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Okay okay okay. Last semester ahead, we've got this!!!!

Excited to be back for the INC 6 workshops, what's even better is that we have 3 hours of it!!! Bec kindly orientated our course for this semester, which consists of 3 x 50 minute classes (simulation, clinical skills and reflection). Going ahead, I contain a bag of mixed emotions such as excitement, nervousness and a tiny bit of burnout. However, I am quite eager to not only advance my practical skills but also deepen my clinical understanding and reasoning of our roles as nurses and what leads us to make clinical decisions in our day to day nursing lives.

Thanks Liam ;)

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Module Two: DKA, Health Literacy Quiz and Avery simulation

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Module Two: DKA, Health Literacy Quiz and Avery simulation

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During this week's module, we delved into the complexities of diabetic ketoacidosis (DKA) in adolescent patients, specifically focusing on a simulated scenario involving a 17-year-old patient named Avery, who was on the verge of being diagnosed with Type 2 Diabetes Mellitus (TDM2). This scenario provided a valuable opportunity to explore the application of nursing standards in a real-world context.

The experience highlighted several critical areas of nursing practice, including the importance of patient-centered communication, health literacy, and clinical care standards. The two student nurses who participated in the scenario effectively demonstrated the need for a calm and reassuring approach when dealing with a nervous adolescent patient. They were successful in creating a supportive environment, actively listening to Avery's concerns, and maintaining a patient-centered conversation. This aligns closely with the NMBA Nursing Standards for Practice, particularly Standard 2.2, which emphasis's engaging and communicating in a therapeutic and professional manner, and Standard 2.4, which provides support and direction to resources to gain a clearer understanding of their health and decision making.

DKA is not my strongest subject. In previous placements and modules, I have found it a bit harder to align the issues/reasoning's to DKA, such as poor health education on diabetes, prolonged hyperglycaemia, medications and electrolyte imbalances. I have found that being a visual and hands on learner I tend to design/draw or focus attentively on animation diagrams to understand module concepts. The link above enables me to connect the dots of the why? what? when? and how? in pathophysiological topics. Rather than watching power slide points or reading chapters where I would not retain the information 5 minutes afterwards. I feel having these visual presentations, just like our debrief setups for simulations can not only drive my motivation of understanding various topics but also develop more subject focused goals that I can complete inside and outside of the clinical setting.

In applying NMBA standards, particularly Standard 5.1, I would use assessment data to tailor a plan that addresses Avery's specific needs, considering their limited health literacy. This includes collaboratively developing a nursing practice plan (5.2) that sets clear, achievable goals and educating them in a way that is easily comprehensible. Documentation and regular evaluation of this plan (5.3) would ensure it remains effective and responsive to them progress. Ensuring that all education and care provided aligns with the relevant policies (6.5) and is delivered within my scope of practice (6.2) is paramount. By effectively coordinating resources, such as engaging a diabetes educator, and providing timely supervision where necessary (6.3, 6.4), I can help facilitate a safe and supportive transition for Avery from hospital to home, empowering them and their family to manage them condition effectively.

As for my future practice, I am to master my understanding of DKA in adolescents, key future strategies include prioritising continuous education on the pathophysiology of DKA and its specific impact on adolescents, actively engaging in simulations and clinical practice to reinforce hands-on skills, and maintaining up-to-date knowledge on the latest research and guidelines for DKA management. Additionally, focusing on developing strong communication skills to effectively educate young patients and their families about DKA prevention and management, while also being culturally sensitive and considering individual health literacy levels, will be essential in providing holistic and patient-centered care.

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Diabetic Ketoacidosis (DKA) explained with cartoons!

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Reflection on students sim, what was done well and room for improvement when looking after patients with DKA, such as Avery

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Week 1 of my placement in the adolescent ward at Canberra Hospital has been incredibly rewarding. I feel privileged to care for young patients in a stressful environment, where my therapeutic skills have been invaluable.

Learning to draw up medication and utilise various tools has been a great experience. I've observed how seriously nurses take weight-based calculations, especially considering the vulnerability of paediatric patients to medication errors. The narrow therapeutic window in paediatric dosing means that even a small miscalculation can have significant consequences.

The mental health aspect of the ward has been particularly challenging. I’ve learned a lot about using appropriate language, especially during meal times with younger patients with eating disorders like anorexia and bulimia nervosa. I believe these disorders profoundly impact decision-making and self-worth, often driven by extreme judgment of one's weight and appearance. I was also not aware of what bulimia nervosa was!! I now know it involves losing control while eating large amounts of food and then attempting to purge the calories through vomiting, laxatives, and diuretics (Loop diuretics: Furosemide and Thiazide diuretics Hydrochlorothiazide). These two eating disorders profoundly impact decision-making and self-worth, often driven by extreme judgment of one's weight and appearance. Preventing the re-occurance of these behaviours required me to take initiative actions such as playing requested musicians on Spotify, conducting trivia and ranking movies, in order to create a stress free environment. They were effective, evidenced by the empty meal trays. I also found that some patients can be deceptive and manipulative when requesting certain tools or items to dispose food in or eliminate, and/or drinking excessive water to flush out food. We constantly reminded that these type of behaviours are not tolerated and further action such as 12/24 hour of restriction to bed rest, passing stools and urine in bed pan, and bolus feeds were taken. These actions are in place not as a punishment, but more so to psychologically remove those negative behaviours/actions for their own good.

