RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

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NAME OF THE CANDIDATE AND ADDRESS

NAME OF THE INSTITUTE

COURSE OF STUDY & SUBJECT

DATE OF ADMISSION

TITLE OF THE TOPIC

Mr. BHAGWAN SAHAY MANGAL.M.Sc NURSING 1ST YEAR, NOOR COLLEGE OF NURSINGNO.5 NOOR BUILDING, BHOOPSANDRA MAIN ROAD, BANGALORE - 94

NOOR COLLEGE OF NURSING,NO.5, NOOR BUILDING, RMV II STAGE,BHOOPASANDRA MAIN ROAD, BANGALORE-94.

M.SC. NURSING, 1ST YEARPEADIATRIC NURSING.

29TH JUNE 2008.

“EFFECTIVENESS OF PEADIATRIC ICU FLOW SHEET ON THE CARE OF CRITICALLY ILL CHILDREN IN THE CRITICAL CARE UNIT OF INDIRA GANDHI INSTITUTE OF CHILD HEALTH BANGALORE”.

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6. BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

Most deaths among sick infants brought to hospitals occur within fist 24 hours.

Many of these deaths can be prevented if very sick infants are identified when they arrive

at the hospital and appropriate treatment is started immediately. A survey of district and

teaching hospitals from developing countries revealed that two thirds of hospitals lacked

adequate setting for priority screening. This was evidenced by poor initial patients

assessment by not using standardized flowchart and delay in treatment. Most emergency

treatment areas were poorly organized and lack essential supply and drugs before they

could be given. It was also observed that most personnel had inadequate knowledge and

skill for assessing and managing these children. There is a need for initial triage

emergency care, assessment with flowchart and checklist and monitoring if mortality

amongst sick infants is to be reduced.

In 2007, the world average on child mortality rate was 68 (6.8%). In 2006, the

average in developing countries was 79 (down from 103 in 1990). Whereas the average

in industrialized countries was 6 (down from 10 in 1990). One in six children in Sub-

Saharan Africa die before their fifth birthday. The biggest improvement between 1990

and 2006 was in Latin America and the Caribbean, which cut their child mortality rates

by 50%. The world’s child mortality rate has dropped by over 60% since 1960.About

25.000 young children die every day, mainly from preventable causes.

Admission to the hospital emergency departments is one of the most frightening

experiences a child can have. The critically ill child may appear extremely anxious and

fearful or withdrawn, solemn and preoccupied with his or her physical condition. The

illness or injury often brings pain, decreases energy and changes the child’s level of

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consciousness. Younger children may be unable to understand what is happening to them.

The environment appears overwhelming, fast paced, and frightening. Being cared by

strangers produces anxiety in the child. The child’s limited ability to move intensifies his

or her feelings of powerlessness and vulnerability (carnevale, 1997)1.

Critical illness is a life threatening event. Critically ill children may face loss of

life, loss of biologic function and body integrity, loss of independence and control over

their bodily functions as well their immediate environment. The term critical care today

extends beyond the immediate crisis. Technologic advance can prolong life and

necessitates ongoing medical interventions. Having a critically ill child can be a heart

breaking experience. Parents with critically ill children are in acute need of support and

invention by caregivers (Amico & Davidhizer, 1994)2

The Nursing staff of the Pediatric intensive care unit (PICU) is responsible for the

physical, physiological care of children and their families in the PICU. The Nursing care

is delivered in an organized comprehensive fashion to meet the needs consistent care

from persons who are concerned about their welfare and coordinator the efforts of all

health care personnel. The current information regarding the child’s condition, progress

and responses are highly essential for the decision making in the care of the child. The

hospital relies on efficient professional to deliver care according to organizational

guidelines and politics (Montenuro, 1988)3

6.1 NEED FOR THE STUDY

“Critically ill child” means a child who is in a clinical state which may result in

respiratory or cardiac arrest or severe neurologic complication, if not recognized and

treated promptly . This term does not refer to any particular disease, but many diseases

can lead onto “critically ill state”. Whether a child presents with a primary

cardiovascular, respiratory, neurologic, infectious or metabolic disorder, the goal is early

recognition of respiratory and circulatory insufficiency.

