Peds Proceures

CIMS COLLEGE OF NURSING, DEHRADUN Administration of oral medication. INTRODUCTION: - Medicine may be defined as a substance used to promote health, to prevent, to diagnose, to alleviate or cure Diseases. DEFINITION: -administrating oral medication it is the most common route and the most convenient route for most patients. OBJECTIVES:1. To prevent the disease. 2. To obtain desired effect of the medication. 3.

To cure the disease

4.

To promote the health.

5. To give palliative treatment 6. To give symptomatic treatment.

ARTICLE: - A trolley to take different medicine bottles. A tray containing :1)

Ounce glass, dropper, medicine glass,

2)

Drinking water in a feeding cup,

3) Mortar and pestle 4) Duster 5) Kidney tray 6) Medicine cards & general order book.

1

PREPRATION OF Parent: -Explain about the action of medication.

Child: - A positive, kind, but firm approach w i l l meet the more success than threats stabiles friendly relationship with child play and talk with child.

Environment: -proper cleanness, proper lighting, free from foul smelling, wall full with cartoon picture or poster, play material .

TEPS OF THE PROCEDURE WITH RATIONALE

Prepare the child and family. And identify the child by checking the identification band. PROCEDURE

RATIONLE

2

1. Wash hands

1 To avoid cross infection

2 Read the physician order and compare it

2 To ensure safety in the

with the medicine card

administration of the medication

3 After reading the medication card take

3 the first safety check to prevent the

the appropriate medicine from the shelf

possibility

compare the level with the medicine card

medicine

of

pouring

the

wrong

4. Omit the medications, 5. Take the required medicine from the shelf.

4

It help Prevent wrong dose

Compare the label with the medicine card. Read the entire label. Before a medicine ticket

5 Recheck the medicine bottle

is written or a drug administered, the

- It helps give correct medication

nurse must calculate the safe dosage range

for

compare

the

individual

it

with

child

the

and

dosage

Prevent wrong dose -It helps prevent wrong dose

prescribed.

6 Take the suspension tablets and capsules first

6 It help to prevent contamination

into the lid and then into the medicine Glass, so that the drug will not come in contact. 7. Shake the bottle remove Cap of the bottle,

7 It helps to administered the correct

holding cork between ring and little finger. Hold

dose

bottle in the light to check for sediment etc. 8. Take a medicine glass in the left hand and place

8. It helps prevent wrong dose

thumbnail at the level which drug 9. Check drug with medicine chart again

9 . It helps to administered the correct

and then pour into the glass.

dose

10. Holding the medicine g1ass at eye level

10 It help to prevent the

again check dosages to see that the lower part of

administrate the wronge medication

medicine fails on the thumbnail line. - Replace stopper in bottle and return it to correct place, again checking the label.

11. Never pour excess medication back into

11 To prevent the contamination,

3

bottle or container, discard it into the Sink. 12 Prepare separate medication for each

12 Proper identification of each medication

patient. Identify the patient with the

assures accurate administration of

medicine card by-

correct medication to correct patient

- Reading the name on the case paper. -Holding the child properly by doing the mimics. 13 It help in the easy sallow wallowing of 13. First give little water to drink with the help of spoon and then give

Medicines

one at a time.

the solid medication 14. Ensure the medication is taken

14. Stay with the child while he takes the drug. 15. Give water to drink, after he takes the medicine. Keep the medicine cup In the bowl of water. 16. Be sure that the child is able to take the medication as it is

prescribed.

4

After care of Patient and Articles –

1. Wipe the face of the Child if necessary, 2. Give him comfortable position 3. Take all articles to utility room Clean the articles with soap and Water and then replace them to their proper places. 4. Wash hands. Recording and Reporting – 1.

Record Medication, Dose, Route, Time.

2.

Record any reaction observed after the administration of the drug.

3.

Report any reaction of the patient to the physician and the ward sister. MEDICATION CARD

PATIENT’S NAME

DIAGNOSIS

AGE/ SEX

D.O.A.

WARD/BED NO.

DR INCHARGE

DATE S

MEDICATION NAME

DOSE

TIME

ROUTE

SIGNATURE

TO

r.N

CALCULATE

o.

THE PAEDIATRIC DOSAGE: Most of the drugs are available in the adult dose. The nurse needs

to know how to prepare the Paediatric dosage. 1) Young’s rule :- (for children over one year of age ) unto 12 years Age of the child (in years)

X Adult dose =Child’s dose

Age of the child (years)+12 2) Clark’s rule :- (According to the weight of the child, therefore it can be used for children of all ages) Weight of the child in pounds

X Adult’s dose = Child’s dose

150

5

3)Fried’s rule :- (For children under 1 year of age) Weight of the child in pounds

X Adult’s dose = Child’s dose

150 CHECK LIST OF ADMINISTRATION OF ORAL MEDICATION Yes

No

ADMINISTRATION OF ORAL MEDICATION 1. Hand washing is done 1. Follow five rights 2. Explaining procedure to child’ parents 3. Prepare the articles 4. Checked the vital sign 5. Follow strict aseptic technique 6. Select correct medication 7. Check the manufacture and expiry date 8. Calculate medication dose 9. Administer drug safely 10. Administer drug on time 11. Took medication tray or cart to patient’s room. Checked pt bed number against medication card or sheet. 12. Placed patient in sitting position, if the child is able or not contraindicated. 13. Checked the patient’s identification asked the child name her parents.

6

14. Told the child’s parent what type of medication explained the actions and how it helps to child. 15. If prepackaged medication was used, read label took medication out of package and put into medication cup.

16. Take a medicine glass in the left hand and place thumbnail at the level which drug should be poured to get correct dose.

17. Check drug with medicine chart again and then Pour into the glass.

19. Holding the medicine g1ass at eye level again check dosages to see that the lower part of medicine fails on the thumbnail line.

20. Pour the medicine from the bottle on the side Opposite to the label

21 Replace stopper in bottle and return it to Correct place, Again checking the label.

22. First give little water to drink with the help of Spoon and then gave medicines one at a time. 23. Stay with the child while he takes the drug. Give Water to drink, after he takes the medicine. Keep the medicine cup in the bowl of water.

Recording 1. Name of Medication, Dose, Route, Time.

7

2. General condition of patient 3. Record any reaction observed after the Administration of the drug. 4. Name and signature of a staff

CARE OF COLOSTOMY 8

INTRODUCTION:-

In some childs, cancer or other conditions, such as inflammatory bowel disease,

require the surgical removal of all or part of the colon, rectum, and anus, In such cases, the proximal portion of the remaining bowel may be redirected through the abdominal wall to the abdominal skin surfaces. When this surgery is performed, it is referred to as a fecal diversion, because the normal route for feces is altered. The information that a child requires an colostomy is received with great concern an apprehension by parents and child prepration of child and parents is necessary for both this included an nature of procedure types of bag DEFINITION: -



STOMA: - The portion of the intestine brought through the abdominal wall is known as a stoma.



OSTOMY: - It means an opening of an organ or part of body onto the body surface to drain its contents.



COLOSTOMY: - it is an opening of the colon onto the abdominal surface to drain the faecal matter. Or



A bowel diversion surgery that brings a segment of the large colon out to the abdominal skin is called a colostomy.

PURPOSE

1.

To Contains drainage and odors for the comfort of the client and allows accurate assessment of output.

2. To Protects the peristomal skin from excoriation.

3. To Provides visualization of the stoma and sutures during the postoperative Purposes 4. To prevent leakage. 5. To prevent excoriation of skin and stoma.

6. To observe the stoma and the surrounding skin. 7. To teach the patient and relatives about the care of ostomy and ostomy collection bag. SCIENTIFIC PRINCIPLES: -



ANATOMY AND PHYSIOLOGY: - the colon is divided into the caecum, ascending colon, transverse colon, descending colon, sigmoid or pelvic colon, rectum and anal canal. The four layers of tissue described as the colon, the rectum and the anal canal. The arrangement of the longitudinal muscle fibers is modified in the colon.

In the sub mucous layer

9

there is more lymphoid tissue than in any other part of the alimentary tract, providing non-specific defense against invasion by resident and other microbes.



MICROBIOLOGY: - During dressing sterile technique should be maintained to prevent invasion of bacteria.. Bacteria in the fecal secretions can cause infection in the incisional area and irritate the skin. Hand washing before procedure is helpful to prevent infection



CHEMISTRY The Zinc oxide used to prevent excoriation of skin and protect skin from breakdown. Minimizes leakage by providing a smooth surface for applying the skin barrier.



PHYSICS: - maintained proper body mechanics, and height of the bed should be adjusted during the procedure. During cleaning stoma stroke should be gentle.



PSYCHOLOGY: - Preoperative instructions about colostomy and how it will be managed will be important for the child and her parents to adjust with a colostomy. They should know that the colostomy need not alter their life, but its care will become a routine part of their daily activity. They may be given chances to talk with someone who has a colostomy and has learned to manage elimination and over come fears. Such conversations will be reassuring and informative.

NURSE'S RESPONSIBILITY IN THE COLOSTOMY

1.Check the name, bed number and other identification of the patient. 2.Check the diagnosis and the purpose of colostomy care.

3.Check the type of colostomy done. Make sure of the proximal and distal loop of the colon. 4.Check the child’s ability for self care.

5.Check

the

doctor's

orders for

specific

instructions

and

the precautions, if any, regarding

the colostomy care, movement of the patient etc. 6.Check the understanding of the patient to follow instructions. Check the articles available in the patient's unit. PRELIMINARY ASSESSMENT •Observe color and amount of drainage from stoma.

•Assess existing pouch for leakage, and note appearance of stoma and incision to determine need to change pouch. A pouch does not have to be changed if it is not leaking and if the skin barrier is intact,

•Inspect condition of peristomal skin for erythema, excoriation, ulceration, or fistulas before selecting type of skin barrier to apply.

