texts 574 References 574 22 Palliative care 577 Introduction 578 Assessment of symptoms 578 Nausea and vomiting 579 Constipation and diarrhoea 580 Dyspnoea 581 Anorexia and reduced fl uid intake 582 External haemorrhage 583 Seizures 583 Signs of impending death 584 After the child dies 585 Preparation of the body 591 Moving the child who dies in hospital 593 After care 594 Acknowledgements 596 Key texts 596 References 596 23 Peri-operative care 598 Introduction 599 Preoperative preparation 599 Perioperative care 603 Recovery 606 References 608 24 Play as a therapeutic tool 609 Introduction 610 The development of play in hospital 610 Normal play for development 611 The importance of play for children in hospital 611 Preparation for surgery and procedures 615 Distraction techniques 617 Therapeutic play 1:1 sessions 620 Key texts 623 References 623 Further reading 624 25 Poisoning and overdose 625 Introduction 626 Non-accidental ingestion and self-harm 626 Common ingestions 627 Initial management following poisoning or overdose 628 Treatment of ingested poisons 629 Gastric lavage 630 References 634 26 Respiratory care 635 Introduction 636 Airway suction 636 Oxygen therapy 642 Chest drain management 648 Key texts and websites 660 References 660 27 Resuscitation practices 663 Introduction 664 Aetiology of cardiorespiratory arrest 664 Airway management 664 Recovery position 668 Advanced airway and breathing management 668 Circulation management 671 Basic life support 676 Choking 681 Cardiorespiratory arrest management 684 Defi brillation 688 Medications in cardiorespiratory arrest 689 Potentially reversible causes of cardiorespiratory arrest 690 Post-resuscitation care 690 Ethical considerations 690 References 691 28 Tracheostomy: care and management 693 Introduction 694 Caring for a newly formed tracheostomy 694 Humidifi cation 699 Management of an established tracheostomy 700 Resuscitation 706 References 714 Appendix 28.1 Tracheostomy tubes for children 715 29 Urinary catheter care 718 Introduction 719 Insertion of indwelling urethral catheters 719 Emptying, drainage and fl ushing 726 Obtaining a catheter specimen of urine 729 References 732 30 Drug withdrawal prevention and management 734 Introduction 735 Withdrawal prevention 736 Withdrawal assessment 737 Withdrawal assessment tools 738 Management of withdrawal 740 Weaning protocols 741 References 744 Index 746