Acute deterioration in patient status is one of the most stressful situations facing

critical care nurses. Resuscitation measures often include intubation, mechanical

ventilation, hemodynamic monitoring, fluid administration and pharmacological support.

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A systematic review of the patient’s progress using a flow sheet enables the ICU staff to

identify potential problems early and take remedial action. Documentation of Nursing

care also ensures continuity of care as well as furnish legal evidence of that care, as an

old saying goes, “If it isn’t documented. It isn’t done” (Bavin, 1988)4

Common predisposing factors for a child becoming critically ill: 1. Age -Younger the age, more the risk

2. Malnutrition / impaired immune status

3. Underlying anatomic / functional defect

4. Nature of illness

5. Bad child rearing / traditional practices

6. Type of medical care received

7. Parent’s knowledge / awareness

A final problem is that legal auditing procedures become difficult with the present

system of documentation. Hence, development of a PICU flow sheet was needed to

simplify the recording of assessments and care so that the staff would have more time to

evaluate the effects of Nursing care and streamline the nursing record so that problems in

patient progress and patient outcomes could be readily identified.

A national survey of end-of-life care critically ill patients was done by T J

Prendergast, M T Claessens, J M Luce, Department of Medicine, Veterans

Administration Medical Centre, White River Junction, Vermont Thomas.j.In some

intensive care units (ICUs), fewer patients who die now undergo attempts at

cardiopulmonary life support actively withdrawn prior to death than did a decade ago. To

determine the frequency of American postgraduate training program with significant

clinical exposure to critical care medicine, who died into one of five mutually exclusive

categories. They received data from 131 ICUs at 110 in patients of which 393 patients

were brain dead. Of the remaining 5,910 patients who died, 1,544 died with

cardiopulmonary resuscitation (CPR); 1,430 (22%) received full ICU care without CPR;

797 (10%) life support was withdrawn. There was wide variation in practice among

ICUs, with ranges of 4 to 79% of categories, respectively. Variation was not related to

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ICU type, hospital type, number of admissions, life support prior to death is the

predominant practice in American ICUs associated with critical care, end-of-life care,

and efforts are needed to understand practice patterns and to establish standards of care.5

The paediatric intensive care unit (PICU) is a highly complex environment where care is

given to those premature babies requiring around the clock monitoring. To preserve the

fragile state of neonates, it is extremely important for primary caregivers to accurately

interpret neonate data and to act accordingly in this highly volatile environment.

Understanding and interpreting an infant’s clinical condition requires a care giver

to assess an array of medical data including: physical exam findings, laboratory test

results, ventilator settings, treatments, etc., as well as how these data points change over

brief periods of time. This is due, in part, to the fact that most of them are not sufficiently

exposed to PICU during medical school, and need to learn an entirely new set of medical

knowledge concerning the anatomy and physiology of the paediatrics.

It ensures adequate monitoring. Timely nursing interventions could be carried out

to bring better outcome for the critically ill child. The flow sheet also decreases the length

of PICU and hospital stay, incidence of complications and mortality; and also increase

time for nursing care.

In Indira Gandhi Institute of Child Health, Bangalore on an average 20-25

children are admitted and 7-10 are admitted in ICU per day. Hence the investigator felt

the need to develop a paediatric flow sheet which will be useful in PICU of the hospital

in day to day care of critically ill children.

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6.2 REVIEW OF LITERATURE

This chapter deals with the literature reviewed relevant to the present study. It is

divided into three sections:

Section a : Literature related care in (PICU)

Section b : Literature related to Physiological status of critically ill children

Section c : Literature related to uses of flow sheet.