•Note presence of skin folds, creases, scars, and abdominal softness or firmness before selecting pouch.

10

EQUIPMENT USE FOR COLOSTOMY CARE •

A clean tray containing

•

Cover sheet

•

Protective sheet and towel

•

Gloves—one pair

•

Cotton swabs and gauze pieces

•

Washcloth and towel

•

Water in a basin

•

Soap in a dish

•

Disposable ostomy collection bag with clamp

•

Stoma measuring guide

•

Zinc oxide (siloderm) ointment

•

Skin barrier

•

Deodorizing solution and dropper

•

Kidney tray and paper bag

•

Night drainage system (drainage tubing, collection bag and connector) if required.

•

Bedpan with cover

PREPARATION OF PATIENT AND ENVIRONMENT 1. Explain the details of this procedure to the child and her parents 2. Gather equipment and place within easy reach.

3. Have the patient assume a relaxed position and provide privacy. The best position may be sitting, reclining, or

Standing.

4. Provide privacy. Remove the undergarments to prevent soiling by the excreta. An old sheet or dhoti may be given to the patient to wear until the irrigation is over.

5. Ask the child or her parents to observe every step, so that he learns the care of the colostomy. It is desirable to have a family member be present to learn the procedure. It is desirable to have some reading material or radio nearby to provide pleasure and diversion of the patient while waiting for the return flow. STEPS OF PROCEDURE 1.Provide privacy. 2.Wear disposable gloves. 3.Gently remove old appliance. If disposable, discard. If reusable, set aside for washing.

11

4. Wash skin thoroughly around stoma with skin cleanser or soap and water. Rinse skin thoroughly and blot dry. Rationale: Soap residue or dampness can interfere with pouch adhesion, resulting in leakage. Blotting the area dry minimizes trauma to the stoma.

5. Observe condition of peristomal Skin, the stoma, and the sutures. Teach the client to make these observations daily. Observation allows monitoring for complications. The stoma is at risk for necrosis during the first postoperative week, as evidenced by dark color and lack of bleeding. The peristomal skin is at risk for breakdown from irritating fecal secretions. Infection is more easily corrected if detected early.

6.Prepare clean pouch: measure stoma and trace circle larger than stoma on the adhesive paper backing. Cut the stoma pattern. Pattern cut slightly larger than barrier avoids risk of paper cuts to stoma and ensures a tight seal with the barrier 7. Prepare skin barrier: measure stoma and cut hole in Barrier the same size as the stoma. Be sure edges are rounded. Close fit of barrier

around stoma prevents fecal secretions from contacting and irritating

the skin.

8.If stoma is located in an abdominal increase or the skin is irregular, use a paste barrier to fill the irregularity. Minimizes leakage by providing a smooth surface for applying the skin barrier. 9. Apply protective skin barrier. a. Backing off wafer and center stoma in hole.

b. Place on abdomen, pressing lightly over all areas of the barrier to promote adhesion with skin surfaces Rationale:- A tight fit will prevent leaking and protect the skin underlying the appliance. 10. Attach drainable pouch to skin barrier. Some equipment attaches by means of a plastic flange that snaps in place; other models adhere through self-adherent tape that is exposed after protective paper backing is removed. Tug gently or inspect for secure fit.

12.Frame every edge of the faceplate with hypoallergenic tape to provide reinforcement. This is called "picture framing." 13.Fold over bottom edge of pouch and clamp.

14.Dispose of old appliance. Clean and store any reusable supplies 15.Wash hands. 16.Document noted observations. AFTER CARE OF PATIENT AND ARTICLE

•

Place

•

Ask the patient to inform for any discomfort at the stoma site.

•

Remove, clean, dry and replace the supplies.

•

If changes of ostomy collection bag procedure have been performed, dispose the bag by burning.

the patient in a

comfortable Position.

12

•

If bag is to be reused, take it to the toilet, empty.

•

After making sure that the patient is thoroughly clean, help him to wear his clean dresses.

•

Help the patient to get into his bed. Change the dressing of incision using aseptic technique. Make him comfortable. Tidy up the unit.

•

Take

all articles to the

utility room.

Clean all

equipments immediately. Rinse them first

in cold water then with warm soapy water. Dry and store them in a convenient place for the next use.

•

Patients

are

instructed

for

the

care

and

cleaning

of the colostomy bags to prolong

its life and keep it free of odors. Cleaning with soap or detergent with water and exposing it to fresh air is sufficient. RECORDING /DOCUMENTATION •

Record the date and time of the pouching system change.

•

Note the character of drainage, including color, amount, type, and consistency.

•

Document the appearance of the stoma and the peristomal skin.

•

Document patient teaching and describe the teaching content.

•

Record the patient's response to self-care and evaluate his learning progress.

•

Type and size of the bag used.

•

Observations with regard to stoma and the surrounding skin.

•

Assessment of the ostomy drainage.

COMPLICATIONS: 1. Diarrhea 2. Faecal impaction and obstruction 3. Excoriation of the skin 4. Stricture of the stoma 5. Failure to fit the pouch properly over the stoma or improper use of a belt can injure the stoma. PATIENT TEACHING: -

•

Teach spouses or other family members to assist with ostomy management, especially if the client is elderly, weak, or has poor fine motor skills.

•

Provide good nurse-client Communication to help the client develop a positive attitude about living with an ostomy.

13

•

Provide the client with the name and phone number of an enterostomal therapist, community support groups, supply vendor, and other resource people to call if they have questions or problems after discharge.

CARE OF EYE INTRODUCTION :-

A common problem of eyes are secretion that dry on the lashes as crusts. This

be need to be softened and wiped away under sterile condition. In newborn, the eye are treated soon after the baby is born to prevent ophthalmia neonatorum. Eye care prevent spread of infection from one eye to the other and to avoid possible recontamination of the same eye. DEFINITION :- Eyes are cleaned from the inner to the outer canthus this prevent the particles and fluid from draining into the nasolacrimal duct each eye cleaned with separate swabs, swabbing each eye once only. OBJECTIVES:•

To prevent infection

•

To maintain eye hygiene

•

To maintain normal eye function

•

To prepare for administration of eye drops and ointment

•

To prevention for ophthalmia neonatorum in newborn.

NURSING RESPONSBILITY:•

Check the diagnosis of the child

•

Check the physician order to see the specific precautions regarding the care of eyes, the child’s movement and positioning

•

Assess the general condition of the child’s ability to follow directions

•

Check the articles available in the patient’s unit.

ARTICLES REQURIED FOR THE EYE CARE ARTICLES

PURPOSE

A tray containing :Mackintosh and towel Sterile bowl with sterile cotton swabs Sterile normal saline or any ordered

To protect the pillow and bed linen To clean the eye To clean the eye

14

solution Kidney tray and paper bag

To receive the wastes

Clean face towel

To wipe the face after the

procedure PREPRATION OF THE PATIENT UNIT :-

1.

Explain the procedure to the child’s parent.

2. Adjust the bed to comfort able working of the nurse. 3. Arrange the articles conveniently on the bed side table 4. Keep the child flat if the condition permits 5. Remove all pillows leaving one soft pillow under the head 6. Protect the pillow and the bed with a mackintosh and towel placed under the head STEPS OF THE PROCEDURE WITH RATINALE: STEPS OF PROCEDURE 1. Wash hand

RATINALE To prevent the cross infection

2. Pour sterile saline into the bowl and wet the cotton swabs 3. Stand in front of the patient clean the eyes with the sterile swabs. Discard the swabs into the paper bag.

Take the following precaution •

Area of the swab touched by the

Continue cleaning till all discharge are

fingers should not come in contact

removed from the eyes

with eyes •

Squeeze off the excessive water from the swab

•

No pressure on the eye ball

•

Gently wipe the lids from the inner to the outer corner

•

One swab for one swabbing

•

Separate swabs for each eye

15

4. For crushed secretion place a wet warm gauze piece or cotton swab over

Warm compress makes the crusts to

the closed eye. Leave it in the place

become soft that it can be removed without

until the crust becomes soft.

traumatizing the mucosa

5. When the eye are clean, stop the Procedure. Wipe the face with the face towel

AFTER CARE OF THE PATIENT AND ARTICLES:•

Instill any medications that is ordered if any

•

Remove the mackintosh and towel from under the patient’s head

•

Adjust the position of the patient’s bed

•

Tidy up the bed and make the child comfortable

•

Take all articles to the utility room. Replace the articles to proper places

•

Wash the hand thoroughly

RECORDING AND REPORTING Record the treatment with date and time. Record the observation made on the nurse’s record.

16

NASOGASTRIC TUBE FEEDING 1. INTRODUCTION. Nasogastric tube feeding, nasal feeding, or Nasal gavage is the term applied to the process of feeding the patient by means of a tube introduce directly into the stomach by way of either mouth or nose(The word gavage comes from the French Gaver, meaning to force feeding of poultry ) this procedure was used for feeding psychiatric patient formerly. But now it was widely used to give foods to adult who are unable to take nourishment in the usual way and for weak babies who are not strong enough to suck or swallow.

2. DEFINITION AND MEANING. 1.

The administration of liquid food into a stomach by a Reyle’s tube inserted through the nostrils is

called Nasogastric tube feeding. 2.

Nasogastric tube feeding or Gastric gavage is an artificial method of giving fluids and nutrients

through a tube that has been passed into the esophagus and stomach through the nose, mouth or through an opening made on the abdominal wall.

Naso:- Nasal Gastric:- Related to stomach. Tube Feeding: Administration of food material or medication through elongated flexible tube. 3. OBJECTIVES OF THE PROCEDURE. TO Provide Nutritional Support Using Gastrointestinal Tract. 4. INDICATION./ REASON FOR PROCEDURE:  When the patient is unable to ingest, chew, or swallow food but is still able to digest and absorb nutrients, a tube feed is indicated, e.g. unconscious and semi-conscious patients etc.

