Benchmarks for children’s orthopaedic nursing carelearntech.uwe.ac.uk/Data/Sites/26/GalleryImages/Journey-Through... · Benchmarks for children’s orthopaedic nursing care

Benchmarks forchildren’sorthopaedicnursing care

RCN guidance

Acknowledgements

The RCN Paediatric Orthopaedic Special Interest Group(POSIG) would like to thank all the contributors fortheir input in developing the benchmarks.

Julia Judd (Co-Chair POSIG), Advanced NursePractitioner, Paediatric Orthopaedics, SouthamptonUniversity Hospitals NHS Trust

Elizabeth Wright (Co-Chair POSIG), Advanced NursePractitioner, Paediatric Orthopaedics, SouthamptonUniversity Hospitals NHS Trust

Siobhan Lalor-McTague, Matron for Children’s Services,Royal National Orthopaedic Hospital NHS Trust

Jo Capron, Clinical Nurse Educator for Paediatrics, RoyalNational Orthopaedic Hospital NHS Trust

Nikki Critchley, Senior Ward Sister, SouthamptonUniversity Hospitals NHS Trust

Hannah Brown, Senior Staff Nurse, RN Child, GreatOrmond Street Hospital for Children NHS Trust

Angie Lee, Advanced Nurse Practitioner, PaediatricOrthopaedics and Trauma, Royal Berkshire NHSFoundation Trust

Pauline Heaton, Clinical Nurse Specialist, CentralManchester and Manchester Children’s UniversityHospitals NHS Trust

Carole Irwin, Practice Educator, Orthopaedic andTrauma Surgery, Head and Neck, Great Ormond StreetHospital for Children NHS Trust

RCN Legal Disclaimer

This publication contains information, advice and guidance to help members of the RCN. It is intended for use within the UK but readers areadvised that practices may vary in each country and outside the UK.

The information in this booklet has been compiled from professional sources, but its accuracy is not guaranteed. Whilst every effort has beenmade to ensure the RCN provides accurate and expert information and guidance, it is impossible to predict all the circumstances in which itmay be used. Accordingly, the RCN shall not be liable to any person or entity with respect to any loss or damage caused or alleged to be causeddirectly or indirectly by what is contained in or left out of this website information and guidance.

Published by the Royal College of Nursing, 20 Cavendish Square, London, W1G 0RN

© 2007 Royal College of Nursing. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmittedin any form or by any means electronic, mechanical, photocopying, recording or otherwise, without prior permission of the Publishers or alicence permitting restricted copying issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London W1T 4LP. This publicationmay not be lent, resold, hired out or otherwise disposed of by ways of trade in any form of binding or cover other than that in which it ispublished, without the prior consent of the Publishers.

R O Y A L C O L L E G E O F N U R S I N G

1

Benchmarks for children’s orthopaedic nursing careRCN guidance

Introduction 2

The benchmarks 3

1 Pre-operative assessment 3

Screening and assessment 3

Practitioner competence 3

Informing the child/young person and carers 4

Implementation of an individualised plan 4

2 Cast care 5

Education and training 5

Patient care 5

Upper body cast 6

Lower body cast 6

Discharge planning 7

3 Neurovascular assessment 8

Education and competence 8

Recording and documentation 9

Communication and information 9

Clinical action 10


4 Traction 11

Education and application of traction 11

Education, management of traction and nursing care 12

Communication and information 13

5 Pin site care 14

Screening and assessment 14

Education 15

Evidence, knowledge and competence 15

Clinical care 16


6 Kirchner wire removal 17

Competency and knowledge 17

Preparation of child/young person and carers 17

Procedure 18

7 Bone or joint infection 19

Admission 19

Assessment and screening 20

Treatment 20


8 Spinal injury 22

Assessment of injury 22

Stabilisation 23

Acute care and rehabilitation programme 23

Psychological impact of a spinal cord injury 24


9 Spinal surgery 26

Pre-operative assessment 26

Nursing care plan 26

Pain management 27

Post-surgical mobility 27

Contents

Introduction

This document provides a portfolio of evidenced-basedbenchmarks, which define best practice in key elementsof paediatric orthopaedic nursing care. They have beendevised by a core team of expert, experienced nursesfrom the paediatric orthopaedic special interest group(POSIG) to identify the optimal care management forchildren and young people with an orthopaediccondition. The benchmarks are based on the format ofThe Essence of Care (DH, 2001) to help practitioners ‘toidentify best practice and to develop action plans toimprove care’. The statements and indicators are aimedto stimulate discussion, help measure individualpractice and guide staff to review the various issuessurrounding each benchmark. The benchmarks are easyto use and auditable, and can be used to inform, updateand change practice.