To prevent these behaviors, it’s crucial for us as nurses to remain vigilant and maintain close supervision, especially during meal times. The use of 1:1 patient care is essential, as the negative actions mentioned can easily occur without proper oversight. While not all patients require continuous one-on-one care, it is important to tailor this decision based on each individual’s engagement with their care plan. As a nurse, I strive to foster a collaborative approach, providing guidance, encouragement, and constructive feedback to support patient recovery.

This approach aligns strongly with NMBA Standard 5.2, which emphasises the collaborative construction of nursing practice plans. By working with patients, their families, and the healthcare team, I can ensure that care plans are personalised, considering contingencies, priorities, and goals to support recovery. Additionally, this collaborative effort allows for the continuous evaluation and modification of care plans, in accordance with Standard 7.1, to monitor progress toward expected goals and outcomes, ensuring the care remains effective and responsive to the patient’s evolving needs. Through this reflective and dynamic process, I can deliver safe, quality care that is adaptable and focused on achieving the best possible outcomes for each individual.

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Paeds ward food eating disorder handbook!

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Paeds ward food eating disorder handbook!

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This is an invaluable guide that I frequently rely on, particularly in challenging situations where the right guidance and encouraging words are essential.

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Toolkit  I used for new paediatric admissions with eating disorders.

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Toolkit  I used for new paediatric admissions with eating disorders.

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What an awesome 2 weeks!!!

In all honesty, I was quite gutted on my last day. I did not want to leave. The trust and rapport I had built with the team were exceptional. They made me feel as if I were a registered nurse. I was involved in leading action plans with my buddy RN, conducting discharge plans, calling the ward team when PEWS scores were above 4, or medications were not charted. I even acted as an educator to both parents and nurses when digital or cultural issues arose

1A was not the most frantic ward and mainly only consisted of 6/8 beds. However, that reduced number did not stop me from participating in every nursing assessment, even if it was not my allocated patient. These assessments and action plans would mainly consist of Neurovascular obs, head injury assessments, wound care management, IV antibiotic admin, traffic light mood behavior assessment, and even putting in Flags on DHR (DV order, Falls risk and risk of code blacks).

One thing that really stood out for me during this placement was how professional paeds nurses are in all aspects in their practice. De-escalating patients who have impulsiveness and mental health complications with phrases such as "I can see that you’re feeling really upset, and that’s okay. It’s normal to feel this way sometimes" and "I’m listening to you. Can you tell me more about what’s bothering you so I can help make things better?". These quotes and constant re-assurance enabled our patients to feel safe and trust that our actions assist and guide them in their health journey. When addressing those questions, I remained consistently aware of my patients' cultural backgrounds, health literacy, and other social determinants. This mindfulness allowed me to respond appropriately. Initially, I found it challenging to convey these messages effectively, but I made significant progress by observing and learning from the best RN's on my ward. Their techniques and insights inspired me to adapt and develop my own authentic approach.

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11853 ASS 1 Professional Portfolio - Part A

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Module Three: Mental Health Adolescents.

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Module Three: Mental Health Adolescents.

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Examining assessment tools like the HEADSS, CRAFFT, and Paeds Symptom Checklist has expanded my understanding of how to approach child mental health assessments and the importance of focusing on key topics that may affect their mental state.

As someone who enjoys engaging with people, the HEADSS tool provided practical tips for my future practice, such as:

Being aware of the environment and ensuring the young person feels comfortable.

Recognising that the goal is not to force trauma disclosure but to listen and acknowledge if it happens naturally.

Focusing on strengths and identifying at least one adult the young person trusts.

"Reading the room" and revisiting topics later if the child isn't responsive initially, especially when family isn't present.

These insights, particularly from the NSW Health videos, have boosted my confidence in connecting with patients and conducting assessments more effectively in upcoming simulations.

Additionally, I aim to expand my knowledge of identifying acute deterioration in patients, determining appropriate treatments, and knowing when and how to involve or refer others. I will also consider factors in escalating care for adolescents with mental health concerns, focusing on:

Who: Key individuals like the adolescent, family, healthcare providers, and school counselors.

Where: Escalation often occurs in hospitals, clinics, or community mental health centers.

What: Recognising deterioration and initiating interventions, including therapy adjustments or hospitalisation.

How: Identifying warning signs, reasons for admission, and past experiences.

When: When the adolescent’s behavior and well-being are at risk, acknowledged by family, healthcare workers, or peers.

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Will be constantly reading over AMH for clarification and understanding of drugs in certain cases!

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Guideline when conducting HEADSSS assessments!

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HEEADSSS Assessment learning video resource

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​HEEADSSS assessment - working effectively with young people is a video learning resource for health professionals about how to use HEEADSSS conversations to engage with young people and do a holistic health and wellbeing assessment

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My video did cut out due to the time. Building on my earlier point about recognising the need to call a MET, identifying normal versus abnormal signs in a patient—such as monitoring chest rise and fall (is the chest rising appropriately?), assessing slower capillary refill time (indicating inadequate circulation of oxygenated blood), and evaluating whether their GCS is within the normal range—is critical. For example, informing the team leader and RMO when Avery’s GCS drastically dropped from 15 to 3 was crucial.

By gathering these clinical data cues, we were able to develop an informed plan for immediate intervention, including calling a MET and administering rapid pharmacological measures to prevent an opioid overdose. This approach aligns with NMBA Standard 5.1, as it utilises assessment data and the best available evidence to guide care planning and response

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Continuing on, I felt that Mat and I were able to stay calm and present our clinical information clearly when handing over to the MET team. The conversation included our actions that we took when managing respiratory depression due to opioid overdose, and reporting clinical findings that did or did not occur during our assessments. Calling this MET required a strong rationale, I strongly recommended administering Naloxone immediately to reverse the opioid effects and restore normal respiration. I emphasised how critical the patients condition is, and that they required immediate interventions.