 When the patient is too weak to swallow food or when the conditions make it difficult to take a large amount of food orally e.g.: acute and chronic infection, severe burns, malnutrition and prematurity.  When the patient is unable to retain food e.g. vomiting, anorexia nervosa etc.

 When the condition of the mouth or esophagus makes swallowing difficult or impossible, e.g. : surgery of the mouth or throat and esophagus, paralysis of face and throat, fracture of jaw, repair

17

of the left palate and the left lip, terminal malignancy etc.  For a patient who refuses food e.g. patient with depression.

5. ARTICLE REQUIRED FOR PROCEDURE.

Articles

Rationale

A tray containing: • A small mackintosh with a towel

To protect the bed, linen and garments

•

A feeding cup with water

To rinse the mouth and clean before and after the feed

•

Cotton tipped application, rubber or disposable rubber A levine tube or Ryles tube in a bowl containing cold water

To clean the nostrils

•

To make the tube hard for easy insertion

•

A lubricant such as water soluble jelly To lubricate Ryles tube to prevent or glycerin or liquid paraffin friction between mucous membrane and tube

•

Adhesive plaster and scissors

•

Gauze pieces in a container

To wipe the secretions

•

Clean syringe or a funnel

To aspirate gastric contents and to give feeding

•

A glass of feed in a bowl of warm water or warm feed

To give the feed at the body temperature

•

An ounce glass

To measure the fluid intake

•

A bowl of water

To test the location of the tube

•

Stethoscope

To test the location of the rube

•

Saline or sodabibicarb solution

To clean nostrils

•

A kidney tray and a paper bag

To collect wastes

To fix the tube in position

6. PREPARATION OF THE PATIENT. /UNIT. •Identify the patient with name, bed No. •Check the doctor's orders for any specific precautions, regarding movement of the patient, positioning etc. •Check the level of the patient's consciousness and ability to follow directions. •Check the patient's ability to move and maintain a desired position during insertion of the tube.

18

•Explain the procedure to the patient to gain confidence and co-operation. •Screen the patient to provide privacy.

•Place the patient in a sitting or high Fowler's position. If his general condition is weak, raise the head with extra pillows. •Place covered treatment mackintosh over the chest to protect garments and bed linen. •Give a mouth wash to clean the mouth. •Clean nostrils if there are secretions or crust formation of nasogastric insertion.

7. STEP OF PROCEDURE WITH RATIONALE. IMPLEMENTATION:Steps

Wash hands with soap

Rationale

Scientific

Nursing

Principles

Principles

To prevent cross-infection. Soap and water help Principle of safety

and water.

in checking the microorganisms' growth (principle of Microbiology, Physics).

Spread the mackintosh

To protect bed linen.

Microbiology

and the towel Clean the nostril with a cotton-lipped

Safety and comfort

To clean nostril.

Microbiology

Comfort and safety

applicator soaked in saline.

19

Take the Ryles tube and

To determine

Anatomy and Physics Safety and

measure the distance for approximate length of insertion of the tube

the tube to reach the

from bridge of the nose

stomach.

individuality

to earlobe plus distance from ear lobe to the tip of the xiphoid process of the sternum and mark with adhesive.

Lubricate the tube for

Lubrication reduces

Physics

Safety

about 2-4 inches with

friction between mucous

thin coat of water

membrane and the tube.

Anatomy

Safety

Tilt back the child's head Passage of the tube is

Anatomy and

Safety and

before inserting the tube facilitated by following

Physiology

therapeutic

soluble jelly.

Hold the tube coiled in

Nasal septum is deviated

the right hand to

into the right side.

introduce the tube.

into the nostril and

the natural contours of

effectiveness

gently pass the tube into the body. the posterior Nasopharynx quickly backwards and downwards. When the tube reaches

Gag reflex is triggered

the pharynx, the patient by the presence of the may gag: allow him to

Anatomy and

Safety

Physiology

tube. Helps to prevent

rest for a few moments. the aspiration of fluids or passing the tube into Trachea.

20

Hold the child's head in

Flexed head position

a partially flexed position makes swallowing easier

Anatomy and

Safety

Physiology

and advance the tube as and the tube less likely he swallows sips of

to enter the trachea.

water.

Swallowing facilitates passage of the tube by closing the epiglottis. Helps in easy passing of the tube and avoids coiling it at Pharynx.

Continue to advance the Mark on the tube tube until it reaches the

indicates that it has

previously designated

reached the stomach.

Physics

Safety

mark.

Aspirate for gastric

Fluids cannot be freely

Anatomy and

Safety and

contents with a syringe.

aspirated from the lungs.

Physiology

therapeutic

Glands of mucous

effectiveness

membrane lining the esophagus and stomach produce mucus, and gastric juices.

Place the end of the tube If the tube is in trachea

Anatomy and

Safety

into a bowl of water and air bubbles will coincide

Physiology

principles

note the rhythm of

with the expiration of

escaping bubbles.

each breath. Normal respiration takes place in lungs. As a result, air will be expelled out with expiration.

21

Ask the patient to speak. The patient will be unable to speak or hum

Physics Anatomy and Safety Physiology

principle

Physics

Safety.

Psychology

Individuality

if the tube is in the trachea. Any injury to vocal cords of Larynx causes difficulty in speech and hum and sounds will not be produced.

Confirmation of the

Hushing sound will be

tube's place can be done heard on the stomach by using a stethoscope.

while air is pushed. Air

Take 5-10ml of air and

pushed by force

push in

produces a hushing

distal end of the tube.

sound.

After the tube is in

Prevents the patient's

place, tape it to the nose vision from being / forehead. Take 5cm of

disturbed, prevents

tape, split length-wise

tubing from rubbing

and comfort

and only halfway, attach against nasal mucosa up split end of the tape to the nose / forehead and cross split ends around tubing.

22

Wait for some time

A few minutes rest will

Anatomy and

before giving the feed.

help to subside the

Physiology

Comfort

peristalsis and prevent nausea and vomiting. Peristalsis is stimulated by any irritation to stomach or by a bolus of food.

Before giving the feed

Expelling air from the

connect tunnel and

tube before the feed is

syringe, pour some

given docs not allow the

water through it and

fluid to run. Air is lighter

lower the funnel slowly

than water, liquid exerts

so as to expel air.

pressure because of

Physics

Safety

Physics

Safety

their weight.

Hold the funnel or

To prevent the damage

syringe 8 inches above

of mucus membrane in

the bed.

stomach. The height of a column of fluid determines the amount of pressure exerted at the point of application.

23

Slowly introduce feeding To prevent distension, into the funnel or

nausea and excessive

syringe barrel, keep it

peristalsis and to

full until total amount

prevent air entry into

has been introduced.

the stomach. Helps in

Physics

Safety

Physics

Safely

Physics

Safety

preventing injury to gastric mucosa by reducing pressure.

When the quantity of

To prevent the blockage

feed is over, clear the

of tube. As the food

tube by introducing a

remains in tube, it

small amount of water.

blocks the lumen and causes obstruction to flow.

Disconnect funnel or

To prevent the leakage

syringe barrel and clamp of gastric fluids back the tube to prevent

from the tube. Fluid

leakage of fluids.

flows only when there is a difference in pressure, the direction is to the area of lower pressure.

24

Tube may be removed or To prevent aspiration of left in the place. To

Physics

Safety

Microbiology

Comfort and

contents into trachea.

remove the tube pinch it b/pulling it out continuously with a moderate rapid motion.

Offer a mouth wash,

To clean mouth and

clean face and hands.

prevent tartar formation

safety

and to moisten the mouth. As the patient is not taking food by mouth there will be less secretion of saliva and dryness.

Remove the mackintosh

To keep the unit clean

and the towel.

Psychology

Comfort and safety

Make the patient

To give a sense of well-

comfortable in bed.

being, comfort.

Comfort

25

To take the articles to

To clean them

Microbiology

Safety

Microbiology

Safety

Psychology

Safety

the utility room. Discard thoroughly. To prevent water and clean with

cross-infection. Helps in

soap and water. Dry

checking growth of the

them and replace in

micro-organisms.

their proper place.

Wash hands

To prevent crossinfection.

Record the time, date,

To have good

amount of feed, nature

communication in team

Therapeutic

of feed, reaction of the

and to maintain fluid

effectiveness

patient, if any, in the

balance for future

nurse's notes and

reference.

intake-output chart.

If the tube is reusable,

Usually disposable ones

Microbiology and

Safety and

clean it with cold water

can be discarded.

Physics

comfort

first then with a warm

Rubber tubes arc kept

soapy solution. Pushing

ready for the next use.

water several times through the lumen boil it, dry it and replace. Disposable tubes to be discarded.

26

8. AFTER CARE OF PATIENT AND ARTICLE. After the procedure replace the article by cleaning thoroughly and ask the child how he felt is there any partial satisfaction of fulfilling appetite, provide fowlers for a while or if child can able to walk then give little time to walking this will help for digestion.

9. RECORDING AND REPORTING. Record the time, Date, Amount of fluid given, toleration. And signature of the nurse who carried out procedure. Report if any adverse effect or intoleration etc.

10. SUMMARY AND CONCLUSION. Nasogastric tube feeding or Gastric gavage is an artificial tube feeding through nose, mouth, oesophagus to the stomach. It should be given by doctor's order only. It has more advantages than parentral feeding. Gastric gavage may be nasogastric, orogastric and gastrostomy feedings. The procedures for all these are the same except some points. As a nurse while proceeding the procedure she must also understand the following points.  GENERAL INSTRUCTIONS

•Screen the elder child for privacy. •Tube feeding is given only by the doctor's order.

•If the elder child is conscious, explain the procedure and reassure him/her to win his confidence and co-operation. •A rubber tube may be placed in a bowl of ice to cool and stiffen.