2

C H I L D R E N ’ S O R T H O P A E D I C N U R S I N G C A R E

Pre-op assessment

Pre-operative assessment forchild/young person admittedfor elective orthopaedic surgery


3

1 Benchmark 1

Scorer name Title Signed

Score

Justify score marked

Score


Factor 2:Practitioner competence

Indicators of best practice for factor 2To stimulate discussion about best practice in yourcomparison group, you may find it helpful to consider:

� knowledge and expertise required for completingscreening and assessment and the process formaintaining and remaining up-to-date

� put in place mechanisms to assess the competenceof the screeners and assessors

� access specialist assessment if required

� document assessment for use by the caring team.

E D C B A

Child/young personis assessed bypractitioners who donot have therequired specificknowledge andexpertise.

Benchmark of bestpractice

Child/young person isassessed by apractitioner who has theknowledge andexpertise, and remainsup-to-date.

Factor 1:Screening and assessment

Indicators of best practice for factor 1To stimulate discussion about best practice in yourcomparison group, you may find it helpful to considerthe:

� assessment of children/young people to identifypotential risk and the initiation of a discharge plan

� adequacy and inclusion of the components of thescreening assessment and what tools are used

� documentation of the screening assessment

� screening assessment is carried out withinacceptable time frame

� inclusion of a manual handling assessment

� evidence-base used for assessment is current.

E D C B A

Child/young personis not given theopportunity to comefor a pre-assessmentappointment.


Child/young person tobe admitted for electivesurgery is given theopportunity to come fora pre-assessmentappointment.

4


Score


Factor 3:Informing child/young personand carers


� range of information available and its format tomeet children/young peoples’ or carers’ individualneeds, such as language, tapes, videos and leaflets

� evidence-base for the information

� children/young peoples’ understanding of theinformation is verified and choices are documented

� record sharing and understanding of information.

E D C B A

Child/young personand carers have noaccess toinformation.


Child/young person andcarers have access toinformation and havethe opportunity todiscuss this with aregistered practitionerat assessment.

Score


Factor 4:Implementation of anindividualised plan


� barriers to the implementation of planned care andhow variance is recorded

� document how the multidisciplinary team isinvolved

� how the parents and child/young person areinvolved.

E D C B A

There is no evidenceof a written care planor evidence of thecare being givenaccording to a plan.

References

Great Ormond Street Children’s Hospital Trust (2002)Pre-admission clinic: family factsheets, London: GOSHTrust.

Lowry L and Lewis V (2004) Redesigning anorthopaedic pre-assessment clinic, Journal ofOrthopaedic Nursing, 8(2), pp.77-82.

Thomas D (1996) Assessing children it’s different, RN,April, pp.38-44.


The assessment leadsto an individualisedplan that is fullyimplemented inpartnership with themultidisciplinary team(MDT), child/youngperson and carers.


5

Cast care

Care of child/young person in a cast

2 Benchmark 2


Factor 1:Education and training


� nurses have attended formal training by a qualifiedand competent practitioner

� nurses have completed practical competencies withannual updates and these are documented

� trained in neurovascular observations (refer tobenchmark 3) and cast complication.

E D C B A

Nurses who have nocast care training,care for thechild/young person.


Child/young person iscared for by nurses whohave knowledge andexpertise in all aspectsof caring for a cast.

Score


Score


Factor 2:Patient care


� type of cast – plaster of Paris, synthetic – and itsspecific care

� handling and positioning of cast – upper/lowerlimb, hip spica, broomstick plasters etc

� cast is handled carefully when wet to avoid unduepressure and potential damage

� carry out regular assessments i.e. neurovascularobservations, ooze, tightness, sharp edges, whetherloose or cracked. Take appropriate action

� documentation of above

� daily review by MDT e.g. physiotherapist,occupational therapist, as needed.

E D C B A

Child/young persondoes not receivecare from acompetent andknowledgeablepractitioner and isnot referred to theMDT team foradditional support.

Benchmark of bestpracticeChild/young personreceives care fromcompetent andknowledgeable nursesand has access to MDTfor additional care andsupport.

6


Score


Factor 3:Upper body cast


� type of cast e.g. backslab/full and specific advice forcare

� assist with hygiene and feeding needs. Address theissues of education needs (e.g. writing, schoolattendance), limitations to sports activities

� appropriate aids for immobilising i.e. collar andcuff/ sling, appropriate for the type for cast

� education/information needs regardingneurovascular observations and advice on elevatingupper limb(s) when at rest (see neurovascularassessment benchmark)

� documentation of care provided/information givenetc.