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ACT Vital Signs and Early Warning Scores Guideline!!

Section 5 had detailed guides of what personnel and actions are required in each MET criteria.

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Module Four: Legislative considerations in the ACT for patients presenting with a mental health condition.

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Module Four: Legislative considerations in the ACT for patients presenting with a mental health condition.

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PRE WORK:

This weeks module looked at mental health considerations for hospital admissions and how legislation plays a role in these situations, including different types of orders e.g. ED11, ED3 & PTO).

Key topics that we will discuss include Voluntary admission and Involuntary admission, PTO, EA, & ACAT.

Voluntary: Happens when a consumer/pt with a mental illness agrees to be admitted to hospital because they may pose a serious risk to themselves or others.

Involuntary: Occurs when a consumer/pt with a mental illness is admitted to hospital without their consent. This is done to assess the most appropriate treatment required, that safely reintegrate themselves into the community without posing to themselves or others.

Australian Civil and Administrative Tribunal (ACAT): Is responsible for making legally binding decisions on mental health matters, such as guardianship and treatment orders. It reviews and hears cases to ensure that individuals' rights are upheld and decisions about their care are made according to legal and ethical standards. The tribunal also provides an independent forum for challenging decisions made by mental health services, ensuring a fair hearing and oversight.

Psychiatric Treatment Order (PTO): Issued by ACAT mandates specific psychiatric treatment for individuals, ensuring adherence to prescribed care such as medication or therapy. It provides a formal legal framework for enforcing treatment and includes oversight by ACAT to ensure that the orders are appropriate, necessary, and in line with legal and ethical standard

Mental health is one of those key subjects that whenever I rediscover it I always learn of different pathways about it. The Mental Health Act 2015, is such a meticulously structured policy that provides clinical appropriate approaches, management and monitoring of mental health. This legislation not only regulates processes and treatments but also ensures a comprehensive framework for addressing mental health issues. It was fascinating to see how methodical and detailed the system is, designed to balance effective care with legal and ethical standards.

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Reflecting on my experience during today’s lab, I recognise how NMBA Standard 6.5 has been deeply interwoven into my practice, particularly in managing mental health cases. Understanding the nuances of the 2015 Mental Health Act, specifically the differences between voluntary and involuntary admissions under Section 4.1, has guided me in ensuring that my care aligns with relevant policies and legal frameworks. This act provides a crucial foundation for how I approach mental health assessments, consultations, and care planning, ensuring that each step complies with the legal obligations and safeguards necessary for patient care.

What has become clear is that applying these policies in practice is not simply about following a set of instructions—it requires a deep understanding of how legislation directly influences patient outcomes and safety. In mental health care, each decision, from an initial assessment to the creation of a care plan, carries significant legal and ethical implications. This complexity has made me more vigilant about how I navigate these policies in practice, ensuring that I not only meet regulatory requirements but also offer care that is tailored to the specific needs of each consumer.

Looking ahead, I plan to further deepen my knowledge of both hospital-specific and broader legislative guidelines, which will allow me to anticipate potential legal or safety issues before they arise. For example, I will continuously review hospital procedures and policies related to mental health care, as these are constantly evolving. This proactive approach will not only ensure that I remain compliant with NMBA Standard 6.5 but also enable me to implement care plans that are both legally sound and patient-centered.

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This week’s debrief was fantastic! We used mind maps to dive into topics like working within a mental health team, building therapeutic relationships, trauma-informed care, and patient rights. It was such a great activity because we got to share our thoughts and learn from each other’s perspectives. It really opened my eyes to how different people approach these areas and why they matter.

I was stoked to take the lead in my group, and we chose to highlight two key topics: Support for Professionals and the Multidisciplinary Team (MDT). For support, we talked about things like using self-care activities (cooking, journaling) to unwind, EAP services like Beyond Blue and Lifeline, burnout prevention training, and the importance of having friends to debrief with—both at work and outside. When it comes to the MDT, we saw it as the brain of patient care. Without all the different roles—nurses, doctors, cleaners, security, physiotherapists—working together, the quality of care would seriously drop. Having a strong team ensures that every part of a patient’s health is addressed, leading to more well-rounded and effective care.

For me, this experience highlighted how crucial it is to have strong collaboration and a clear plan in mental health care. It fits perfectly with NMBA Standard 5.3, which emphasises documenting, evaluating, and tweaking care plans as needed to hit our goals. It is not just about making a plan—it is about staying flexible and adjusting as the situation changes. We also covered Standard 5.4, which talks about planning and agreeing on how to measure success. In mental health, things can shift quickly, so having clear markers for progress is key to making sure the care we give stays on track.

We also touched on NMBA Standard 6.6, which focuses on spotting and reporting risks. I’ve learned that staying on top of potential issues—whether they’re system problems or areas where practice might fall short—is crucial for maintaining safe, high-quality care. It is all about being proactive and making sure we were constantly improving.

Looking ahead, this debrief has reinforced how important teamwork and self-care are in mental health nursing. By focusing on strong collaboration within the MDT and looking after myself, I will be better equipped to provide the best care possible while keeping my own well-being in check.

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Module Five: Care of paediatric patient experiencing a burn injury & their family.

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Module Five: Care of paediatric patient experiencing a burn injury & their family.

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Pre Work Summary:

Burn severity is determined by body surface area, depth, and anatomical site. Total Body Surface Area (TBSA) is measured using tools like the ‘Rule of Nines,’ Lund and Browder chart, or Rule of Palm. Burns trigger fluid leakage due to inflammatory responses.