•Lubricate the tube with a suitable lubricant preferably with a water-soluble jelly, e.g., mineral oils (glycerine, liquid paraffin) are used; it should be applied to the minimum with a soft paper or cotton. (A drop of mineral oil, if dropped into the respirator)' passage acts as a foreign body because the lung tissue does not absorb it).

•If the tube is dipped in a liquid or lubricant before insertion, make sure that the blind end is not left filled with the fluid or lubricant, because this may drop into the larynx and choke the child.

•All equipment used for feeding should be clean. The food has to be prepared, handled and stored under hygienic conditions because many organisms enter the body through food and drink.

•Every time before giving the feed, make sure that the tube is in the stomach by aspirating a small quantity of (5 to 10ml) stomach contents.

•While removing the tube, pinch the tube and pull it out gently and quickly so that the fluid may not trickle down the pharynx. •During the introduction of the tube, never use force as it may cause injury to the mucous membrane.

27

•Avoid introducing air into the stomach during each feed by : -Expelling air from the tube by lowering the tube below the level of the stomach.

-Pinching the tube before the fluid runs into the stomach completely from the syringe. •Restraints use should be limited to the minimum. For infants and restless children, some form of restraints may be necessary, but they should not feel that they are punished.

•Feedings may be given at intervals of two, three or four hours and the amount is not exceeding 50 to 100ml per feed. The total amount in 24 hours varies between child to child and weight. If the drip method is used, the speed of the flow should not exceed 10 to 20 ml per minute. This minimizes distension, nausea, regurgitation and excessive peristalsis usually associated with too much and too rapid administration. The food calories should be calculated according to the condition of the disease. •Intake and output are to be recorded accurately.

•Watch for complications such as nausea, vomiting, distension, diarrhea, aspiration, pneumonia, asphyxia, fever, water and electrolyte imbalance. These may be reflected in changes in the skin, and mucus membrane thirst vital signs, intake and output chart, level of consciousness, body weight etc.

•Patients receiving tube feeding should receive frequent mouth care to prevent complications of neglected mouth care. •Warm the feed to room temperature "before administration. •Use gloves as per universal precaution.  TYPES OF GASTRIC GAVAGE Gastric gavage may be divided as follows, based on the route of insertion and method of administration: Route of insertion :

•Nasogastric tube feeding: A tube is passed through the nose and oesophagus into the stomach. It is also called nasal feeding.

•Oro-Gastric feeding: A tube is passed through the mouth and oesophagus. So the food reaches the stomach.

•Gastrostomy tube feeding: Giving a liquid diet through a tube or catheter, which is introduced into the stomach through the abdominal wall, is called Gastrostomy feeding (gastro = stomach, ostomy = making an opening into).  Methods of Administration

•Continuous Feeding Method: Used for critically ill clients. Continuous drip-feeding helps to minimize cramping, nausea and diarrhea; the gravity flow of fluid by an infusion pump is used at the rate of 50ml/hr.

28

•Intermittent Feeding Method: Feeding given periodically. Each time 400 ml over 30 minutes duration and four to five times a day by the drip method.

•Bolus Feeding Method: Pour a prescribed amount of fluid (250-400ml) slowly into the barrel of a syringe or funnel attached to the end of the tube. The fluid flows by gravity into the stomach. The gastric gavage procedure is similar for infants, children and adults except for the size of the tube and the length passed and the amount of feeding given. Methods of tube feedings :

Nasogastric (NG) feeding

Jejunostomy (JT) feeding

Nasoduodenal feeding

Nasojejunal feeding

Gastrostomy (GT) feeding

RELATED LITERATURES TO THE NEXT PAGE:……… 29

COLLEGE OF NURSING BHARATI VEEDYAPEETH, PUNE. Final Year Msc Nursing [Pediatric Specialty] STUDENTS NAME:-___________________________DT:__ CHECKLIST FOR NASOGASTRIC TUBE FEEDING SR. NO * 1. 2 3. 4. 5. 6. 7. 8. 9. 10. * 11. 12. 13. 14. 15.

PARTICULARS

YES

BEHAVIORAL GUIDES APROACHES THE CHILD/PARENT WITH CONFIDENCE. GIVES A RELAVANT EXPLAINATION INWAYS THAT CHILD OR PARENT CAN UNDERSTAND. ORIENTS THE CHILD/PARENT THE POSIBLE DICOMFORT AND TO HIS ROLE DURING THE PROCEURE. ANTICIPATES CHILDS EMBARSEMENT AND PROTECTS PRIVACY. MAKES ALLOWANCES FOR INDIVIDUAL DIFFERENCES IN TOLERANCE OF TREATMENT. SHOW PATIENCE. NOTICES CUES INDICATING CHILD’S DISCOMFORT AND ATEMPTS TO ALLEVIATE IT. PLACES THE PROCEDURE APROPRIATELY TO TOLERANCE AND/OR CONDITION OF CHILD. FOCUSSES ATTENTION ON THE PROCEDURE TO THE EXTENT THAT READINESS TO RESPOND TO OTHER EVENTS IS LIMITED. INDICATES AWARENESS OF RESPONSIBILITY TO THE CHILD FOLLOWING THE PROCEDURE. FEEDING

NO

N.A

OBSERVED NOT OBSERVED

ENSURE 30-45DEGREE UPRIGHT POSITION OF CHILD IF UNLESS CONTRAINDICATED. ENSURE TUBE IS CORRECTLY POSITIONED. CHECK THAT PRESCRIBED FLUID IS AT APPROXIMATELY NORMAL BODY TEMPERATURE. INTRODUCED ORDER AMMOUNT OF FLUID THROUGH THE TUBE. INSERTS MININMUM 10 ML OF WATER FOLLOWING FEED TO FLUSH THE FEED. TOTAL

N.A = NOT APPLICABLE.

POINTS:

/15

COMMENTS: STUDENTS SIGN:-

30

OXYGEN THERAPY IN CHILDREN 11. INTRODUCTION. Air, water and food are the three essentials of life. Oxygen, the most important component of air, is vital to all existence. Oxygen is given when there is interference with normal oxygenation of body tissues. Inhalation is also one of the common routes of administration of drugs. Drugs may be given by inhalation for either a systemic or a local effect. The systemic effect is produced immediately, because of the large surface area of lungs and the rich supply of blood vessels. Drugs used for a local effect may be in the form of medicated steam and fumes. The fumes method is rarely used.

12. DEFINITION AND MEANING. Oxygen is a colorless, odorless, tasteless and combustible gas. Oxygen therapy is defined as the administration of oxygen by inhalation from a cylinder, piped in system liquid oxygen reservoir or oxygen concentration by various methods to relieve anoxemia.

13. OBJECTIVES OF THE PROCEDURE.  To facilitate normal metabolism of the tissues.  To reduce / correct arterial hypoxemia (low concentration of oxygen in the blood) and tissue hypoxia.

14. SCIENTIFIC PRINCIPLES. 15. Anatomy and physiology: The anatomical structure of respiratory tract is an important aspect of O2 Administration procedure nurse must know of its basics before initiation of the procedure for normal alignment.

16. Microbiology: As a procedure is related to human subject there may be a chances of spreading nosocomial infection so as a nurse she must take care to provide aseptic procedure

17. Pharmacology: some times with oxygen some drugs used in a procedure are mostly bronchodilator which are the chemical composition and may produce the side effect so the nurse must aware of pharmacokinetics of the particular drug before administration.

18. Physics: use the body mechanics is important while transferring the oxygen cylinder. 19. Psychology: Nurse must aware of mental status of the child and his parents to provide anxiety free procedure.

20. INDICATION./ REASON FOR PROCEDURE: 31

The indications for oxygen therapy are as follows: •Breathlessness or laboured breathing. •High altitudes. •Shock and circulatory failure.

•child under anesthesia. •Children who are critically ill. •Child with a decreased respiratory capacity. 21. ARTICL REQUIRED FOR PROCEDURE. Sr.No. 1.

Articles Oxygen cylinder with stand ,or central supply oxygen with a flow meter, humidifier / Wolffs

2. 3.

bottle and connecting. A tray containing: a) Nasal catheter / canula / oxygen /flow meter & mask of

Rationale To deliver oxygen. To humidify oxygen

To check the amount of oxygen going to the patient.

an appropriate size clean / disposable type in a covered container. 4.

b)

Water and soluble

To lubricate the nasal catheter.

5. 6. 7.

lubricating jelly c) Adhesive tape d) A bowl of water e) Swab sticks and normal

To attach the nasal catheter. To check oxygen flow. For cleaning nostrils.

8.

saline in a container. f) No smoking (indicator)

To take fire precautions

22. PREPARATION OF THE PATIENT. /UNIT. Preparation of the patient •Check name, bed No. and other identification marks of the patient.

•Check the diagnosis and the need for oxygen therapy, •Check doctor's orders for initiation of the therapy and dosage.

•Assess the child for any sign of clinical anoxia. •Assess the child's vital signs and breathing patterns carefully before starting 32

therapy. •Explain the need of oxygen therapy; and the sequence of the procedure. •Gain the patient's confidence.

•Keep the child in a propped up position or Fowler's position. 23. STEP OF PROCEDURE WITH RATIONALE. Steps Wash hands

Rationale Reduces transmission of micro-organisms.

Scientific Principles

Nursing Principles

Microbiology

Safety

Physics

Safety, comfort

Soap and water reduce surface tension and thus remove dirt and check the growth of micro-organisms.

Attach canula / catheter mask Prevents drying of nasal and. oral to oxygen tubing and

mucous membranes and airway

humidified oxygen source

secretions. Use of a humidifier prevents

adjusted to the prescribed

drying of mucus membranes.

flow rate. Place lips of canula into the

Directs flow of oxygen into the upper

Therapeutic

patient's nares. If mask,

respiratory tract. Prevents loss of

effectiveness.

apply snuggly to face.

oxygen.