� offer coloured cast.

E D C B A

Child/young personreceives minimalcare, teaching anddischarge advice.

Benchmark of bestpracticeChild/young person iscared for by the MDTmeeting all aspects oftheir needs.

Score


Factor 4:Lower body cast


� type of cast and implications to care e.g. long legcast, backslab, hip spica

� personal hygiene is attended to by nursing team andtaught to the family

� care needs, particularly manual handling andmobility needs, are assessed, documented andtaught by appropriate practitioner e.g. nursing staff,occupational therapist /physiotherapist

� pressure area care and regular turning of child incast, as appropriate for type of cast e.g. hip spica cast

� patient taught safe use of crutches/Zimmerframe/wheelchair/buggy by appropriate practitioner

� offer coloured cast and crutches.

Benchmark of best practice as for upper body


7

Score


Factor 5:Discharge planning


� implement care plan at earliest opportunity e.g. atpre-admission/admission. Discharge plan isdocumented

� document and perform the nursing assessmentappropriately i.e. neurovascular observations, ooze,tightness, sharp edges, looseness, cracked cast

� address and evaluate the family’s needs. Give advice(verbal and written) and education and informationabout neurovascular observations, mobility and castcare

� provide care for child by appropriately trained andexperienced MDT.

E D C B A

Child/young personreceives minimalcare, teaching anddischarge advice.

Benchmark of bestpracticeChild/young person iscared for by MDT anddischarge planning isevident.

References

Altizer L (2004) Casting for immobilization,Orthopaedic Nursing, 23(2), pp.136-41.

Clarke S and McKay M (2006) An audit of spica castguidelines for parents and professionals caring forchildren with developmental dysplasia of the hip,Journal of Orthopaedic Nursing, 10(3), pp.128-37.

Hart ES, Albright MB, Rebello GN and Grottkau BE(2006) Developmental dysplasia of the hip: nursingimplications and anticipatory guidance for parents,Orthopaedic Nursing, 25(2), pp.100-11.

Newman DML (2005) Functional status, personalhealth, and self-esteem of caregivers of children in abody cast: a pilot study, Orthopaedic Nursing, 24(6),pp.416-25.

Prior M and Miles S (1999) Principles of casting,Journal of Orthopaedic Nursing, 3(3), pp.162-70.

Sparks L, Ortman MR and Aubuchon P (2004) Care ofthe child in a body cast, Journal of Orthopaedic Nursing,8(4), pp.231-5.

8


Neurovascular assessment

Neurovascular assessment (NVA) for child/young person at risk ofdeveloping compartment syndrome

3 Benchmark 3


Factor 1:Education and competence


� clinical need for individual neurovascularassessment and the appropriate frequency ofobservations

� ‘best placed’ health care professional to make thedecision for frequency of NVA and the qualificationsor level of experience they possess

E D C B A

Health professionalsfail to assess thechild/young person’sclinical need for NVAand have not receivededucation relating tocompartmentsyndrome or training inthe correct use of theNVA tool.

Benchmark of bestpracticeThe health professionalhas received appropriateeducation and training inthe assessment of thechild/young person’sclinical need for NVA, thecompletion of the NVAtool and can demonstrateknowledge relating tocompartment syndrome.

Score


� any clinical protocols, guidelines or literature thatexists to guide this process

� training required to achieve knowledge andcompetence relating to this factor, the frequency oftraining updates and how this will be demonstrated.


9

Score


Factor 2:Recording and documentation


� educational needs of the health professionalcompleting the NVA tool

� importance of documenting why a part of the tool isnot completed e.g. plaster in situ

� legal implications of documenting nursing practice

� who determines interval times for completion of theNVA tool.

E D C B A

The NVA tool isincorrectly or onlypartially completedand there is nodocumentation inthe child/youngperson’s nursingnotes relating to thecompletion of, orfindings from theNVA tool.

Score


Factor 3:Communication andinformation


� what information child/young person and parentsrequire and their communication needs

� appropriate format for the information.

E D C B A

The child/youngperson and parentsare not informedabout the necessityof NVA.

Benchmark of bestpracticeThe NVA tool iscompleted correctly andat the predeterminedinterval times, withevidence ofdocumentation in thechild/young person’snursing records ofcompletion and of theclinical findings.