(a) LITERATURE RELATED CARE IN (PICU)

Pediatric ICU’s have grown in number, degree of sophistication and level of

technology in the last quarter of the century. The word ICU brings many pictures in ones

mind like strange machinery, piercing alarms, complicated procedures and patient lying

between life and death (Ruttimann, & Pollack, 1996)6

It is easy to recognize a critically ill child when there is an obvious problem like

severe trauma or unconsciousness. On the other hand it is important to identify a child

with physiological derangement in its early stages when signs subtle. “The golden hour”

concept applies to all children with illnesses presenting as emergency. Early recognition

of critically ill child requires a systematic and rapid clinic assessment with background

knowledge of age appropriate physical signs and developmental level.

The modern day critical care Nursing began early in the 19th century when Florence

Nightingle recruited and trained women to improve the inadequate care and hygiene of

wounded soldiers during the Crimean War. During the polio epidemic in the 1950’s, the

influx of patients requiring skilled care overburdened both large and small hospital and

this led to the establishment of intensive care units for these patients. The evolution of

intensive care in pediatric practice has been gradual. Initial ignite came from advances in

neonatal surgery with high demand for the more post – operative support. In 1971, the

first ICU in the children’s Hospital was opened at Glasgow, Scotland, U.K (Downes,

1992)7.

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(b) PHYSIOLOGICAL STATUS OF CRITICALLY ILL CHILDREN

The heart and respiratory rates of an infant or child are normally faster than those

of the adult. In addition, the blood pressure of the infant or child is usually lower than

that of the adult. Small quantitative changes in these vital signs may indicate significant

changes in child’s clinical condition (Bruno, 1995)8

Throughout care, the nurse is attempting to determine if the child “looks well” or

“looks sick”. This observation made by a skilled critical care nurse is often the single

most valuable assessment performed during the child’s stay in the intensive care unit. The

experienced and sensitive critical care nurse can usually anticipate changes in the child’s

vital signs or laboratory value changes (Hazinki, 1985)9.

RESPIRATORY SYSTEM

Whenever the child’s vital signs are assessed, the nurse should check the

following ventilator variables like respiratory rate, tidal volume, minute ventilation, peak

inspiratory pressure and inspired oxygen concentration. During mechanical ventilatory

support of the child, level of consciousness and vital signs should be appropriate for the

child is agitated or unusually lethargic, or if deterioration is noted in the child’s vital

signs or systemic perfusion, the nurse should suspect inadequate ventilatory support, tube

obstruction, or pneumothorax; and initiate appropriate invention. The child’s chest

should symmetrically move during each cycle of positive pressure and bilateral breath

sounds be equal in pitch and intensity (Hazinski, 1985, as cited in show, 1984).9

CARDIOVASCULAR ASSESSMENT

Signs of poor systematic perfusion in the children include cool extremities,

mottled color or pallor, weak peripheral pulses, delayed (over two seconds) capillary

refill, decreased urine output, and metabolic acidosis. The child’s arterial blood pressure

may remain normal even though systemic perfusion is prior to cardiopulmonary arrest

(Schamberger, 1996)10.

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Intravenous access in critically ill children is usually very difficult to obtain. In

addition, the very ill child must receive specific small amounts of intravenous fluids or

drugs. At least hourly, the nurse should verify the function and integrity of each

intravenous or monitoring system (Hazinski, 1985).9

When calculating fluid balance, all sources of fluid intake should be considerd,

including oral and intravenous fluid intake, tube feedings and unrecorded tube irrigations,

and fluid used to flush monitoring lines or dilute medications. All sources of fluid loss

must be totaled, weighing diapers before and after use. One grain increase in weight

indicates approximately one ml fluid output. Additional sources of fluid loss include

vomiting, diarrhea, gastrointestinal suction, chest tube drainage, and blood drawn for

laboratory analysis. Daily insensible water losses in children normally total

approximately 300 ml/m2 body surface area. Insensible water losses are increased with

fever, tachypnoea, excessive diaphoresis, and use of radiant warmers (Hochman, Grodin

& Crone, 1979).11

NEUROLOGICAL ASSESSMENT

When children are critically ill, they usually act ill. Irritability may be a sign of

cardiopulmonary or neurological compromise, pain, fear, or sleep deprivation. Lethargy

is almost always abnormal and further investigation is required. The nurse must use

nonverbal cues to assess the child’s level of consciousness. The critically ill child will

usually not smile or be playful. Decreased response to painful stimuli is abnormal at any

age. Whenever the child is at risk for development of increased intracranial pressure, the

nurse must perform neurological assessments frequently and record the results carefully

