CHHS18/031

Canberra Hospital and Health ServicesClinical Procedure Caring for Children During ProceduresContents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................3

Scope........................................................................................................................................ 3

Section 1 – General Information...............................................................................................3

Overview...............................................................................................................................3

Preparation...........................................................................................................................4

Coping strategies:.................................................................................................................4

Positioning:........................................................................................................................... 5

Section 2 – Neonates ≤ 28 days................................................................................................5

Positioning and Coping Strategies:........................................................................................5

Section 3 – Infants/ Toddlers....................................................................................................5

Infants:..................................................................................................................................5

Toddlers:............................................................................................................................... 5

Positioning Infants/Toddlers:................................................................................................6

Coping Strategies:.................................................................................................................6

Section 4 – Preschool age 3.5 – 5yrs.........................................................................................6

Preschoolers:........................................................................................................................ 6

Positioning:........................................................................................................................... 6

Coping strategies; Example: IV cannulation or venepuncture..............................................7

Section 5 – School Age 5yrs+.....................................................................................................7

School Age Children:.............................................................................................................7

Adolescents:..........................................................................................................................8

Positioning:........................................................................................................................... 8

Coping strategies; Example: IV cannulation or venepuncture..............................................8

Section 6 – Distraction tips Infants, Toddlers, Preschool, School Aged and Adolescent...........9

Section 7 – Post Procedure.....................................................................................................10

Section 8 – Oral Sucrose + Topical Analgesia..........................................................................10

References.............................................................................................................................. 11Doc Number Version Issued Review Date Area Responsible PageCHHS18/031 1 30/01/2018 01/02/2023 WY&C –

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Definition of Terms................................................................................................................. 12

Search Terms.......................................................................................................................... 12

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Purpose

This guideline outlines how to prepare children for, and care for them during procedures. The guideline should be read in the context of other procedures describing the pharmacological modalities that may be used in conjunction with these techniques.

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Scope

These guidelines pertain to all staff who provide care for children (under 12 years) in a clinical setting.

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Section 1 – General Information

OverviewThere are three components essential for preparing a child for a procedure: The development of trust The child’s understanding of what is involved The child’s mastery of experience

Utilise the Three P’s: Preparation (including timing where possible) Procedure Post Procedure

Consideration should be given throughout the procedure to the individual characteristics of the child. Children with more complex needs (eg intellectual impairment, high anxiety, frequent hospitalisation, vision or hearing impaired, those from culturally and linguistically diverse backgrounds) may require more time taken to ensure as high a level of participation in each of the steps as is possible for them. In any situation, but particularly for children with complex needs, a child’s usual coping strategies and comfort needs should be discussed with caregivers, and every effort made to incorporate this into the procedure.

During all stages of a procedure, consider the resources available: Paediatric Play Therapist (business hours, Monday-Friday, telephone (614)26156 Clown Doctors (Friday only) Please note that the Starlight Captains have no specific training in procedural assistance,

and this is outside of their scope of practice.

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PreparationThe aim of this phase is to develop a rapport with the child. A therapeutic alliance is crucial to the preparation process, and requires honesty in explanations and responses.

Assess the child’s: developmental age, cognitive ability and emotional maturity coping mechanisms in response to injury, pain, new environment previous hospital experiences and misconceptions (correct misconceptions if necessary)

Prepare: Parents – if the child is < 3yrs of age, provide parents with information about the

procedure to enable them to give support and comfort to the child. Child – if the child is > 3 yrs of age provide the child with information appropriate to

their cognitive ability. Ensure the parents also understand this information.

Steps in preparation WHO - is going to do the procedure? WHY - does it have to happen? HOW - is it going to be done? WHAT - is it going to feel like? WHEN - will it be done? WHERE - on the body will it be done? Explain what they may feel, see, hear and be expected to do throughout the procedure.

Please note while most preschool children will benefit from an explanation there may be some instances in which it is ineffective.

Techniques: Demonstrate the procedure on a doll or teddy. Encourage coping strategies during the demonstration.

Coping strategies:Work with the parents and the child to develop coping strategies Suggest to the parent/child strategies, i.e.

o Blowing bubbles (encourages deep breathing), breathing and relaxation techniqueso Telling and reading stories – encourage the child to tell you their favourite story,

bookso Music and/or singingo Playing with toys, electronic games, eye spy, peek-a-booo Guided imagery – if the child does not want to participate, discontinue o Counting – this enables the child to see that there is an end. Counting backwards

requires far greater concentration.