Benchmark of bestpracticeThe child/young personrequiring NVAassessment and theirparents have beeninformed of thenecessity andunderstand therationale for NVA.

10


Score


Factor 4:Clinical action


� optimal clinical action for each indicator of potentialcompartment syndrome

� whether this differs according to experience andqualification of the health care professional

� appropriate health professional from whom thenurse should seek further advice, if neurovascularcompromise is a concern

� action taken if the referral is unsuccessful and theclinical cause of concern remains

� documentation of the event in the medical andnursing notes.

E D C B A

The nurse fails torespondappropriately anddoes not refer ortake clinical actionwhen aneurovascular causefor concern isidentified.

Score




� content of the information given and in what format

� to whom it should be given

� where this should be documented.

E D C B A

There is no evidenceof dischargeplanning relating tothe ongoingneurovascular careof the child.

Benchmark of bestpracticeWhen a neurovascularconcern is identified thenurse takes effective,speedy and appropriateclinical action.

Benchmark of bestpracticeThere is evidence ofdischarge planning anddocumentation relatingto the parents andchild/young personbeing given verbal andwritten informationregarding ongoingneurovascular care.


11

References

Altizer L (2002) Neurovascular assessment, OrthopaedicEssentials, 21(4), pp.48-50.

Dykes PC (1993) Minding the five P’s of neurovascularassessment, American Journal of Nursing, (6), pp.38-39.

Love C (1998) A discussion and analysis of nurse-ledpain assessment for the early detection of compartmentsyndrome, Journal of Orthopaedic Nursing, 2(3),pp.160-167.

Scott J and Mubarak MD (1995) Technique of diagnosisand treatment of the lower extremity compartmentsyndromes in children, Operative Techniques inOrthopaedics, 5(2), pp.178-189.

Swain R and Ross D (1999) Lower extremitycompartment syndrome: when to suspect acute orchronic pressure build up, Post Graduate Medicine,105(3), pp.159-168.

Wright E (2007) Evaluating a paediatric neurovascularassessment tool, Journal of Orthopaedic Nursing, 11(1),pp.20-29.

Traction

Traction application andmaintenance for the clinicalmanagement of children withfractures or pre or post-orthopaedic surgery

4 Benchmark 4


Factor 1:Education and the applicationof traction


� ‘best placed’ health care professional to teach andassess staff competency, depending on thequalifications or level of experience they possess

� clinical protocols, guidelines or literature that exist

� training required to achieve the knowledge and

E D C B A

Health careprofessionals havenot receivededucation relating tothe application oftraction.


The health careprofessional hasreceived appropriateeducation and trainingin the application oftraction and candemonstrate the skillcompetently.

12


Score


competence relating to this factor, thefrequency of training updates andhow this will be demonstrated

� choice of different types of tractionand their uses.

Score


Factor 2:Education, the management of tractionand nursing care

Indicators of best practice for factor 2To stimulate discussion about best practice in your comparisongroup, you may find it helpful to consider:

� principles of safe practice in the maintenance of traction (e.g.safety checks, maintenance of traction pull, neurovascular statusof limb in traction) and the availability of clinical protocols,guidelines or literature

� recognition of deterioration of child/young person’s condition dueto immobility

� tools that can assist with the assessment of potentialcomplications of immobility and traction (e.g. neurovascularcompromise and pressure sores) and the preventative measuresthat can be used to reduce the risk (e.g. see benchmark forneurovascular care)

� recognition of child/young person’s schooling and psychologicalneeds whilst in traction

� involvement of play specialist

� ‘best placed’ health care professional to care for the child/youngperson in traction

� legal implications of documenting nursing practice and thefrequency of documentation for checking traction equipment andof patient clinical reviews.

E D C B A

Maintenance andcare of thechild/young personin traction issuboptimal.

Benchmark of bestpracticeTraction is safelymaintained and theequipment is regularlychecked. The child/youngperson receives optimalcare while in traction, withevidence of documentation.


13

Score


Factor 3:Communication andinformation


� what information parents and the child/youngperson require

� appropriate format of the information.

E D C B A

The child/youngperson and carersare not informedabout the necessityfor traction.

Benchmark of bestpracticeInformation about thenecessity for tractionhas been given to thechild/young person andtheir carers verbally andis supported with awritten leaflet, so thatthey understand therationale for treatment.

References

Davis P and Barr L (1999) Principles of traction, Journal of Orthopaedic Nursing, 3 (4), pp.222-227.