(Hazinski, 1985).9

Whaley and Wong (1995) stated that the pediatric version of the Glasgow Coma

Scale (GCS) recognizes that expected verbal and motor responses must be related to the

child’s age. The GCS is a useful predictor of outcome, particularly in the group of

children who are admitted with a GCS score of five or more.12 Grewal and Suteliffe

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(1991) stated that the presence of abnormal planter and pupilary light reflexes predicts an

outcome of death or severe disability.13

GENITOURNARY SYSTEM

If renal perfusion and function are good fluid intake is adequate, the child’s urine

output should be average two cc/kg body weight/hour. Mehta (1991) stated that neonatal

renal failure should be considered in an anticipatory manner with careful monitoring of

urine output and serial measurements of blood urea Nitrogen (BUN) and serum creatinine

in all sick neonates.14

Perkin and Levin (1980) stated that, if the patient is either depleted of or

overloaded with any particular electrolyte, and renal function is normal, a maintenance

solution should be used that will provide the needed doses of electrolytes and glucose.

Losses that require replacement occur in the course of many diseases and careful

attention to the composition and volume of the ongoing losses is required so that

adequate replacement can be made. If the patient is deprived of oral intake, maintenance

fluid requirements must be calculated and supplied parenterally. Physiologic losses of

water and electrolytes relate directly to energy metabolism and roughly parallel to surface

area.15

GASTROINTESTINAL SYSTEM

As soon as the child arrives in the intensive care unit, a plan should be made to

provide the child with adequate nutrition through enteral alimentation including oral or

“tube” feedings or parenteral alimentation. Before any enteral feedings are begun,

auscultate the child’s bowel sounds carefully. Feedings should not be started if the

critically ill child does not have bowel sounds or if the child has gastro esophageal reflux,

or necrotizing enter colitis. The normal abdomen is flat with no visible loops of bowel. A

shiny appearance, presence of spidery veins, along with abdominal distension, can be a

sign of necrotizing enterocolitis (Bruno, 1995).8

The desired amount of fluid intake is dependent on the infant’s age, weight,

gestation, caloric requirements, and the presence of therapies, such as ventilatory support,

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phototherapy, or the use of a radiant warmer. The most sensitive indicators of an infant’s

fluid status are weight and serum electrolytes (Bruno, 1995).8

INTEGUMENTARY SYSTEM

The large surface area to mass ration in the infant and small child; and diminished

subcutaneous fat, especially in chronically ill child, allows a greater transfer of heat from

the interior of the body, to the body surface, where it is then lost (Riggs & Lister, 1987)16

Limit the use of any chemicals on the skin, as they easily absorbed and may cause

toxity. Wash off alcohol and betadine if they are used. Check all intravenous lines. For

integrity at the insertion sites and signs of swelling, redness, discoloration or drainage.

Make sure the tapes are not too tight. The fingers, toes and feet must be in proper

anatomical position when taped to a splint (Bruno, 1995).8

(c) LITERATURE RELATED TO USES OF FLOWSHEET

A study was done by Joann Green Rheiner, Mary et al. to assess the nurses

assessments and management of pain in children having orthopedic surgery Subjects

included 19 children aged 5 to 17 years who experienced 20 orthopedic surgical

procedures. Five days after surgery, pain levels were reported using the Oucher scale.

Post operative pain was reported at moderate levels and showed only a gradual decrease

throughout the hospital stay. The child’s complaint of pain and reported Oucher scores

were most influential in influencing nurses to intervene in the child’s pain.