Early Management:

Dressing changes require effective analgesia, such as titrated morphine, especially for children where distractions (e.g., stories, bubbles) are useful for calming.

Burn Types and Care:

1. Superficial Epidermal (scalds, sunburn):

Appearance: Pink, blistered, wet, painful.

Dressing: Saline cleaning, non-stick dressings.

2. Partial Thickness (second-degree):

Appearance: Red/white, blistered, painful.

Dressing: Antibacterial dressings like silver.

3. Deep Dermal (flame, chemical):

Appearance: Mottled, dry, less painful.

Dressing: Acticoat, moist wound dressings.

4. Full Thickness (third-degree):

Appearance: White/charred, dry, no spontaneous healing.

Treatment: Excision/grafting, antibiotics.

5. Hands/Feet Burns:

Dressing: Silver sulphadiazine, individual dressings to maintain function.

Pain Assessment:

Multidimensional Approach (QUESTT): Combine self-report (age-appropriate tools), behavioral observation, and physiological measures (tachycardia, hypertension)

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Burns Unit:

Key clinical information that has enhanced my understanding of the various types of burns and the effective treatments required.

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There are many different burns unit's throughout the world. In providing this information we hope to educate you that even though there are differences the main outcomes are still the same. This should help to also give conformity in the specialised care needed. The consultants Russell Taylor, Tom Clarnette, Warwick Teague, Sian Fairbank and Jonathon Burge are the experienced surgeons in this field.

Kathy Bicknell is the Burns CNC. She provides clinical care, coordinates inpatient and outpatient care for burns patients and provides education to patients, families, nursing, medical and allied health. She is also involved in developing prevention strategies and providing education in the community.

Kellie Smith and Kate Glassford are the burns unit Care Managers. They co-ordinate the care of burns patients on Platypus ward who have a severe burn injury.

The Clinical Facilitator provides education and support to staff within the hospital.

The multidisciplinary team meet weekly on a Wednesday morning at 0930am to discuss the care of patients.

Thank you for taking the time to read this information.

Clinical information

There are five functions of the skin that make it so important.

These are:

Protection

Fluid balance

Thermo-regulation

Sensory organ

Produces vitamins

Information required prior to admission

The following questions to ask/tell the Ambulance Officer/Admitting Officer/Burns unit staff are important in assisting the Medical and Nursing staff to ascertain the severity of the burn injury.

Estimated time of arrival

Name, Age of the child

What type of burn and location on the body

Estimated percentage (how have they made this estimate)

?Inhalation injury

How it occurred and time it occurred

first Aid

What treatment was given, if any

Is intravenous access established

Has analgesia been given

?Tetanus status current

Are the parents/guardians aware. Will they accompany the child

Is an interpreter required

Past medical history ie. asthma, diabetes, epilepsy

Classification of burns

Burns are classified into five categories:-

Burns dressings

The method of dressings we use at The Royal Children's Hospital involves a "closed" dressing technique, with the exception of burns to the face and perineum. We use this method for a number of reasons. The main reasons are for protection and absorption and for decreasing stress of both the patient and the family, Dressing changes can but may not necessarily be 'painful' however the emotional and psychological distress can be enormous. Because of this the number of dressings required should be kept to as few as possible.

The moistness, size, depth, and area of the burn needs to be taken into consideration for dressing selection. The aim of the burn dressing is to keep the wound clean and dry, and prevent infection.

Epidermal burns - Involves the epidermal layer only and will heal usually within a few days

Superficial burns

A superficial burn involves only the epidermis and the upper part of the dermal papillae. The burn may appear bright pink or red in colour (erythema). Blisters may or may not be present. The texture is normal or firm and the area is very painful and hypersensitive to touch. On pressure the burn area will blanch and capillary return will be brisk. In time the erythema will fade and spontaneous healing will occur with no surgical intervention.

An occlusive non-stick dressing can be used for this sort of burn:

Generally dress with a non stick dressing like Mepite/Jelonet/Bactigras, Melolin and crepe bandage. Secure with Hyperfix if necessary.

Mepitel is a low adherent wound contact dressing made of silicone gel bound to a flexible polyamide net.

It is preferable to leave the dressing intact until the patient is reviewed after 7 days, or earlier if necessary. Spontaneous healing will occur. These sorts of dressings allow the child a certain amount of mobility within a given area, without concern of further injury to the wound or discomfort to the child. It allows for greater ease and comfort for both the patient and the care givers when nursing the child.

Protection is a two way process in the "closed" method. An closed dressing protects the wound, but also protects the "outside", be it patients, staff, family or anyone who comes into contact with the patient.

Partial thickness (Mid - Deep Dermal)

This type of burn injury results in the entire epidermal layer being destroyed along with varying thickness of the dermis. Hence a Partial Thickness injury can be either Superficial, mid or Deep.

The substructures - sweat glands and hair follicles generally remain undamaged, but some can be affected. It is characterised by a creamy coloured base which is mottled in appearance. Usually a Superficial Partial thickness burn will heal itself by regeneration of the epithelial layer but will take longer to heal than a superficial burn. A deep partial burn where the deeper substructures, sweat glands and hair follicles are affected, if left untreated will leave scar tissue.

Unfortunately the depth of a Partial thickness burn may take up to 7 - 10 days to declare it self as superficial or deep.

A closed dressing should be used:

Generally we use Acticoat or Acticoat 7(moisten with sterile water, cover with IntraSite Conformable, cling film, and crepe bandage. Secure with Hyperfix)

The exudate from the wound determines the number of dressing changes required.