Safety, economy of

Check cannula/equipmcnt

Ensures patency of canula and oxygen

every eight hours.

flow. Also ensures safe delivery of

material Safety

prescribed oxygen. Keep the humidification jar

Prevents inhalation of dehumidified

Safety and

filled al all times.

oxygen. Prevents drying of mucus

therapeutic

membranes.

effectiveness.

Observe the patient's nares

Oxygen therapy can dry nasal mucosa.

Safety, comfort

and superior surface of both

Pressure on ears from canula

ears and skin breakdown.

tubing/elastic can cause skin irritation.

Check the oxygen flow rate

Ensures delivery of the prescribed oxygen

and the physician's orders

flow rate.

Safety

Therapeutic effectiveness.

every eight hours.

33

Wash hands before removing

Reduces transmission of microorganisms

Microbiology.

Safely

Inspect the patient for relief

Indicates that hypoxia is

Anatomy and

Therapeutic

of symptoms associated with

reduced/treated.

Physiology

effectiveness.

the oxygen mask pr tube.

hypoxia. Record procedure in the

Documents correct use of oxygen therapy

Safety, good

nurse's notes.

and the patient's response.

workmanship

14. AFTER CARE OF PATIENT AND ARTICLE. •Stay with the child till he/she is at ease. •Keep the child warm and comfortable. •Evaluate the child’s progress by observing the vital signs and symptoms. •Watch the child for any deteriorating symptoms after the removal of oxygen inhalation. Inform the doctor.

•Request for an arterial blood gas analysis at specified intervals to make sure hypoxia is treated. •Take all articles to the utility room.

•Clean nasal catheter with cold water, then warm soapy water and finally with clean water (if not disposable). Boil and store or send for sterilization.

15. RECORDING AND REPORTING.  Record procedure with date, time.

16. SUMMARY AND CONCLUSION. As we sum up the procedure a Nurse also must keep following points in a mind that Methods of Oxygen Delivery •

Nasal Catheter: Nasal

Catheters are used less frequently these days.

It involves

inserting an oxygen catheter/simple rubber catheter into the nose upto the nasopharynx.

It

needs to be changed at least every eight hours and inserted into the other nostril, it is also painful and can cause trauma. Thus, it is less desirable.

♦

Nasal Canula : A nasal canula is a simple comfortable device.

The two canula, about 1.5

cm (1/2 in) long, m the centre of a disposable tube and are inserted into the nares.

34

•Trans-tracheal Oxygen : In trans-tracheal oxygenation, oxygen is delivered directly into the trachea via a catheter (small intravenous-size) into the trachea through a surgical opening in the lower neck.

•Oxygen masks / B.L.B. Mask (Boothby Lovelace and Bulbulian) : Oxygen mask is a device used to administer humidified oxygen, it is strapped to fit snugly to the mouth and nose and is secured in place with a strap.

•Oxygen tent / the Seymour tent: When a patient has facial injuries or for any other reason cannot tolerate an oxygen mask, then this method can be used. The tent is first flooded with oxygen and then a flow of 4-5 liters per minute is given. This will maintain a service of 40 % - 50% in the tent. General Instructions

•Oxygen should be treated as a drug; the five rights of medication administration also pertain to oxygen.

•When using an oxygen cylinder or central supply oxygen, use a regulator and humidifier. •Every part of the apparatus should be clean to prevent infection.

•Change nasal catheters at least every eight hours or more often to prevent blockage of the nasal catheter by a mucus plug. •When oxygen therapy is to be discontinued, it should be done gradually.

•Pay attention to conditions that can interfere with the flow of oxygen from source to the patient. This may include tubing, loose connections and faulty humidifying apparatus. •Always keep a spare oxygen cylinder in close vicinity.

•Watch the patients receiving oxygen therapy continuously to detect the early signs of oxygen toxicity.

•Since oxygen supports combustion, fire precautions are to be taken when oxygen is on flow, e.g. smoking, use of matches, lighters etc. Contraindications

•Administer with caution to the patient with COPD (Chronic Obstructive Pulmonary Disease) as it induces hypoventilation. •Atelectasis.

•Oxygen toxicity. •Paraquat poisoning.

35

Match the correct delivery device with your assessment of the patient: Device

F

Concentration

Indications

Considerations

low Cannula

1-6 Rate

Low flow

Use

in

infants

who

are

liters

24% -

obligatory nose breathers or if

44%

you do not have a correct size mask

Simple

6-10

Moderate

Must maintain a minimum of 6

mask

liters

flow 35% -

liter flow

60% Blow by

6-15

Mod.

-

High

liters

flow Depends

all

children. Use

on

patients

corrugated tubing,

flow rate

Can

be

used

in Use for infants and young a

simple or

and proximity to

tubing

face

bottom of a paper (not

mask, 02

threaded through the

Styrofoam) cup. Non-

12-15

High flow

•

rebreather liters

80% -

obstruction •

--mask

90%

Respiratory distress •

Partial airway

Inhaled poison •

Altered mental status •

Shock •

Trauma

Bag

15

Valve Mask liters

High flow

Be

familiar

= 90%

valve

and

with

the

manometer

pop-off port

if

present

36

NEBULIZATION IN CHILDREN 24. INTRODUCTION. The simplest and most natural route of drug delivery to the lungs is the inhaled one. From the historical and medical point of view, it was a Greek, Pedanus Discorides, the father of the science of pharmacy, who, during the first century prescribed inhaled fumigation. Pipes were also used to inhale hallucinogenic substances. All shamans knew the psychotropic effects of poisonous plants such as Datura stramonium, especially Red Indians, in their peace calumets; but Indians of Madras used fumigations of Daturaferox to treat asthma. Since 1803, this therapeutic was imported in Great Britain and cigarettes with leaves of datura were used by asthmatics until 1992. In the middle of the nineteenth century, to treat grapevines diseases and in response to the fashion of inhaling thermal waters, spray technology was developed for the effervescent waters at the thermal spas. The onslaught of tuberculosis, similar to AIDS a century later, brought back into practice the inefficacious use of antiseptic aerosol therapy. With the discovery of adrenaline, ephedrine aerosols enjoyed a rebirth. The perfecting of jet nebulizers by R. Tiffeneau, father of FEV1 and M.B. Wright, father of peak-flow, allowed a better practice of inhalotherapy. In 1949, the United States, ultrasonic nebulizers made their first appearance in the form of humidifiers, but doctors were quick to add medications to produce therapeutic aerosols. After 150 years, with the improvement of nebulizer systems and new nebulized medications, the nebulization story is still not concluded.

25. DEFINITION AND MEANING. Nebulisation is a process of giving Nebulizer, and Nebulizer is a device for producing fine spray of liquid. It can be with medicine or without medicine.

26. OBJECTIVES OF THE PROCEDURE. To deliver continuous nebulization through a fine droplets of a medicine or plane solution to the child that are in a closely monitored area in the hospital.

27. SCIENTIFIC PRINCIPLES. a) Anatomy and physiology: The anatomical structure of respiratory tract is an important aspect of Nebulisation procedure nurse must know of its basics before initiation of the procedure for normal alignment.

b) Microbiology: As a procedure is related to human subject there may be a chances of spreading nosocomial infection so as a nurse she must take care to provide aseptic procedure

c) Pharmacology: Drugs used in a procedure are mostly bronchodilator which are the chemical composition and may produce the side effect so the nurse must aware of pharmacokinetics of the particular drug before administration.

37

d) Physics: Compressor of Nebulizer works on principles of physics and the nurse here also must use the body mechanics.

e) Psychology: Nurse must aware of mental status of the child and his parents to provide anxiety free procedure.

28. INDICATION./ REASON FOR PROCEDURE: 1. Provide long term bronchodilation for children with serious asthma exacerbation of COPD bronchitis and pneumonia. 2. Liquefaction of thick secretion. 3. Improvement of clearance of secretion.

29. ARTICLE REQUIRED FOR PROCEDURE. 1. HOPE tm Nebulizer. 2. Oxygen and or / medical air at 50 Psi. 3. Blender, [O2 Analizer] (Optional). 4. Cardiac monitor if indicated and pulse oximeter. 5. Aerosol tubing, mask [ or other delivery device]. 6. Sputum cup.

30. PREPARATION OF THE PATIENT. /UNIT. Nurse must take care of following headings 1. Preparation of Environment Note: Room temperature Ventilation Clean and tidy Privacy 2. Preparation of Patient Note: Explanation and reassurance Privacy Position Comfort Culture 3. Preparation of Equipment Note: Hand washing Collect all required equipment prior to commencement. Check equipment is in working order. Consider cost and reuse. Consider if the procedure for the patient is really required. 4. Completion of procedure : Note: Leave patient clean and comfortable, equipment disposed off and cleaned correctly. Area left clean and tidy. Hand washing. 5. Documentation Note: Maintain nursing record. Ensure replacement of used equipment.

38

31. STEP OF PROCEDURE WITH RATIONALE. PROCEDURE: A.

Therapy must be initiated in either the ER, Critical Care Unit, pediatric area or in an area in which the patient's EKG may be monitored continuously.

B.

The treatment must be reordered every 24 hours by a physician. After an order has been received, the therapist is to verify the order in the patient's chart.

C.

After checking the patient's ID, the therapist is to explain the procedure to the patient and answer any questions they may have.

D. Wash hands and assess patient's heart rate, breath sounds, respiratory rate, peak flow, color, use of accessory muscles, patient's oxygen needs (current ABG) or SaO2. E.

The therapist then sets up a continuous pulse oximeter to establish a baseline and monitor

the patient. F.

Attach flow meter to 50 psi gas source.

G. Attach HOPE1™ to flow meter or blender. H. Attach corrugated tubing to the HOPE11" Nebulizer output and to the aerosol mask or other delivery device. I. J.