Recommendations included development of nursing flow charts that provide space to

record pain levels and nursing interventions, in-service education for nurses on non

pharmacological interventions, and further research with a larger sample and a single

pain rating scale.17

Documentation is a source of empowerment for nurses and gives validity to their

professional role. It brings about recognition to the unique contribution nursing can make

in the overall care of the patient or family and generates greater interdisciplinary

collaboration (Mc Duff lie & Booker, 1992). Tsien and Fickler (1997) identified that an

intelligent monitoring system deliver significantly improved patient care.18

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Documentation of patient status and daily nursing care is becoming increasingly

complex and time consuming. Detailed documentation requires time, as much as 15% of

an eight hour shifts (Denise, 1986).19 Thus, a major question is inevitable how can

nurse’s document efficiently, be cost effective, without losing accuracy, completeness

and evidence of professional practice. Berger son (1998) stated that FACT system

(Factual, Accurate, Complete, & Timely) can be used as a guide for charting.20

Staff members were asked to evaluate PICU flow sheet introduced by Joint

Commission on Accreditation of Hospitals (JCAH). All respondents indicated that flow

sheet system saved time in charting, ranging from 30 to 90 minutes per shift. Comments

included “easy to read”, “enhances consistency in charting”, “stops repetitive charting”,

“increases time available to spend with patients. Legality of charting was felt to be too

easy. (Kleinberg & Chase, 1989).21

Documentation task force at Methodist Medical Centre, a 292 bedded hospital for

trauma and acute care in Dallas, Texas, developed a flow sheet. They found that the flow

sheet was efficient and cost effective. Daily documentation emphasizes nursing

contribution on patient outcome even in increasingly complex acute care setting. By

using a flow sheet, standardization of routine elements in observation and care was

possible and hence, the nursing staff obtained more time to provide care and eminent

professional care delivery (Miller & Pastor no, 1990).22

R Moreno, et al (1995) conducted a study evaluate the performance of total maximum

sequential organ failure assessment (SOFA), as a descriptor of multiple organ

prospective. The first factor comprises respiratory, circulatory, second coagulation,

hepatic and renal systems. Delta SOFA also presented a good correlation to (ROC) curve

was 0.742(SE 0.017) for delta SOFA, lower than the total maximum SOFA, impact of

delta SOFA on prognosis remained significant after correction for admission total SOFA;

maximum SOFA score and delta SOFA can be used to quantify the degree of dysfunction

/failure that appears during the ICU stay and the cumulative insult suffered by the

patients to be used in the evaluation of organ dysfunction/failure.23

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STATEMENT OF THE PROBLEM

A study to evaluate the effectiveness of pediatric ICU flow sheet on the care

of critically ill children in the critical care unit of Indira Gandhi Institute of Child

Health Bangalore.

6.3 OBJECTIVES OF THE STUDY

1. To determine the effectiveness of the Pediatric ICU flow sheet in the care of

critically ill children

2. To determine the attitude of the nursing personnel regarding the new Pediatric

ICU flow sheet in the care of critically ill children.

3. To find the association between assessing proficiency of nursing personnel

with their selected demographic variables.

4. To develop an appropriate PICU flow sheet for the care of critically ill children.

HYPOTHESIS

H1. There will be significant difference in nursing care given using flow sheet

between the control group and experimental group.

H2. There will be significant association between the level of knowledge of staff

nurses with selected demographic variables.

OPERATIONAL DEFINITIONS

EFFECTIVENESS

The level or best use of flow sheet to monitor critically ill child and render

appropriate nursing intervention to achieve predetermined outcome like – reduce

severity, decrease incidence of complication, minimize hospital stay.

FLOW SHEET

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Refers to the structured format or a comprehensive tool which provides

continuous monitoring of the critically ill, or gives a detailed assessment of the

systems as well as nursing interventions of the critically ill child.

CRITICALLY ILL CHILDREN

Any child who had suffered from one or more of the following condition at the

time of admission.

(i) Altered level of consciouness with a Glasgow coma score of 8 or less.

(ii) Dehydration 10% and above (dry tongue, depressed fontanelles, sunken eyes,

weight loss 10% or more of the weight before the episode of the illness)

(iii) Congestive cardiac failure (respiratory distress, rapid heart rate, oliguria and

signs of fluid overload such as edema)

(iv) Shock (weak and thready pulse with unrecordable or low BP for the age)

(v) Poisoning, stings, envenomation

(vi) Suspected stepsis – Temperature above 1020F with rapid pulse above 120/min,

or temperature less than 970F.