Acticoat is a silver impregnated antimicrobial barrier dressing. Acticoat can stay intact for 3 days and Acticoat 7 for up to 7 days. Acticoat needs to be activated by moistening it with Sterile water before applying it on the wound bed. Ensure dressing is moist not wet to avoid maceration of the wound. The moisture releases the silver that protects the wound from bacterial contamination. the Acticoat can be applied either side to the wound.

IntraSite Conformable is a conformable hydrogel dressing that combines the advantage of IntraSite gel with a non woven dressing. It creates a moist wound environment.

Full thickness

In a full thickness burn, injury occurs to the entire thickness of the epidermis, epithelial elements and dermal appendages. Spontaneous healing is not possible. If left, the area will heal by contraction thus reducing function. A full thickness burn is usually characterised by its whitish leather appearance but it can also be brown, cherry red or charred black. It is firm and leathery in texture. Few, if any, blisters are present. Those blisters that are present are thin walled and break easily and should be debrided. Areas will not blanch under pressure. Initially, nerve sensation is greatly diminished or lost completely when the injury is sustained. Later pain associated with the burn area can be severe as the child undergoes grafting.
The eschar of a full thickness burn is extremely inelastic and leads to compression of the underlying tissues as oedema occurs.

A closed dressing could be used:

Generally we use Acticoat TM or Acticoat 7 TM(as per consultant choice) moisten with sterile water, covered with IntraSite Conformable TM, cling film (eg Gladwrap), and crepe bandage. Secure with Hyperfix and Tubigrip.

1- Apply moisten Acticoat to the burn wound

2- Cover the Acticoat with a layer of Intrasite Conformable

3- Secure the Intrasite Conformable with Hypafix tape to prevent slipping

4- Cover the Intrasite Conformable with a layer of cling wrap to keep moisture within the dressing

5- Secure the entire dressing with Hypafix / Mefix tape

6- Apply Tubigrip / bandage over the dressing for support

Different dressings may be used. The decision to use other dressings is made by the consultant.

Facial/respiratory burns

More people die in a fire from pulmonary insufficiency caused by the inhalation of heat and smoke, than they do from the direct burn injury, thus airway management is a priority. With the advent of new furnishing materials, we are seeing a more complex form of injury.

Inhalation injuries are uncommon in children, but are potentially more dangerous than in an adult because of ;

the diameter of the child's airway is smaller and more prone to obstruction by a given degree of oedema

the chest wall is soft and immature

less respiratory reserve - respiratory failure from fatigue is more likely

greater metabolic demands, including oxygen consumption are compounded

the younger the child the greater the risk of respiratory distress, with increased mortality

greater fluid requirements for fluid resuscitation.

Supraglottic oedema, laryngeal oedema or upper respiratory tract obstruction can develop as a result of a direct thermal injury such as the inhalation of flames, steam and the aspiration of hot liquids, or the inhalation of a chemical agent. Superheated air can transmit sufficient heat throughout the respiratory tract resulting in damage to lung tissue. If a child requires intubation, they will be nursed in the Intensive Care Unit. Occasionally, a tracheostomy may be indicated if prolonged respiratory support is required.

Signs of respiratory burn will be singed nasal hair, facial burns, blood stained sputum, carbonaceous sputum, oedema in the neck and facial area, respiratory distress, uneven noisy respirations, shallow breathing, tachypnoea, stridor, hoarseness, changes in mental state, restlessness, cyanosis and eventually loss of consciousness. Even if there are no signs present, children burned in an enclosed space must be considered to have an inhalation injury until disproved. Upper airway obstruction may result due to inhaled smoke even in the absence of cutaneous burns on the face.

Symptoms of hypoxia and respiratory distress may be delayed, but usually occur within the first 24 hours. Progressive obstruction may occur rapidly and careful observation is necessary for early detection and intervention.

In a facial burn, injury to the eyes, nose, mouth and ears are checked and treated accordingly. Facial burns need frequent cleansing with normal saline as exudate collects below eschar and may lead to infection and a delay in the healing process. Vaseline is applied twice a day after the face is cleaned. It can be reapplied as required if the wound becomes dry.

It must be explained to the child and family that facial oedema will occur. This usually peaks 48 hours post injury. Parents often do not recognise their own children and nursing staff need to explain that this oedema resolves itself in a few days.

Eyelids and ears may be swollen, thus impairing sight and hearing. Frequent eye toilets and the use of Chloromycetin ointment is necessary until swelling subsides sufficiently.
Lip swelling and oral burns can make it difficult for the child to maintain adequate oral intake so a Nasogastric tube may be required and NG feeds commenced and mouth toilets given.

Facial tissue is highly vascular and heals quickly. If grafting is required a specially fitted pressure mask is worn as soon as grafts are stable. The current literature supports that a face should be left no longer than 21 days to heal and that early debridement is needed.

Refer Fact Sheet on Kids health info for parents web site:Facial Burns

Fluid resuscitation

Not required for a burn <10%TBSA.

Burns Resusitation fluid is given for burns >10%. Formula used: TBSA 3ml/kg/TBSA% = 24/hr total. Give 1/2 of this volume in the first 8 hrs from the time of the injury.

Maintenance fluid is administered concurrently.(not included in resuscitation fluids)

Lund and Browder chart

This assessment chart has been developed to assist health professionals to accurately calculate the percentage of burn surface area. It allows for the varying rates of growth in the head, thigh and lower leg of different age groups.