Grippen Bryant G (1998) Modalities for immobilisation,cited in Maher AB, Salmond SW, and Pellino TAOrthopaedic Nursing (2nd edition), Philadelphia: WB Saunders.

Judd J (2007) Thomas splint traction cited in GlasperEA, McEwing G and Richardson J (2006) Oxfordhandbook of children’s and young people’s nursing, New York: Oxford University Press.

Hakala BE and Blanco JS (2000) Pediatric femoral shaftfractures, Medscape Orthopaedics and Sports Medicinejournal, 4 (1). www.medscape.com/medscape/OrthoSportsMed/journal

Nichol D (1995) Understanding the principles oftraction, Nursing Standard, 9 (46), pp.25-28.

14


Pin site care

Care of pin sites forchild/young person with anexternal fixator

5 Benchmark 5


Factor 1:Screening and assessment


� signs of potential pin site infection through aconsensus of opinion and as described in theliterature

� training needs of the nurse in assessing the patient

� any clinical protocols, guidelines or literature thatexist to guide this process.

E D C B A

The healthprofessional fails toassess correctly forevidence of potentialpin site infection andhas not received therelevant educationand training.

Benchmark of bestpracticeThe health careprofessional hasreceived appropriateeducation and trainingin the assessment forsigns of potential pinsite infection and candemonstrate thisknowledge andcompetence.

Score



15

Score


Factor 2:Education


� the provision of information that parents andchildren require

� that information is given in an appropriate format.

E D C B A

The child/youngperson and parentsare not taught thesigns of pin siteinfection or informedas to what actionthey should take if apin infection issuspected.

Benchmark of bestpracticeThe child/young personand parents areknowledgeable indetermining the signs ofpotential pin infectionand understandrationale for promptintervention. They havebeen given an actionplan for treatment if pininfection is suspected.

Score


Factor 3:Evidence, knowledge andcompetence


� literature that supports best practice in pin site care

� availability of a guideline for practice

� frequency for reviewing the guideline.

E D C B A

An evidence-basedguideline is notavailable for healthprofessionals toguide their practice.Pin site care isperformed based ontradition.

Benchmark of bestpracticeAn evidence-basedguideline for bestpractice in pin site careis available and healthprofessionals candemonstrate knowledgeand competence inperforming pin site care.

16


Score


Factor 4:Clinical care


� rationale for quick and effective treatment of actualor potential pin site infection

� optimal clinical action and drug therapy for earlyand late signs of pin site infection

� documentation of clinical findings and actionstaken

� potential for improving practice-based auditfindings.

E D C B A

The nurse fails torespondappropriately anddoes not refer ortake clinical actionwhen a pin siteinfection is evident.

Benchmark of bestpracticeWhen a pin siteinfection is evident thenurse takes effectiveand appropriate clinicalaction.

Score




� information that should be given

� format of the information

� documenting that information has been given to theparents and child/young person.

E D C B A

There is no evidenceof dischargeplanning relating tothe informationgiven to thechild/young personand carers tomanage pin sites athome.

Benchmark of bestpracticeThere is evidence thatdocumentation wasgiven to the carers andchild/young personwith verbal and writteninformation regardingpin site care.

References

Davies R, Holt N and Nayagam S (2005) The care of pin sites with external fixation, Journal of Bone Joint Surgery, 87-B, pp.716-719.

Judd J (2007) Pin site care cited in Glasper E.A, McEwing G and Richardson J, Oxford Handbook of children’s andyoung people’s nursing, New York: Oxford University Press.

Lee-Smith J, Santy J, Davis P, Jester R and Kneale J (2001) Pin site management, Towards a consensus: part one,Journal of Orthopaedic Nursing, 5, pp.37-42.

Santy J (2000) Nursing the patient with an external fixator, Nursing Standard, 14(31), pp.47-52.

Sims M and Saleh M (2000) External fixation – the incidence of pin site infection: a prospective audit, Journal ofOrthopaedic Nursing, 4 (2), pp.59-63.


17

Score


Kirchner (K) wire removal

Removal of percutaneous K wires from child/young person in anoutpatient setting, following fixation of a fracture

6 Benchmark 6


Factor 1:Competency and knowledge


� level of experience, education and training needs fora practitioner to be competent

� assessment of the practitioner and by whom

� guidelines and evidence-base for practitionerassessment.

E D C B A

The procedure isperformed by aninexperiencedpractitioner with nopaediatric ororthopaedicknowledge andskills.

Benchmark of bestpracticePractitioners removingK wires have paediatricand orthopaedicexperience, areknowledgeable, skilledand competent inperforming theprocedure.