PREPARE MEDICATION [ Eg. Albeterol 0.3mgto 0.5mg/kg/hour.] Pour medication into the HOPE Nebulizer reservoir using aseptic technique. K. Set flow meter

to 10 liters per minute and adjust FiO2 per chart or blender to meet patient needs after attaching appropriate size mask to the patient. L. Monitor the patient for adverse reactions and check the HOPE Nebulizer Q 30 minutes x 2 hours. M.

To determine approximate use of medication, look at the marks on the side of the Nebulizer (marks on Nebulizer are in 25 ml increments). Adjust flow meter by small increments to achieve desired output of 25 ml/hour without auxiliary flow.

N.

When using auxiliary flow, output increases. Mix one more hour of medication to accommodate increased output.

32. AFTER CARE OF PATIENT AND ARTICLE. A.

Pulse before, during treatment, Q 30 minutes x 2 hours, then Q 2, and post treatment.

B.

Breath sounds before, during and post treatment.

C.

Pulse oximeter before, during and post treatment.

39

D.

In pediatrics a TCM may be used to monitor patients pre, post and during the treatment to monitor PaCO2,

E.

Peak flow rates before treatment, during treatment Q 1x2, then Q 2 and post treatment.

F.

Sputum production.

G. Subjective statements by patient. H.

Patient position, color and level of cooperation.

I.

Complications or problems noted during therapy.

J.

Electrolyte levels at physician discretion, if patient is receiving beta agonist therapy > 4 hours.

K. l.

Re-evaluate patient after initial 2 hours for possible decrease in drug dosage level. Ensure replacement of used equipment.

33. RECORDING AND REPORTING. A.

Check the patient and document the following information Q 30 minutes for the first 2 hours, then Q 2 on the Continuous Bronchodilator Therapy Work sheet

1.FiO2. 2.Heart rate. 3.Respiratory rate. 4.Breath sounds. 5.Oxygen saturation/TCM reading or ET CO2. 6.Peak expiratory flow. 7.Side effects and remarks 8.Respiratory Care Practitioner signature

9.Date and time. 10.ABG information. 11.Mental status. 34. SUMMARY AND CONCLUSION. As Nebulizer produces a shower of fine droplets that can be breathed in by blowing compressed air through a reservoir containing a solution of the bronchodilator drug. Younger children who may find it difficult to operate an aerosol it is manage best with a compressor Nebulizer which delivers medicine through a face mask over several minutes. In hospitals, the compressed air or oxygen is used to nebulize drugs used in the emergency treatment of asthma. If the child is prone to frequent attacks consider buying a Nebulizer . This is a very handy for use during an acute attack However a metered – dose inhaler with an easily available spacer device and

40

facial mask is considered better than a Nebulizer for the treatment of acute wheezing in children less than 2yrs. As a nurse she also take care of following headings. HAZARDS: A-

Exhaled aerosol or patient coughing may spread active pulmonary infections.

SAMPLE MEDICATION CALCULATION: This is a sample calculation. Ideally, when setting up CNBT, the initial fill and dosage should be for 3 hours. A.

MEDICATION + DILUENT - OUTPUT OF NEBULIZER (25 ml/hr. @ 10 lpm Albuterol 0.5% (5 mg - 1 ml, 10 mg=2 ml, 15 mg-3 ml, 20 mg=4 ml)

1.Mg/hr of medication ordered x 0.2= ml of medication used per hour. 2.(Output of nebulizer) - (ml of medication) = ml of diluent (normal saline) 3.Multiply diluent and medication times hours you want to deliver, up to 8 hours @ 10 pm (maximum volume of nebulizer is 220 ml). CONTRAINDICATIONS: A.

Absence of the above indications.

B.

Increased heart rate of >25 beats or as defined by the physician.

TREATMENT COMPLICATIONS: A.

A complete reassessment is indicated any time the patient vomits. Failure may include, but is not limited to the following. 1.Failure to significantly respond in 8 hours.

2.Decreasing aeration over time or increased wheezing without a simultaneous increase in operation. 3.Worsening blood gases.

4.Decreasing pulse oximeter readings or an increasing need for higher FiO2's to maintain the same saturation.

5.Decreasing level of consciousness or decreased ability to awaken the patient. 6.Increased work of breathing. 7.Anything that leads you to believe, through your patient assessment, that the patient is getting worse. B.

When treatment failure is suspected, re-evaluate the patient and contact the physician immediately.

41

NOTES: Nebulization to empty may lead to evaporative concentration of the drug at the bottom of the nebulizer. When nebulizing for a long period of time, it may be appropriate to change the medication solution when 10% is left in the bottom of the nebulizer.

Neonatal resuscitation-Protocol During the intrauterine life the baby gets oxygen through the placenta. As soon as the baby is born, the respiratory center is stimulated and lungs expand and the baby initiates spontaneous breathing. Most newborn babies breathe spontaneously after birth and may not require resuscitation measures. If the newborn does not breathe spontaneously nor has breathing problem then the baby is asphyxiated, so immediate steps should be taken to resuscitate the newborn. About 5-10% of newborns need resuscitation. Nearly one million newborns are die because of birth asphyxia. Hence it is essential that knowledge and skills required for resuscitation be taught to all involved in neonatal care. INDICATION Maternal condition- pregnancy induced hypertension, placenta previa or placenta abruptio, prolonged or obstructed labour, fever in labour, post- term pregnancy, maternal sedation, prolonged rupture of membrane, Fetal conditions – umbilical cord around the babies neck, short cord, knot on the cord, prolapsed cord During or after the birth- premature baby (before 37 weeks of pregnancy) difficult delivery,(breech, multiple birth, stuck shoulders, vacuum extraction, forceps) meconium in the amniotic fluid, congenital anomalies. PREPARATION OF PATIENT Anticipation and preparation are very important for effective resuscitation. Anticipation of likelihood of resuscitation is only possible if proper antenatal history and all the maternal documents are available before delivery, which can help to identifying the high risk infants. It is important to keep resuscitation articles before delivery. When a baby has asphyxia, you must start resuscitation immediately. PREPARARTION OF ARTICLES

 Warm environment  Place to do the resuscitation (resuscitation corner)  Personnel  Equipments 42

 Supplies Keeping a newborn baby in a warm environment saves the baby’s energy for breathing. There are many ways to keep a baby warm. This includes the baby in a warm room, providing heat by various means, drying the baby etc. Warm environment: keep the room warm (at least at a temperature of 25 degree c) and keep it free from air currents. Providing heat: place the baby under a radiant warmer or use heater or 200 watt bulb above the baby. For babies needing routine care, use skin to skin contact for providing warm. Drying the baby: dry immediately after the birth, then remove the wet sheet/cloth and cover the baby with another warm, dry sheet/or cloth. Resuscitation place The resuscitation must be done on a flat surface. A table or trolley in the room can be used or it can be done in a place next to the mother. The place needs to be clean and warm. Personnel It is essential that at least one person skilled in neonatal resuscitation should be present at every delivery. For performing complete resuscitation two persons must be available for ventilation and chest decompression. NEONATAL RESUSCITATIONS SUPPLIES AND EQUIPMENTS:



De Lee trap



Mechanical suction



Suction catheters No. 12FG, 14FG



Feeding tube 6F and 20ml syringe

Bag and mask equipment



Neonatal resuscitation bag



Face masks, term and pre term size



Oxygen with flow meter and tubing

Intubation equipment



Laryngoscope with straight blades No. 0(pre term) and No. 1 (term)



Extra bulbs and batteries for laryngoscope



Endotracheal tube; 2.5, 3, 3.5, 4.mm internal diameter



Scissors

Medication 

Epinephrine

43



Naloxone hydrochloride



Normal saline



Sodium bicarbonate



Sterile water



Miscellaneous



Watch with second hand



Linen and shoulder role



Radiant warmer



Stethoscope



Adhesive tape



Syringe 1,2,10,50ml



Gauze pieces



Umbilical catheters



Three way stopcocks



Sterile gloves Routine care Nearly 90% of newborns are vigorous term babies with no risk factors and clear amniotic fluid.

These babies do not need to be separated from their mothers to receive initial steps. Receive the baby in a warm and dry sheet. Dry the baby and wrap in another dry and warm sheet covering the head put the baby on mother’s abdomen while drying. Keep the baby in direct skin to skin contact maintains warmth and prevent hypothermia. Clear the airway by wiping the baby’s nose and mouth with sterile cloth. At birth you must make quick assessment and assess/look for following.



Was the baby born after a full-term gestation?



Is the amniotic fluid clear of meconium and evidence of infection?



Is the baby breathing or crying?



Does the baby have good muscle tone?

If the answer to any of these question is yes then you must give routine care to the baby’s given above If the answer to these question is no, then you must start the initial steps Initial steps 

Preventing heat loss



Positioning



Suctioning



Evaluation

44



Tactile stimulation



Free flow oxygen

Preventing heat loss An important step in the Care of the newborn is to prevent the heat loss of body heat. This can be especially critical in a newborn who needs resuscitation. Even healthy term infants have a limited ability to produce heat when exposed to a cold environment, particularly during the first 12 hours of life. Drying the infant As soon as the baby is placed under the radiant warmer, the baby should be quickly dried to remove the amniotic fluid to prevent the evaporate heat loss. It is preferable to dry the infant with a pre warmed towel or blanket. After drying remove the wet towel or blanket from the infant and lay the infant on another prewarmed towel or blanket. This will further reduce the heat loss. Using radiant heat source /other means to keep the infant warm Prevention of heat loss can be achieved by placing the baby under the radiant warmer which should be switched on manual mode before the delivery of the baby. An overhead radiant heater provides a suitable thermal environment that minimizes radiant heat loss. It is important to switch on the radiant warmer so that the infant is placed on a warm mattress. A radiant warmer allowed easy access to the baby and provides the full visualization of the infant. If heat source is not available, a lamp with 200w bulbs or a suitably fixed room heater can be used for keeping the baby warm. Positioning Place the neonate on his or her back or side with the neck slightly extended or in shifting position. Prevent hyperextension or under flexion of the neck since either may decrease air entry. Maintain the correct position by placing a rolled blanket or towel under the shoulders, evaluating them ¾ to 1 inch. if the infant has copious secretions coming form mouth, turn the head to the side. This will allow secretion to collect in the mouth, from where they can be easily removed.