The "Rule of 9's" is inaccurate for paediatric patients - there is a modified "Rule of 9's" for paediatric use. The palmer method may also be used - the size of the child's palm can be used to estimate 1% Body Surface Area.

Fluids

Please see attached a copy of the fluid resuscitation regime

A modified Parkland Formula is used to calculate Burs Resuscitation fluids at RCH.

3/kg/%TBSA - 24hr total

Half of this volume is given in the first 8 hrs from the time of injury.

The second half is given over the next 16hrs

Fluids used at RCH are :

N.Saline

5% Dextrose & N.Saline (for maintenance fluids)

Naso-gastric feeding can replace maintenance fluids

Nutrition

Escharotomies

Full thickness circumferential burns can cause a tourniquet effect. Early elevation of the affected area can help prevent the increase of oedema. Increased blood viscosity, localised oedema, eschar formation and reduced circulatory blood volumes results in venous stasis and ischaemia may result. When this occurs an escharotomy is performed by the consultant as a prophylactic measure to reduce the likelihood of further damage to the tissues that lie distally to the circumferential eschar.

The tension within the tissues is relieved by cutting the skin with a scalpel. The wound will gape open exposing fatty tissue and some bleeding will occur. The escharotomy is dressed with Acticoat Absorbent and Acticoat to the area around the escharotomy. Then apply IntraSite conformable, plastic wrap loosely and a loose bandage.

Limb observations are necessary, as is elevation to monitor the effectiveness of the escharotomy. Escharotomies are often performed in the the ward, however, if possible theatre is more appropriate.

Before the patient is transported or if 4 hours has elapsed since the injury and circulation appears compromised, the referring doctor should consider Escharotomies.

Admission to the Burns Unit

Firstly the patients are seen in emergency, wounds debrided and dressed and then transferred to Platypus or Possum Ward.

These guidelines are followed:

Smaller burns can be dressed with a closed dressing and reviewed in outpatients.

Any child >10%TBSA should have the following :

Fluid Resuscitation

IDC on 1hrly measures

NG tube with feeding started within 6 hours

Strict Fluid Balance

Flame burns/ burns that are oozing are to be dressed with Acticoat

Scald burns can be dressed with Mepilex Ag or Acticoat

Any Circumferential burns to have 1 hourly Colour, Warmth, Movement and Sensation and the limb elevated

As always there are circumstances that warrant a change from these guidelines, this can be discussed with the consultant on call

When to transfer

Types of Burns Requiring Admission at The Royal Children's Hospital

All Burns with a surface area greater than 10%, except very superficial burns.

All full thickness burns except those that are extremely small. (All burns to face, ears, eyes, hands, feet, genitalia, perineum or a major joint. Even if less than 5%.)

1. Electrical burns (including lightening injury)

2. Chemical Burns

3. Burns associated with significant fractures or other major injury, in which the burn injury poses a significant risk of morbidity or mortality

4. Inhalation burns of any nature (ICU admission)

5. Burns in children under the age of 12 months (emergency transfer may not be required but assessment should be made)

6. Small area burns - in patients with social problems, including children at risk

7. Any other patient that is deemed appropriate on consultation
Note: For those requiring admission the consultant on call must be notified.

Antibiotics

Systemic antibiotics are not routinely prescribed. They are only given when a known infection is present and they are altered according to their sensitivities. The prophylaxis use of antibiotics does not reduce the risk of infection.

In the early post burn phase, febrile episodes are common, they do not necessarily indicate infection, but they do warrant close monitoring. These episodes are usually related to large amounts of pyrogens that are released as a result of the burn injury.

A wound swab is used for diagnosing infection in burnt areas.

In theatre, when grafting, Prophylactic antibiotics are given if the patient is not already on antibiotics.

Common antibiotics used are :

Blisters

The care of blisters depends on their size and location.

If the blisters are not large and will not obstruct the dressing, they can be left alone. The fluid within the blisters is sterile and therefore offers protection of the underlying skin.

If large bulbous blisters are present that are obstructing a dressing or restricting circulation to a limb/digit it is necessary to puncture the blister, release the serous fluid and debride the skin so that the dressing is compact and in contact with the skin.

When left intact, after a few days, if the fluid within the blister is opaque and infection is suspected, the blistered epidermis should be removed completely. Loose epidermis from broken blisters should be trimmed off if floating free. It should be noted that bleeding can occur if removal is attempted while it is still adherent.

If purulent fluid is present within a blister, it should be deroofed, and swabbed for infection. On the hand or sole, white keratin can be associated with blistering and such loose keratin (which has no sensation) can be excised if floating free.

Non accidental injuries

ERC are on call to have photos taken, please page them through switch (anytime)

Where to get more information

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There are many different burns unit's throughout the world. In providing this information we hope to educate you that even though there are differences the main outcomes are still the same. This should help to also give conformity in the specialised care needed.

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Watching the interview with the mother of a paediatric burns patient like Quinn highlighted the critical need for nurses to thoroughly understand burn first aid and ongoing care. Administering a 20-minute cold shower within the first 4 hours is essential for minimising tissue damage. Ensuring the water is tolerable, even if distress is present, and removing burnt clothing immediately are key priorities to prevent further harm.

Importance of cold shower?
Cold water halts burn progression by preventing the spread to deeper tissues, helping localise and minimise damage. It is a vital early intervention in burn management.

The interview also highlighted the significant challenges faced by families in rural and remote areas, where access to specialised burn care is often limited. In these regions, the absence of burn specialists, advanced medical equipment, and adequately trained healthcare staff can delay essential treatments, such as early cooling or wound care. This often results in poorer outcomes for pediatric patients, who need immediate and specialised care. For families, the additional burden of traveling long distances to access burn units, along with the emotional and financial strain, further complicates their ability to manage their child’s care.

