Pediatric Trauma - Hennepin County Medical Center

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RN Perspectives FASTR-HUG can be a simple way to remember the esentials of ICU care that arenʼt always in the forefront of our priorities for critically ill patients with numerous medical needs. RN Perspectives: Give your patients a “FASTR HUG” by Shayna Hamiel, RN, BSN, CPN, CCRN Hennepin County Medical Center You may have heard about the acronym “FAST HUG”, introduced by Jean-Louis Vincent in relation to the essential aspects of care for all ICU patients. When patients are being rushed into the unit in critical condition, their medical needs are great, with our minds shifting gear to prioritization of stabilization and our classic ABCs. However, there are several aspects of intensive patient care that need to be addressed in order to optimize stability and improve patient outcomes. The FAST HUG acronym helps guide us through these important aspects of care that can have adjunctive effects leading to overall wellbeing. These aspects need to be addressed on admission as well as on a daily basis as we strive towards comprehensive care. With skin being the largest organ in the human body, it is becoming more of a focus among health care workers in all areas, but has yet to be fully given the importance that it deserves. Wounds, pressure ulcers, and skin breakdown of all types, both acute and chronic, can lengthen hospital stay and increase morbidity and mortality. Hospital related skin issues need to be more of a priority for hospital workers at all levels, with an emphasis on early detection and intervention, but more importantly, prevention. In our practice in the PICU, we are working on a way to incorporate skin and prevention into our daily care of ICU patients, and have added the “R” to Vincentʼs acronym in order to put skin into the forefront of our thinking with each admission to our unit. F-Feeding Consider nutrition right from the start. Malnutrition can complicate all body systems and worsen outcomes for critically ill patients. Good nutrition is especially essential for wound healing and is a part of the Braden and Braden Q risk assessment tools for skin breakdown. If you know your patient is not going to be able to eat normally for any extended period of time, don't delay feeding tube placement. Enteral nutrition is generally preferred over parenteral nutrition. Although the Braden scale does not give full points for tube feedings, many dieticians will argue that the right formula being fed into the stomach or jejunum can offer equal or better nutrition than what the patient might be getting on a regular diet. 16 | Approaches in Critical Care | June 2011
RN Perspectives A-Analgesia Make sure your patient has adequate pain control. Pain can affect a patientʼs psychological and physiological well being. Most sedatives do not provide analgesia, so sedation and analgesia should go hand in hand for intubated patients. Even if your patient does not have an obvious source of pain such as a wound or fracture, remember that all invasive lines and tubes, as well as immobility, can create a source of pain or discomfort. Make sure you are an advocate for your patient's comfort. S-Sedation Sedative administration must be individualized. This is especially important for pediatric patients or those who are less tolerant of invasive lines and procedures. Safety must be our priority, and keeping patients comfortable helps with hemodynamic stability, keeping lines and airways intact, and allows for adequate rest for optimal healing. T-Thromboembolic Prophylaxis Mortality and morbidity rates increase with venous thromboembolism, so prophylaxis is imperative. ICU patients are at a high risk due to immobility and invasive lines. Although this risk is significantly lower in children compared to adult patients, femoral venous lines or the use of birth control in adolescent females can increase this risk. Make sure your patient has pneumoboots, and unless contraindicated, consider subcutaneous anticoagulants. Also ensure that range of motion exercises are being performed if tolerated and appropriate. R-Repositioning ICU patients have several risk factors for skin breakdown, including immobility, sheering and friction, moisture related to incontinence or diaphoresis, poor tissue perfusion related to oxygenation issues and vasopressor medications, decreased sensory perception, and poor nutrition. These risks are outlined by the Braden Q risk assessment scale, adapted for pediatrics by Quigley and Curley from the original Braden scale developed by Braden and Bergstrom in 1987. Utilizing the tool to assess the patientʼs level of risk can aid in implementing appropriate interventions, and minimizing these risk factors as well as frequent repositioning can help prevent skin breakdown. All ICU patients need to be repositioned regularly. If your patient isn't able to independently make frequent full position changes, you should be assisting them with repositioning at least every two hours. All patients need a complete skin assessment on admission, which would be a great time to do your first position change. When a patient is just arriving in the ICU, they may have already been laying in one position for several hours or even longer, in the ED or the OR, or even at the scene prior to arrival at the hospital. If a patient cannot be fully turned, use positioners for sacral offloading or micro-turns with slight tilting from one side to the other. If they already have a sacral or coccyx wound, minimize the amount of time spent supine. If your patient is difficult to reposition or has several risk factors for breakdown, they may benefit from an alternate surface such as a low air loss mattress or air bed, but remember that patients on specialty beds still need to be repositioned regularly. Also ensure that the patientʼs heels are elevated off the bed regardless of their position. H-Head of bed elevation Elevating the head of the bed decreases risk of reflux and ventilator associated pneumonia. It also aids in decreasing intracranial pressures. However, increasing the head of bed also results in sheering and friction, so unless ordered higher, keep the head of the bed to 30 degrees. You can also use positioners under the patientʼs legs to minimize friction from sliding down in the bed. U-Stress ulcer prevention ICU patients are at high risk for GI ulcers due to stress, respiratory failure, coagulation abnormalities, gastric tube placement, and lack of gastric feeds. Ensure that patients are on H2 blockers if appropriate, or alternate therapies if gastric bleeding is suspected. G-Glucose control Glucose control can help reduce mortality rates in ICU patients. The actual desired level of glucose remains controversial, and more data is needed in pediatrics. However, it is clear that hyperglycemia is associated with increased morbidity and worse outcomes. Make sure your patient's blood glucose levels are being followed either in daily labs or more frequent finger sticks. Utilizing the FASTR HUG acronym on admission as well as in daily patient care can be a simple way to remember the essentials of ICU care that arenʼt always in the forefront of our priorities for critically ill patients with numerous medical needs. Remember to include full skin inspections on all of your patient assessments, and that prevention is easier and faster than treatment. Please join me in giving each of your patients a FASTR HUG today! ■ References Vincent JL. Give your patient a fast hug at least once a day. Crit Care Med. 2005; 33:1225-1229. Quigley SM, Curley MAQ. Skin integrity in the pediatric population: preventing and managing -pressure ulcers. JSPN. 1996; 1(1):7-18. Approaches in Critical Care | June 2011 | 17
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