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Suctioning If no meconium is present, suction the mouth and nose. The mouth is suctioned first to prevent aspiration which can happen if nose is suctioned first. A bulb syringe or a mechanical suction can be used to remove the secretions. Be carefully not to be too vigorous as you suction and do not insert the catheter deep in the mouth. Stimulation of the posterior pharynx during the first few minutes after the birth can produce a vagal response, causing severe bradycardia or apnea. If bradycardia occurs stop suctioning and re evaluate the heart rate. Evaluation The infant should be evaluated on the basis of three vital signs 1. Respiration: observe and evaluate the infant respiration by observing the chest movements. If breathing spontaneous, go on to check the heart rate. If not, begin tactile stimulation. If still no spontaneous respiration, start positive pressure ventilation (ppv). 2. Heart rate: check heart rate by ascultating the heart or by palpating the umbilical pulsations by 6 seconds. Whatever the number or pulsation multiply by by 10 to obtain the heart rate per minute. If heart rate more than 100 beats per minute, look for color. If less than 100 beats per minute, initiate PPV. 3. Color : if the infant is breathing spontaneously and the heart rate is more than 100 beats per minute, evaluate the infant’s color by looking by cyanosis at lips/ tongue(central cyanosis) If central cyanosis is present administer the oxygen.

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Providing tactile stimulation Both drying and suctioning the infant produces stimulation, which for many babies is enough to induce respirations. However, if the infant does not have adequate respiration, additional tactile stimulation by stepping the sole or flicking the heel and / or and quickly rubbing the newborns back (rub twice) may be briefly provided to stimulate breathing . if you choose to provide tactile stimulation , free – flow oxygen should be given along with while you are stimulating the infant. Tactile stimulation can be safely and appropriately provided by following two methods. 

Slapping or flicking the soles of the feet



Rubbing the infant’s back



Slapping in back



Squeezing the rib cage



Forcing thigh on abdomen



Using hot or cold compress



Shaking

One or two slaps or flicks to the soles of the feet or rubbing the back once or twice will usually stimulate breathing in an Using free – flow oxygen

infant with apnea. However, if the infant remains apneic , tactile

Free flow oxygen to blowing nose ofinitiated the baby to enable the baby to breath stimulation shouldrefers be abandoned and oxygen bag and over mask the ventilation immediately. oxygen enriched Thisstimulation can be done by infant holding thedoes endnot of respond an oxygen tube close toand themay nose, within a Continued use ofair. tactile in an who is not warranted cupped hand or by holding the oxygen mask over the mouth and nose.

be harmful, since valuable time is being wasted.

Free flow of oxygen is used when an infant has established regular respirations and the heart

rate is greater than 100 beats per minute but central cyanosis persists. In these circumstances free – flow 100% oxygen at 5 L/min be given. Once the infant becomes pink while breathing room air. If cyanosis persists despite 100% free – flow oxygen , a trial of bag and mask ventilation may be indicated. Bag and Mask Ventilation

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Objectives: Participants will be able to learn •

When to give positive – pressure (bag and Mask) Ventilation.

•

Selection of bag and mask equipments.

•

The similarities and differences among flow – inflating bags and self inflating bags and T- piece resuscitators

•

The operation of each device to provide positive pressure ventilation.

•

The correct placement of masks on the newborn’s face.

•

Identify the indications and contraindication of bag and mask.

Ventilation of Lungs is the single most important and most effective steps in cardiopulmonary resuscitation of the compromised newborn baby. Bag and Mask Equipment Resuscitation bags: Two types 1. Flow inflating bag (Anesthesia bag ) 2. Self inflating bag

1. The flow – inflating bag – fills only when gas from a compressed source flows into it. It is collapsed like a deflated balloon when not in use. It inflates only when a gas source is forced into the bag and opening of the bag is sealed, as when mask is placed lightly on a baby’s face. Peak inspiratory pressure is controlled by the flow of incoming gas, adjustment of the flow control valve and how hard the bag is squeezed. Positive and expiratoratory pressure (PEEP) or (CPAP) is controlled by an adjustable flow control valve. Preparation of resuscitation devices for an anticipated resuscitation. 1. Assemble all the necessary equipments. 2. Testing the equipments. Bag and Mask procedure Indications: Apneic or gasping following initial stimulation. •

Heart rate < 100 \ min in a spontaneously breathing baby.

•

Spontaneously Breathing infant – cyanotic despite free flow oxygen

Contra Indication: •

Diaphragmatic hernia

•

Non- vigorous baby born through meconium – stained liquor.

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Selecting bag and mask equipments: Size of bag (240-750 M1): it deliver a tidal volume of 68 ml per kg. •

Oxygen capability: Oxygen source, Reservoir.

•

Safety Features : - Pop off valve , pressure Gauge (optional )

•

Mask Size: 0 and 1 (cover chin, mouth nose) Cushioned Edges.

Forming Seal: •

Positioning the infant

•

Position of resuscitator

Forming and checking the seal: •

Positioning and holding the mask: Enclose chin, mouth and nose , ensure snuff seal , avoid pressure over neck and eyes.

•

Squeeze the bag with fingertips: Don’t squeeze or empty the bag with whole hand.

•

Observe chest movements noticeable rise and fall of chest , shallow and easy breathing

•

Rate: 40-60 Breaths per minute. Squeeze – two three squeeze

•

Pressure : Increase in heart rate if noticeable rise and fall or chest

•

Initial breath pressure 30-40 cm of H20 later 15-20 cm of H20

Improvement assessment •

Increasing Heart rate

•

Improving color

•

Spontaneous breathing

No improvement \ deterioration •

Chest movement not adequate

•

Inadequate seal

•

Reapply mask

•

Blocked airway :

Reposition Clear Secretion Ventilate with open mouth Reliably.

A good resuscitation bag: •

Size 200-750 ML

•

Capable of avoiding excessive pressure

•

Capable of giving 100% Oxygen

•

Appropriate sized mask.

Masks:

Cushioned \ non – cushioned marks Round \ anatomical shaped

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A mask comes in a variety of shapes, sizes and materials. Selection of mask fro use with particular newborn’s depends on how well the mask fits to the newborn’s face will achieve a tight seal between mask and newborn’s face available ; size 0 or 1. Be sure to have a various sized mask available. Effective ventilation of a preterm baby with term infant size mask is impossible. Use correct size and correct position of the mask. Advantages: Delivers 100% Oxygen at al time. •

Easy to determine the adequacy of seal.

•

Stiffness of Lungs can be felt.

•

Can be used to deliver 100% free flow Oxygen.

Disadvantage: Requires a tight seal to remain inflated. •

Requires a gas source to inflate

•

No safety pop – off valve.

•

Requires more experience

The self – inflating bag – Fills spontaneously after it is squeezed pulling gas

(Oxygen

of

air

mixture of both) into the bag . Advantages: •

Does not need a gas source to inflate

•

Pressure release valve is there

•

Easier to use

Disadvantages: •

Will inflate even if there is not a seal between mask and patients face.

•

Requires Oxygen reservoir to provide high Concentration 100% Oxygen

•

Cannot be use to deliver free flow oxygen

•

Insufficient pressure

•

Increasing pressure

Deterioration: •

Check delivery system

•

Check Oxygen supply

•

Check Oxygen Tubing

Preterm Newborns •

Avoid Excessive chest wall movements (Large tidal volume )

•

Monitoring of pressure and avoiding unnecessary high pressure

•

CPAP after resuscitation may be helpful.

Bag and mask ventilation procedure Points to be keep in mind •

Select bag & connect Oxygen source capable of giving 100% Oxygen

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•

Select Appropriate size mask

•

Test Bag

-

Good pressure

-

Pressure release valve working

-

Pressure manometer 30-40 cm H20

•

Baby need bag & mask ventilation

-

Position your self at head end or side of baby

-

Position baby’s head in sniffing position

-

Position bag and mask properly on baby.

-

Begins ventilation at appropriate rate and pressure

-

Check easy chest rise during first 2-3 breaths CHEST COMPRESSIONS

Objectives: •

Identify the indications of chest compression

•

Locate the site of chest compression

•

Demonstrate technique of chest compression on manikin

Introduction: The newborn baby’s survival is dependent on his ability to adapt to his extra uterine environment. This involves adaptations in cardio pulmonary circulation and other physiological adjustments to replace placental function and maintain homeostasis. Simultaneously newborn has to make adjustment in respiratory and circulatory system as well as maintain body temperature. These initial adaptations are crucial to his subsequent well being and should be facilitated by trained and skilled nursing personnel. The heart circulates blood throughout the body, delivering oxygen to vital organs. When an infant becomes hypoxic, the heart rate slows and myocardial contractility decreases. As a result, there is a diminished flow of blood and oxygen to the vital organs. The decreased supply of oxygen can lead to irreversible damage to the brain, heart, kidneys and bowel. Chest compressions are used to temporarily increase circulation and oxygen delivery. Indication of Chest Compression: The decision to initiate chest compression is based on neonate heart rate. Chest compression is indicated when heart rate is below per minute after30 seconds of positive pressure ventilation with 100 percent oxygen. Technique of chest compression: The neonate should be posited on flat firm surface and neck slightly extended Ensure that neonate’s back is firmly supported so that heart can be compressed between the sternum and spine. Two trained personnel are needed i.e one for chest compression and another for positive pressure ventilation.

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Chest compressions must always be accompanied by ventilation with 100% oxygen ventilation must be performed to ensure that the blood being circulated during chest compression gets oxygenated. There are two ways for chest compression: Two finger method: The tip of the middle and the index finger should be used for compression. Other hand can be placed under back of the neonate to provide support.