Score


Factor 2:Preparation of child/youngperson and carers


� putting in place evidenced-based guidelines forappropriate selection of children/young people forwire removal in outpatients

� what guidelines exist for appropriate pain relief forthe child/young person e.g. simple analgesia and/orEntonox (gas and air)

� advising parents/carers appropriately on pre-procedural pain relief

� the information needs of the child/young personand their family, the format of the information andthe timing of when to give the information.

� the involvement of a play specialist to facilitatechild/young person’s understanding of theprocedure and to engage in distraction therapy.

E D C B A

The child/youngperson and theircarers do not receiveany informationrelating to theprocedure of K wireremoval.

Benchmark of bestpracticeThe child/young personand their carers referredfor wire removal in out-patients, receive fullverbal and writteninformation on theprocedure to enableinformed consent.

18


Score


Factor 3:Procedure


� what evidenced-based guidelines exist for theclinical procedure of removal of K wires in theoutpatient setting

� what evidenced-based guidelines are available forthe pain management and psychological care of thechild/young person

� whether the practitioner has appropriate medicalsupport available if required

� whether a play specialist is available for support anddistraction therapy and there is provision ofappropriate toys

� performing the procedure in a child-friendlyenvironment

� that the child/young person’s notes and X-rays aremade available to the practitioner

� the documentation of the procedure.

E D C B A

The wires are notsafely and effectivelyremoved,traumatising thechild.

Benchmark of bestpracticeA competentpractitioner safelyremoves K wires, thechild/young person’scare is individualised,evaluated anddocumented.

References

Boyd DQ and Aronson D (1992) Supracondylarfractures of the humerus. A prospective study ofpercutaneous pinning, Journal of PediatricOrthopaedics, 12, pp.789-94.

Symons S, Persad R and Paterson M (2005) The removalof percutaneous Kirchner wires used in the stabilisationof fractures in children, Acta Orthopedica Belgica, 71,pp.88–90.

Wilson M and Hunter J (2006) Supracondylar fracturesof the humerus in children – wire removal in theoutpatient setting, Injury Extra, 37, pp.313-315.


19

Score


Bone or joint infection

Care and treatment of a child/young person with boneor joint infection

7 Benchmark 7


Factor 1:Admission

Indicators of best practice for factor 1To stimulate discussion about best practice in yourcomparison group, you may find it helpful to considerthe:

� admission criteria for a child/young person withsuspected bone/joint infection

� advantages of being admitted to a specialistpaediatric orthopaedic ward with appropriatelytrained and competent nursing and medical staff

� availability of a paediatrician and microbiologist foradvice and support

� knowledge and skills of nursing staff to ensure thatinfection management is explained to thechild/young person and family.

E D C B A

The child/youngperson is admittedto a generalchildren’s surgicalward and cared forby staffinexperienced in themanagement ofbone and jointinfections.

Benchmark of bestpracticeThe child/young personis admitted to apaediatric orthopaedicward and cared for bystaff experienced inmanaging bone andjoint infections.

20


Factor 2:Assessment and screening


� format for assessment and screening

� role of the nurse in ensuring that appropriate bloodtests are performed at the appropriate time and theaffected area is X-rayed

� role of the nurse in explaining to the child/youngperson and family the need for furtherinvestigations e.g. bone or ultrasound scans, MRI

� role of the nurse in monitoring vital signs forevidence of infection, the frequency and accuracy ofscreening observations particularly temperatureand neurovascular observations.

E D C B A

Nursing and medicalstaff are notknowledgeable inthe assessment andscreening of thechild/young personwith suspectedbone/joint infection.

Benchmark of bestpracticeNursing and medicalstaff are knowledgeablein the assessment andscreening of thechild/young personwith suspectedbone/joint infection.

Score


Factor 3:Treatment


� the availability of a local evidence-based protocol forintravenous antibiotic (IVAB) therapy.

Also, consider if nurses are:

� competent to administer IVAB

� aware of the rationale for resting and/orimmobilising the affected area

� competent in preparing the child/young person forsurgery and in recovery (where appropriate) andexplain the process to the family

� able to recognise deterioration in condition andreport to appropriate health professional.

E D C B A

Nursing staff cannotdemonstrateknowledge aboutthe management ofbone/joint infection.

Benchmark of bestpracticeNursing staff have theknowledge and skill tocare for the child/youngperson with bone/jointinfection and keep thechild/young person andfamily informed.

Score



21



� that the nurse regularly updates child/young personand family on clinical progress.