(vii) Severe pneumonia (according to W.H.O) – tachypnoea (respiratory rate >

60/min till two months, > 50/min for three to twelve months to five years),

chest indrawing and inability to feed.

(viii) Renal failure – Reduced urinary output less than 1-2 ml/kg/hr, or 300ml/24

hours or no output, serum creatinine > 1.5 mg/dl, blood urea > 80 mg/dl.

(ix) Convulsions lasting more than half an hour without intervening period of

recovery.

(x) Hypertension (Diastolic BP>90 mm of Hg)

(xi) Meningitis – With or without alteration in sensorium or convulsions.

NURSING PERSONNEL

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Refers to all registered nurses (Pc.B.Sc., B.Sc. or Diploma) and students

(Pc.B.Sc., B.Sc or Diploma) taking care of critically ill children.

ASSUMPTIONS

1. Critically ill children require expert care from the caregivers to meet their

complex physiologic and psychological needs.

2. Nurses carry out the Nursing interventions based on timely monitoring.

3. A decrease in the documentation time, increases the time spend by Nurses to

provide efficient quality nursing care.

LIMITATIONS

1. Data collection period is limited to 6 weeks

2. Study is limited to paediatric patients under 12 years of age

3. Study is limited to staff and student nurses on duty during the study

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7. MATERIAL AND METHOD

7.1 SOURCES OF DATA:-

Children who are critically ill admitted in pediatric ward and nursing personnel

working in pediatric ward of Indira Gandhi Institute of Child Health, Bangalore.

7.2 Method of data collection

Type of study - An Evaluative study

Research design - Quasi Experimental Research Design

Sampling Technique - Non probability convenient Sampling

Technique

Sample Size - 60 children

Setting - The study will be conducted in pediatric ward

of Indira Gandhi Institute of Child Health,

Bangalore.

CRITERIA FOR SAMPLE COLLECTION

Inclusion Criteria: -

Children under 12 years of age who are critically ill as per operational definition

at the time of admission.

Exclusion Criteria: -

Children with less than 24 hours of stay in the hospital

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DATA COLLECTION TOOL:-

Tool consists of two parts:-

Part I - Observational checklist to assess the severity of illness of critically ill children

with flow sheet prepared by modifying the 24hour ICU flow sheet of Muhs, Mooney and

Cerrate (1995) for adult critically ill patient.24

Part II – Attitude scale (10 point) will be used to find out the attitude of nursing

personnel.

DATA COLLECTION PROCEDURE

Prior to data collection, ethical clearance will be obtained from the concerned

authority, a written consent will be obtained from the participant regarding their

willingness to participate in the study after obtaining the consent, sample will be selected

by using purposive sampling technique. The period of the study will be for 4 to 6 weeks.

The sample obtained in first 2 weeks will be placed in the control group remaining 2

weeks will be experimental group.

DATA ANALYSIS METHOD

The data obtained will be analyzed in terms of objectives of the study by using

descriptive and inferential statistics

Descriptive Statistics: -

Frequency and mean percentage will be used to analyze the study findings.

Inferential Statistics:-

‘t’ test will be used to determine the effectiveness of PICU flow sheet on the care

of critically ill children.

Chi square will be used to find the association.

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7.3 Does the study required any investigation or intervention to be conducted on

pts / human / animals.

Yes –PICU flow sheet will be used to assess the care of critically ill children.

7.4 Has ethical clearance been obtained

Ethical clearance will be obtained from consent authority and written consent

from the participant, anonymity and confidentiality of the subject will be maintained.

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8. REFERENCE

1. Carnevale, F.A. (1997). The experience of Critically ill children: narratives of

unmaking. Intensive Critical Care Nurse,13(1), 49-52.

2. Amico, J., & Davidhizar, R. (1994). Supporting families of criticallyill children.

Journal of Clinical Nurse, 3(4), 213-218.

