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fearful or withdrawn, solemn and preoccupied with his or her physical condition.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