� that hospital and community multidisciplinaryteams involved in discharge planning should includecontribution of nursing and play staff whereappropriate, to ensure compliance by child/youngperson with antibiotic regime

� that there is evidence of documentation of dischargeplanning in notes, to include the written and verbaladvice given, and provision of contact numbers

� that local protocols for ongoing antibiotic therapyare followed, drugs to take home are ordered and theregime is explained to the child and family prior todischarge

� that a nurse has arranged and explained theoutpatient's appointment and rationale for furtherblood tests to family.

E D C B A

Child/young personis dischargedwithout appropriateplanning orinformation.

Benchmark of bestpracticeChild/young person isdischarged witheffective planning andinformation.

Score


References

Burden J and Kneale J (2005) Orthopaedic infectionscited in Kneale J and Davis P, Orthopaedics and traumanursing, pp.217-219.

Judd J (2007) Acute osteomyelitis cited in Glasper EA,McEwing G and Richardson J, Oxford handbook ofchildren’s and young people’s nursing, New York: OxfordUniversity Press.

Stott NS (2001) Pediatric bone and joint infection,Journal of Orthopaedic Surgery.

22


Score


Spinal cord injury

Care of a child/young person following a spinalcord injury

8 Benchmark 8


Factor 1:Assessment of injury

Indicators of best practice for factor 1To stimulate discussion about best practice in yourcomparison group, you may find it helpful to considerthat:

� a patient receives a full assessment of initial injurycarried out by a competent practitioner usingappropriate tools, to identify potential risks

� guidelines for assessment are available andevidence-based

� injury management is defined and recorded.

E D C B A

The child/youngperson sustaining aspinal cord injury isnot assessed orreferred forassessment.

Benchmark of bestpracticeAll children/young peoplesustaining a potentialspinal cord injury areassessed on the day ofinjury. The level and typeof injury is determined anda referral is made to aspecialist centre whereappropriate.

� knowledge and expertise for completing screeningand assessment is in place and mechanisms forassessing practitioner competence exists (considerthe ASIA score – the assessment of motor andsensory pathways determined by the AmericanSpinal Injury Association). Specialist knowledge isaccessed if required

� specialist assessment is accessed if required.


23

Factor 2:Stabilisation


� a child/young person is immobilised by a competentpractitioner prior to diagnosis in order to preventfurther injury

� appropriate imaging has been carried out and adiagnosis made

� appropriate referral is made

� transfer is in an appropriate ambulance and anystabilisation prior to the transfer is carried out by acompetent practitioner

� staff are appropriately trained to move patient in asafe way i.e. if unstable using a five-person turn.

E D C B A

Child/young personsustaining a spinalcord injury is notimmobilised orstabilised beforetransfer.

Benchmark of bestpracticeChild/young personsustaining a spinal cordinjury is appropriatelyimmobilised and/orstabilised before beingtransferred to aspecialist centre forongoing management.

Score


Factor 3:Acute care and rehabilitationprogramme


� acute care and rehabilitation programmes areindividualised and devised by appropriate MDTprofessionals

� rehabilitation programmes are reviewed andupdated on a regular basis

� a programme has an allocated amount of time forgoal planning meetings with the patient and theirfamily/carer and the MDT

� all members of the MDT communicate and ensurethat spinal cord injury care is a team approach

� patients and their families are able to accessappropriate spinal cord injury education toempower them to take control of their own care.

E D C B A

Children/youngpeople sustaining aspinal cord injury donot have a plannedrehabilitationprogramme.

Benchmark of bestpracticeChildren/young peoplesustaining a spinal cordinjury have anappropriate acute careand a rehabilitationprogramme that isplanned through amultidisciplinaryapproach.

Score


24


Factor 4:Psychological impact of aspinal cord injury


� regular MDT meetings are held to discuss anyconcerns between the family and/or team

� MDT, patients and their families have regular accessto child and adolescent psychiatric andpsychological services

� regular and ongoing assessment is carried out by theMDT

� members of the MDT have the knowledge andunderstanding of the psychological impact of aspinal cord injury

� specialist knowledge is accessed if required.

E D C B A

No consideration isgiven to thepsychological impactof a spinal cordinjury.

Benchmark of bestpracticeThe psychologicalimpact of a spinal cordinjury to the child oryoung person and theirfamily is adequatelyassessed andsupported by anappropriateprofessional.