3. Montenuro, M, (1998). Core documentation: a complete system forcharting

nursing care. Nursing Management, 11(8), 28-32.

4. Bavin, R.(1988). Documentation in pediatric critical care: more time at the

bedside. Pediatric Nursing,14(5), 387-392.North America, 27(3), 587 – 590.

5. Prendergast. T.J., Claessens M.T., A national survey of end-of-life care for

critically ill patients, Pneumologie.2008 Jun; 62(6): 361-6 18535981

(P,S.G,E,B,D)

6. Ruttimann, E., & Pollack, M.M. (1996). Variability in duration of stay in pediatric

intensive cae units: a multi institutional study. The Journal of Pediaric,128(1), 35-

43

7. Downes, J.J. (1992). The historical evolution, current status, and prospective

development of pediatric critical care. Critical Care Clinics, 8(1), 1 -22.

8. Bruno, S. (1995). Systemic neonatal assessment and intervention. MCN,19(1), 21

– 24.

9. Hazinski, M.F. (1985). Nursing care of the critically ill child: a seven – point

check. Pediatric Nursing, 11(6), 453 – 461.

10. Schamberger, M.S. (1996). Cardiac emergencies in children. Pediatric

Annals,25(6), 339-344

11. Hochman, H.I., Grodin, M.A., Crone, R.K. (1979). Dehydration, diabetic

ketoacidosis, and shock in the pediatric patient. Pediatric Clinics of North

America,26(4), 803 – 805.

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12. Whaley, & Wong, D.L. (1995). Nursing Care of Children (5 th ed.). St. Louis:

Mosby Company. Http://www. Childmortality.org/

13. Grewal, M, & Sutcliffe, A.J. (1991). Early prediction of outcome following head

injury: and assessment of the value of GCS score trend and abnormal plantar and

papillary light reflexes. Journal of Pediatric Surgery, 26(2),1161.

14. Mehta, K.P. (1991). Neonatal renal failure. Indian Pediatrics,28(1), 7-9.

24. Muhs, S.M.J., & Mooney, F. (1995). Finally, an ICU flow sheet that makes

sense. RN, (12) 37-47.

15. Perkin, R.M., & Levin, D.L. (1980). Common fluid and electrolyte problems in

the pediatric intensive

16. Riggs, C.D. & Lister, G. (1987). Adverse occurrence in the pediatric intensive

care unit. Intensive Care,34(1), 93-112.

17. Joann Green Rheiner; Mary Erickson Megel, et al , Issue in comprehensive

pediatric nursing. Volume 21, Issue 1, 1998, pages 1-18.

18. Mc Dufflie, A.F.(1992). Documenting the primary nursing summary note: a leap

toward professionalism. Pediatric Nursing 10(2), 102-106.

19. Bergerson, S. (1998). Charting with a jury in mind. Nursing 51-58.

20. Denise, A. (1986). A flow sheet that saves time and trouble. RN (1), 42-44.

21. Klebierm C., & Chase, L. (1989) Solving documentation problems with a

pediatric flow sheet. Pediatric Nursing 15(3) 253-257.

22. Miller ,P., (1990). Daily nursing documentation can be quick and through!

Nursing Management,21 (11),47-49.

23. Moreno. R , Vincent. J.L. et al , The use of maximum SOFA score to quantify

organ dysfunction/failure in intensive multicentre study, pneumologie. 2008

June;62 (6):361-6 18535981 (P,S,G,E,B,D).

24. Muhs, S.M.J., and Mooney, F. (1995). Finally, an ICU flow sheet that makes

sense. RN, (12) 37-41

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9 SIGNATURE OF THE CANDIDATE

10 REMARKS OF THE GUIDE

11 11.1 NAME AND DESIGNATION OF GUIDE

11.2 SIGNATURE

11.3 CO-GUIDE

11.4 SIGNATURE

11.5 HEAD OF THE DEPARTMENT

11.6 SIGNATURE

12 REMARKS OF THE CHAIRMAN AND PRINCIPAL

12.1 SIGNATURE

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