In addition to these core interventions, NMBA Standard 7.1 and 7.2 underscore the need for continuous evaluation of outcomes. For example, fluid intake and output, vital signs, and pain levels must be regularly assessed to ensure the child is progressing as expected. Adjustments to the care plan, such as increasing fluid volumes or altering analgesia dosages, are made based on these evaluations to optimise the Quinn's recovery.

Communication is another critical factor in achieving successful outcomes. NMBA Standard 7.3 emphasises the importance of maintaining clear and regular updates with the healthcare team. Effective communication ensures that all members of the multidisciplinary team, including doctors, nurses, and allied health professionals, are aware of Quinn’s current condition and any changes in the treatment plan. This coordination helps deliver consistent, high-quality care and avoids any lapses in critical interventions.

Beyond physical treatment, psychosocial support is essential in burn care. Paediatric burns affect not only the child but also the family. Nurses must provide emotional support by explaining procedures in age-appropriate terms, offering resources like social workers, and engaging children in activities like play therapy to aid emotional recovery. This holistic approach ensures comprehensive care that addresses both the physical and psychological needs of pediatric burns patients, ultimately promoting better health outcomes.

In my future practice, I will consistently implement these NMBA standards to provide the highest quality of care. My approach will be comprehensive, ensuring that physical interventions, such as early cooling and fluid resuscitation, are complemented by robust pain management, continuous outcome monitoring, clear communication, and emotional support. By addressing both the clinical and psychological needs of pediatric burns patients like Quinn, I will be well-prepared to meet the complex demands of nursing practice, delivering care that is both evidence-based and deeply compassionate.

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Module Six: Primary and Secondary Surveys.

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Module Six: Primary and Secondary Surveys.

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Primary and Secondary Surveys

These are systematic patient assessments used in emergencies:

Primary Survey: Rapidly identifies life-threatening conditions using the ABCDE approach—Airway, Breathing, Circulation, Disability (neurological status), and Exposure—to manage immediate threats first.

Secondary Survey: A detailed head-to-toe examination after stabilization to find additional injuries or conditions. Involves vital signs, thorough physical exam, and patient history using AMPLE—Allergies, Medications, Past medical history, Last meal, Events leading to injury/illness. Includes focused assessments of body systems and may involve diagnostic tests.

Timely identification through these surveys is crucial for prompt treatment, better outcomes, and reduced long-term complications.

Workplace Injury

Workplace injuries profoundly affect individuals, their loved ones, and the broader community across four domains:

Physical: Temporary or permanent disabilities limiting activities and performance.

Emotional: Mental health challenges like anxiety, depression, and stress.

Financial: Loss of income, increased medical costs, and resource strain.

Social: Reduced ability and confidence to engage socially, affecting relationships and community participation.

Nurses' Role

Nurses play a vital role in providing holistic care to patients with workplace injuries:

Short-term: Address immediate physical and emotional needs—assess injuries, manage pain, provide emotional support, and engage patients and families in care decisions.

Medium-term: Facilitate recovery by collaborating with rehabilitation teams, educating on self-care and injury prevention, coordinating with multidisciplinary teams, and tracking progress.

Long-term: Manage chronic effects, ensure access to rehabilitation and mental health resources, advocate for community support, and help patients set realistic recovery goals while adapting to permanent changes.

This therapeutic approach promotes resilience and optimal recovery outcomes.

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This week's focus was on primary, secondary and tertiary assessments in a fast paced environment.

In the assessments we covered the key factors on gas-exchange with the a rib fracture and head knock. Key findings was Paradoxical Breathing, where the the chest wall moves inward during inhalation and outward during exhalation, which is the opposite of normal chest movement. This fracture also consisted symptoms of high resp rate, shallow sharp breathing and reduced or absent breath sounds over the affected side due to the collapse of lung tissue. Signs of possible pneumothorax (collapsed lung).

In the lab, myself and a few other colleagues unpacked some key questions in the administration of analgesic and antiemetic medication. In this case, our patient was on spinal precautions and had been vomiting. I initially suggested administering Morphine (Analgesic) first to treat the pain (9/10), however one team member addressed that our patient was currently experiencing nausea from the head knock. Another member identified that our patient was on c-spine precautions. Through healthy debate and discussion, we came to an ultimatum of administering IV Ondansetron then IV Morphine. Rationale behind this consisted of multiple factors, including IV Drug Handbook, Ondansetron could be given rapidly over atleast 30 seconds, whereas Morphine, being a strong dose requires dilution of water due to it's strength, over a period of 4-5 minutes. 4-5 minutes is because a rapid dose may cause worsening of nausea, vomiting and dizziness. Other factors included the vomiting, main focus was keeping airway clear to improve oxygenation. And finally, treating the nausea may not be the direct reason for the pain.

NMBA Standard 6:

The initial reasoning and subsequent teamwork allowed for the discussion of crucial information, highlighting the importance of effective communication and shared-decision making in rapidly changing situations, such as rapid deterioration. This approach helps ensure patient safety from multiple perspectives.

NMBA Standard 4:

In managing a patient post-traumatic injury, conducting comprehensive and systematic assessments is critical for prioritising care and detecting early signs of deterioration. By utilising a range of assessment techniques in line with NMBA Standard 4.2, I can accurately evaluate the patients' condition and identify the most urgent clinical needs. This allows me to implement timely and appropriate interventions, ensuring that care is both responsive to the patients' evolving condition and aligned with their individual risks, such as c-spine precautions. Such an approach not only mitigates potential complications, like airway obstruction from nausea, but also ensures that all interventions are informed by a thorough understanding of the patient’s overall clinical picture. This process, grounded in collaborative communication with the healthcare team, ensures holistic and patient-centered care that adheres to the highest standards of clinical practice.