Score




� discharge planning starts on admission withcontribution from the whole MDT

� assessment of the child and family’s livingarrangements is undertaken early in the admission

� appropriate outside services are accessed early inthe admission

� discharge planning takes into consideration theworst possible case scenario (no improvement ofcondition following rehabilitation)

� discharge planning takes into equal considerationthe psychological and physical aspects of a spinalcord injury, with a MDT approach to resolving bothprior to discharge or arranging follow-up support

� patients are not discharged until adequate servicesare in place and safety can be assured.

E D C B A

There is no evidenceof dischargeplanning.

Benchmark of bestpracticeDischarge planning forchildren and youngpeople with spinal cordinjuries starts onadmission, is thoroughand provides a safe andtimely discharge thatconsiders theirindividual needs.

Score



25

References

Kirk S, Glendinning C and Callery P (2005) Parent ornurse? The experience of being a parent of a technologydependent child, Journal of Advanced Nursing, 51(5),pp.456-464.

National Institute for Health and Clinical Excellence(2005) Post-traumatic stress disorder (PTSD): themanagement of post-traumatic stress disorder in adultsand children in primary and secondary care (clinicalguideline 26), London: NICE.

NHS Institute for Innovation and Improvement (2005)Improvement leaders’ guides, Warwick: NHS Institutefor Innovation and Improvement. www.institute.nhs.uk

Thomas D (1996) Assessing children it’s different, RN,April, pp.38-44.

26


Spinal surgery

Care of a child/young personundergoing elective spinal surgery

9 Benchmark 9


Factor 1:Pre-operative assessment


� that the pre-operative assessment bench mark isreferred to

� that you ensure patient and family have fullunderstanding of procedure, recovery pathway andpost-surgery management

� the involvement of MDT

� the reduction of anxiety by sharing of information

� the start of individualised care pathway.

E D C B A

Environment isunsafe.

Benchmark of bestpracticeEach child or young personhas the opportunity to attenda pre-operative assessmentappointment for electivespinal surgery.

Factor 2:Nursing care plan


� child/young person has undergone pre-operativescreening and assessment

� staff have appropriate knowledge to care for patientfollowing spinal surgery, e.g. log rolling, pressurearea care, positioning, bowel management, nutritionrequirements, pain management, mobilising

� involvement of the MDT

� involvement of patients and parents/carers.

E D C B A

There is no evidenceof a care plan or carehas not beenprovided accordingto the plan.

Benchmark of bestpracticeThe child/young personhas a plan of careappropriate to age andneed, reflecting thespecific care followingspinal surgery.

Score


Score



27

Factor 4:Post-surgical mobility


� a physiotherapist should work with the patient onmobility practice for first time following surgery asper surgeons written instructions

� a patient should become mobile as soon as possiblepost-procedure

� if a brace is needed it should be cast and available assoon as possible

� sitting tolerance should be increased gradually

� the patient needs adequate rest between episodes ofmovement.

E D C B A

The child/youngperson is notmobilised in a safeor controlled mannerwith appropriateassistance.

Benchmark of bestpracticeThe child/young person ismobilised post-surgerywith guidance from thephysiotherapist and in asafe and controlledmanner.

Score


Factor 3:Pain management


� pain history

� whether assessment tools used are appropriate forage and competence of patients

� if pain management treatments are available andused

� the knowledge and expertise of staff and theirongoing development

� access to specialist pain service.

E D C B A

There is no evidenceof appropriate painmanagement.

Benchmark of bestpracticeThe child/young personhas their pain assessedregularly usingappropriate tools and hassufficient analgesiaprescribed.

Score


References

Harvey CV (2005) Spinal surgery patient care, Orthopaedic Nursing, 24(6), pp.426-442.

Kester K (1997) Epidural pain management for the pediatric spinal fusion patient, Orthopaedic Nursing, 16(6),pp.55–60.

Kotzer AM and Foster R (2000) Children’s use of PCA following spinal fusion, Orthopaedic Nursing, 19(5), pp.19–27.

Slote RJ (2002) Psychological aspects of caring for the adolescent undergoing spinal fusion for scoliosis, Orthopaedic Nursing, 21(6), pp.19-31.

December 2007

Review date December 2009

Published by the Royal College of Nursing 20 Cavendish SquareLondon W1G 0RN

020 7409 3333

The RCN represents nurses and nursing,promotes excellence in practice and shapeshealth policies

Publication code: 003 209

ISBN: 978-1-904114-80-2

Documents

Benchmarks for children’s orthopaedic nursing carelearntech.uwe.ac.uk/Data/Sites/26/GalleryImages/Journey-Through... · Benchmarks for children’s orthopaedic nursing care