Thump technique: Thumbs of both hands are placed either side by side or one over the other win fingers encircling the ribcage. The thumbs are used to compress the sternum while fingers provide support to the back of the chest. The chest should not be squeezed by the hands but sternum compressed with thumbs.

Site: Lower one third of the sternum i.e the area just below the inter nipple line and above xiphisternum. Rate of compression: The sternum should be compressed at the rate of 120 beats per minute and the ventilation is given at the rate of 40 to 60 breaths per minute. Rate of cardiac massage should be coordinated with ventilatory support i.e. three chest compression and one breath. One and two and three and squeeze should be the sequence followed for chest compression and positive pressure ventilation. Compress the chest to a depth of one third of the anterior posterior diameter of the chest.

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Maintained a steady rate and depth of compression. After 30 seconds of chest and ventilation evaluate heart rate and make your decisions based on the heart rate. If heart rate is below 60 per minutes continue chest compression and ventilation If heart rate is above 60 per minute discontinue chest compression whereas ventilation should be continued till the heart rate is above 100 per minute and neonate is breathing spontaneously. Complications If the technique of chest compression is incorrect it can cause trauma to the heart, lungs or liver. Excessive pressure over the ribs and xiphoid and lead to fractured ribs , laceration of liver and pneumothorax.

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FORMULA FEEDING Introduction: Nutrition is an important component of the care of al babies for their survival and proper growth and development. Full term new born normal babies usually has food sucking reflex and they have breast feed easily whereas low birth weight babies especially babies who cannot suck breast feed those require to be fed by watty spoon. Definition: Formula feeding is method of giving synthetic milk and nutrients to a new born by using clean and boiled watty spoon for their proper growth and development. Purposes: 1. To promote appropriate nutrition 2. To ensure adequate physical growth and should mimic intrauterine growth curves in case of preterm baby 3. Provide nutrients specially required for preterm to prevent micro and macro nutrient deficiency and 4. To ensure normal land term neurodevelopment outcomes. Indication 1. The baby >34 weeks and weight less than 2000 grams. 2. Poor swallowing and sucking reflux. 3. The baby is risk for aspiration 4. Congenital anomalies like cleft lip and cleft palate. Principles 1. The baby should be fed in upright position and burped after each feeds. 2. The milk should be always directed to the side of the mouth 3. All utensils used for feeding have been boiled in water for at least 10 minutes. Articles: Feeding tray contains -

Boiled watty and spoon

-

Boiled cooled warm water

-

Recommended feeding powder like lactogen , lactose .

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-

Napkin

-

Preparation of environment parents and baby.

-

Establish rapport with baby’s mother by explaining properly.

-

Prepare clean bed well light & ventilation

-

Check babies cloth, if it is wet change it.

-

Wash hands and prepare feed and cover & keep ready.

Procedure: 1. Wash hands 2. Take boiled Wati spoon with boiled

1. To prevent infection 2. Boiled articles to prevent

water & warm 30 ml.

gastrointestinal infection to baby.

3. Take boiled Wati spoon with boiled

3. Boiled articles to prevent

water & warm 30 ml

gastrointestinal infection to baby.

4. Add 1 spoon powder in 30 ml of water

4. to avoid lump of powder becoming &

and mix it with spoon evenly.

to prepare proper milk

5. Hold the baby gently in lap. To stimulation just tap the sole of feet. 6. Elevate 30degree head of baby on our

6. To prevent aspiration & milk while

left hand.

swallowing

7. Give small quantities & spoon feed to

7. to prevent vomiting

baby to prevent vomiting 8. this provides comfort to the child 8. Let the baby swallow completed then give other spoon this way slowly feed the baby. 9. After 10 ml of milk burp the baby

9. It helps to prevent the regurgitation

by holding in an upright position & support the head and neck while gently patting or rubbing the back.

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10. Clean the mouth lips & neck.

10. To keep the baby clean.

11. Place the baby in a bed on the left

11. to prevent vomiting

lateral side to prevent vomiting. Do not leave a baby on his or her back immediately after feeding to prevent regurgitation aspiration.

After the procedure: care of baby & articles – 1. Clean the mouth , lips neck with water swab gently & dry 2. Make the body comfort & give to mother 3. Take all articles to utility room, wash it thoroughly keep it in proper place After proper boiling put all the stove & keep it in a proper place Recording and reporting 1. Record the strength & amount f feed & time on chart 2. Record response of baby tolerated \ not tolerated 100 gm lactose = 495 kcal 1 scope = 4.5gm = 25 kcal Required cal. Rate & new born 110-165kg /day

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INTRAVENOUS ADMINISTRATION A

number of medications that are to be given to

children require different routs of

administration and once the physician ordered the drug and dosage to be given, it is the duty of nurse to ensure that it is given properly while observing the five rights and universal precautions of medication administration. Definition The introduction of a fluid or liquid medicine to the body via the veins is termed as I.V infusion. Purposes 1. To prevent the disease. 2. To restore the fluid volume that is lost from the body due to hemorrhage or diarrhea. 3. To prevent and treat shock and collapse. 4. To promote the health. 5. To give palliative treatment. 6. To give symptomatic treatment. 7. To obtain the desired effect of the medication. Objectives 1. To administer the medicine in a safe and effective manner. 2. To prevent the injury.

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3. To treat the disease condition. 4. To obtain the desired effect of medicine. INDICATION 1. This method is used for giving drugs to children who have poor absorption as a result of diarrhea, dehydration, or peripheral vascular collapse. 2. Children who need a high serum concentration of drugs. 3. Children those who have resistant infection that require parental medication over an extended time. 4. Children those who need continuous pain relief. 5. Children who require emergency treatment. SCIENTIFIC PRINCIPLES: ANATOMY AND PHYSIOLOGY.  Give proper position to the patient and select the proper vein site.  Careful selection of the site is important to avoid the injury to the blood vessel. MICROBIOLOGY.

 Wash your hand thoroughly before and after the procedure to avoid the cross infection.  Use all autoclaved equipment to prevent entry of infection to the into the body.  Use autoclaved one syringe one syringe and one needle to each patient.  Use sterile drugs and sterile water.  Clean the top of the vial or neck of the ampoule with spirit before putting the needle into the drug.  Follow strict aseptic technique.  One swab is used for swabbing. PSYCHOLOGY.

 Explain the procedure thoroughly to the patient to win the confidence and co-operation.  Distracting the patient while putting intracath will minimize the pain.  Pain is reduced by using sharp needles.  Maintain the privacy.  Keep the patient relax both mentally and physically.

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PHYSICS AND CHEMISTRY.

 Maintain proper body mechanics.  Fluid tend to flow an area of low pressure so that the solution comes into the syringe.  Diffusibility and solubility of the drugs also effects absorption.  Solution having the same osmotic pressure as the blood are absorb more quickly than other fluids.  Absorption is slow in sluggish circulation.

 When solution is drawn from an ampoule into a syringe the needle is put into the fluid and the piston is pulled back thus the pressure in the syringe is lowered.  The deeper the penetration of the fluid the faster is the rate of absorption. PREPARATION OF a. Article: A tray containing A sterile bowl with cotton swabs Spirit in a container A syringe with medicine Kidney tray Mackintosh and towel. Medicine card and general order book (Should not take medicine to the syringe in front of children. Prepare the medicine in the treatment room.) b. parent: Parents are told about the procedure, including the reasons for the procedure, what they can expect during and after the procedure. They should be offered the opinion of remaining with their child or leaving. c. child Explaining to the children what is being done during each procedure and how they can participate helps to obtain their co operation and reduce their stress.

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Play always an excellent stress reducing technique, can be employed during the preparation phase. Allow the children to handle the equipment and to “push” an IV infusion on a toy animal or doll helps familiarize them with the frightening aspects of the procedure.

c. Environment Arrange for a quiet, private setting for the child while giving IV injection. Maintain proper lighting, cleanliness, The assurance of privacy relieves the child of some anxieties concerning of loss of control in front of others, it will also helps to avoid subjecting other children to the potentially stress provoking scene. STEPS OF PROCEDURE WITH RATIONALE.

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PROCEDURE

RATIONALE

1. Wash hands.

To prevent cross infection.

2. Check the medicine card with doctors’ order, And

It helps to take the correct medication

check the five rights.

and prevent the wrong doses.

3. Again check the medicine and medicine dosage

It

with another sister.

administration.

helps

to

prevent

wrong

4. Prepare the IV injection: a. carefully removes the bottle seal

from the

Every steps of the procedure requires

top of the bottle, clean the bottle with spirit swab;

clean

technique

holding the bottle upright position and take the

contamination.

to

prevent

the

medicine in the syringe. Keep the syringe in the sterile tray. 5. Prepare the child, parent. Explain all the

It helps to gain the confidence.

procedure. 6. prepare the venupuncture site: a. keep the hand in a dependent position( lower

Gravity impend venous return.

than the patient heart) b. keep the Mackintosh and towel below the hand.

Helps to maintain the cleanliness.

c. remove the stopper from the intra cath, clean the port of entry with spirit swab, wait for three

It helps prevent the entry of micro

seconds.

organism.

7. Administer the injection slowly. After giving injection, close the port of entry with

It helps to find out the immediate

stopper and be with the child with 15 minutes.

reaction after giving the medicine.

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AFTER CARE OF CHILD AND ARTICLE 1. Give the child comfort position. 2. Dispose the syringe and needle. 3. Take all articles to utility room and clean the article with soap and water and replace the article in proper position. 4. Wash hands. RECORDING AND REPORTING 1. Record medicine, route and time, child response 2. Record and report any reaction observed after administration of drug. IV CALCULATION Flow rate =

Total volume infused in ml X drops/ml ------------------------------------------------Total time of infusion in minutes.

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