Future Practice:

I will work to deepen my understanding of spinal precautions to enhance the quality of care I provide to my patients. I will conduct thorough and systematic assessments to identify all areas of concern, enabling me to exercise sound clinical judgment and critical thinking when formulating care plans. Collaboration with other nurses and the multidisciplinary team will remain a priority, ensuring that we prevent further harm and optimize patient outcomes. To support my critical thinking and decision-making, I will continue to ask reflective questions, such as, "What is the immediate problem?" and "What poses the greatest risk to my patient's wellbeing at this moment?" These strategies will aid in effective prioritisation and the delivery of safe, patient-centered care.

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Pre Work Summary:

This week's preparatory material focused on infection control, hydration management, and symptom relief in viral gastroenteritis. Managing this condition across multiple patients requires prioritising care, minimising cross-contamination, and offering holistic support.

Nurses must skillfully navigate various clinical settings by prioritizing patient care based on acuity while balancing the diverse needs of each individual. For instance, managing dehydration through timely administration of IV fluids and medications, alongside strict infection prevention protocols, becomes vital in ensuring both patient safety and effective care delivery. This requires a delicate balance between addressing urgent needs and maintaining comprehensive care for all patients under their watch.

Strategies for key prioritisation in nursing:

Effective Communication: Use ISBAR for clear, concise updates with the healthcare team to manage multiple patients efficiently, especially during outbreaks.

Example: A nurse uses ISBAR to quickly communicate with a physician about a dehydrated patient, ensuring prompt IV fluid intervention.

Rapid Assessment & Critical Thinking: Prioritize patients using tools like AVPU and vital sign monitoring to quickly address deteriorating conditions.

Example: A nurse identifies dehydration in a gastro patient by assessing lethargy and tachycardia, prioritizing IV fluids immediately.

Infection Control: Strictly follow hand hygiene, PPE, and isolation protocols to prevent cross-contamination in infectious environments.

Example: Cluster nursing tasks in contaminated areas, limiting the need to re-enter the room while using disposable gowns and gloves.

Resource Allocation: Strategically allocate staff and equipment, focusing on critical needs like IV pumps for severe dehydration, while monitoring stable patients with oral rehydration.

Example: Nurses prioritize equipment for the most critical patients while delegating tasks to assistants for less urgent cases.

Patient Education: Empower patients and families with self-care tips, reducing the demand for resources and improving outcomes.

Example: Educating families on signs of dehydration and proper hand hygiene to manage mild symptoms at home, preventing hospital re-admissions.

Flexible Prioritisation: Constantly reassess patient needs, adjusting priorities based on changing conditions.

Example: A nurse shifts focus from a moderately dehydrated patient to another patient showing respiratory distress, ensuring the critical patient is stabilized first.

Time Management: Utilize shift planners and task lists to break down tasks and ensure timely interventions.

Example: A nurse plans out IV administration and reassessments, ensuring each task is completed on time without delaying critical care.

Delegation & Collaboration: Assign appropriate tasks to support staff, such as personal care, while focusing on critical interventions yourself.

Example: Delegating hygiene care to assistants while focusing on IV administration for high-acuity patients.

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Reflection on Strengthening Prioritisation Strategies in Future Practice:

To enhance my prioritisation strategies, I recognise the need for a more structured, systematic approach. Reflecting on both past experiences and recent simulations, it is clear that well-organised methods significantly improve patient safety, care outcomes, and team efficiency, especially in high-pressure environments.

One key lesson I’ve learned is the importance of acuity-based care for prioritisation. In complex ward settings, where patients present with varying conditions like gastroenteritis or chronic illnesses, using the ABCDE framework (Airway, Breathing, Circulation, Disability, Exposure) ensures life-threatening issues are managed first. This approach allows for swift responses to critical conditions, such as respiratory distress, while also addressing more stable cases. Moving forward, I will continue using this framework to maintain focus on urgent needs.

In the recent simulation, I adhered to NMBA Standard 7.1 by evaluating patient progress toward goals, such as monitoring nasogastric-fed patients and adjusting care as needed. While I successfully revised care plans and delegated tasks per Standard 7.2, I identified a need to respond more quickly to shifting priorities in high-acuity situations. Improving my speed in real-time decision-making will be a focus for future practice.

Time management tools such as task lists and shift planners proved crucial in organising workflow and coordinating with the team. Delegating routine tasks, such as vital sign monitoring, while managing complex care interventions for patients with COPD, enabled me to ensure quality care across the board. This aligns with NMBA Standard 7.3, where I clearly communicated revised goals and priorities to the team, ensuring cohesive patient management.

Prioritisation isn’t just about immediate needs; it involves balancing patient safety and holistic care, as reflected in NMBA Standard 4.1. Moving forward, I plan to improve resource allocation and delegation by ensuring equipment and staff are utilised efficiently in high-acuity situations. For example, I will prioritise critical resources, like high-flow oxygen, for the most urgent cases while delegating routine care tasks to assistants.

Effective communication remains essential for prioritisation. Clear handovers using ISBAR are crucial for maintaining continuity of care and guiding the team to focus on what matters most. In future practice, I aim to refine my communication to ensure critical information is conveyed efficiently throughout the shift, enabling the team to function cohesively and deliver high-quality care.