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Positioning:Generally speaking an upright position is preferred as this enhances the child’s sense of control. However there may be some procedures for which an upright position is not appropriate e.g. urinary catheterisation or lumbar puncture. Encourage the child to sit on their own Parent/staff to sit beside or near the child throughout the procedure

*Restraining:On some occasions restraining will be required e.g. for a lumbar puncture. This should be kept to a minimum and the reasons for restraint explained to the parents or care givers, verbal consent obtained and documented in the clinical notes

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Section 2 – Neonates ≤ 28 days

Positioning and Coping Strategies: Skin-to-skin contact with mother (Kangaroo care) Non-nutritive sucking (NNS) Minimise exposure Swaddling Massage Speaking with a soothing voice Reduce environment stressors such as light/noise Providing eye contact during procedures

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Section 3 – Infants/ Toddlers

Infants: “Approach the child through the parents” Procedural education is for the parents. This reduces their anxiety Encourage the parents to utilize the infant’s personal preferences for comforting and

soothing the child during the procedure

Toddlers: “Understand the world in the here and now through direct body experiences” Use simple explanations, allow the toddler to handle and explore the equipment Offer choices where possible and involve the parents in the procedure < 2.5 yrs - Involve parents in comforting the infant during the procedure Use sensorimotor comforting i.e. rocking, stroking, singing, distraction Correct position essential (upright positioning where possible) Simple toys for distraction

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Positioning Infants/Toddlers: Encourage the parent to hold and comfort the child Staff to hold when the parent declines Hold in an upright position/cuddle position

Child sits on bed or adult’s lap

‘Hugging hold’ torso and feet Used with or without distraction

Coping Strategies: To help toddlers alleviate stress and anxiety, have equipment available such as mask,

syringe and a stethoscope to touch, feel and play with.

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Section 4 – Preschool age 3.5 – 5yrs

Preschoolers: “Inability to understand cause and effect, the boundaries between fantasy and reality are often blurred” Give simple and concise explanations Give concrete explanations using pictures, dolls and other visual aids Provide physical proof that the procedure will come to an end during preparation

Positioning: Encourage the child to sit on their own or have a parent sit with the child offering

support ‘Hugging hold’ with adult’s arm around child’s torso and free arm Used with distraction Adult’s free hand on shoulder or forearm of the child Give the child the choice to look

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Child sits on adult’s lap ‘Hugging hold’ with adult’s arm around child’s torso and free arm Used with distraction

Adult sits on table with child in ‘hugging hold’ Adult places child’s arm in front / around torso

Coping strategies; Example: IV cannulation or venepuncture Show the equipment to be used (describe the cannula as a straw) Discuss veins (blue lines) Discuss the reasoning for topical anaesthetic cream (put that bit of skin to sleep) Discuss the tourniquet (gives your arm a hug) Demonstrate the cannula process on a doll or bear Accurate step-by-step instructions

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Section 5 – School Age 5yrs+

School Age Children: “Logical thinking developing, concrete thinkers” Educate using diagrams, pictures, objects Explain procedure using step-by-step instructions Follow these instructions throughout the procedure Explain “why” in honest and age appropriate terms Allow release of feelings and validate fears

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Give the parents and the child a role to perform throughout the procedure. Include them in the decision making process

Adolescents: “Logical reasoning can think abstractly” Give detailed information Respect their individuality and needs for privacy Involve them in the decision making process

Positioning: Encourage the child to sit on their own Parent/staff to sit beside or near the child throughout the procedure

Distraction is used as a visual block Good position for pin care, catheter insertion, dressings

Coping strategies; Example: IV cannulation or venepuncture Discuss skin layers (can use a book) Discuss topical anaesthetic effect Use other strategies outlined above Explain the reason for the procedure Utilise the coping strategies outlined above.

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Section 6 – Distraction tips Infants, Toddlers, Preschool, School Aged and Adolescent

Taken from “Infants and children: management of acute and procedural pain in the emergency department Appendix 9” NSW Health

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Section 7 – Post ProcedureDoc Number Version Issued Review Date Area Responsible PageCHHS18/031 1 30/01/2018 01/02/2023 WY&C –

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Children’s memories of painful experiences are strong predictors of subsequent reports of pain intensity. Due to this, it important to end a medical procedure positively by taking steps to: Reduce the child’s distress before leaving the procedural setting Provide positive reinforcement of what went well during the medical procedure Promote appropriate rewards Ask if there is anything the child would like to try differently next time. Document the child’s response to the medical procedure and procedural preferences to

help inform subsequent interventions.

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Section 8 – Oral Sucrose + Topical Analgesia

Oral sucrose for procedural pain management is a sweet solution which reduces pain in neonates and infants by providing taste stimulation to the cellular membrane receptors in the brain. Stimulation of these receptors release endorphins effective in pain reduction.

Oral Sucrose analgesic effect lasts 5-8 minutes and is more effective if given with a dummy as this promotes Non-Nutritional Sucking (NNS) which contributes to calming. There is no analgesic effect if sucrose is given directly into the stomach via a nasogastric tube.

Oral Sucrose Dosing Guide

Taken from “Sucrose (oral) for procedural pain management in infants” Royal Children’s Hospital Melbourne

For further information regarding dosing and management please see the “Sucrose (oral) for procedural pain management in infants” (Reference list, page 10)

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Topical Analgesia is used in preparation for cannulation or venepuncture. For application for children of different age groups:

Taken from “Infants and children: management of acute and procedural pain in the emergency department” Table 3, page 15 NSW Health

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References

1. Hockenberry, M., & Wilson, D. (2014). Wong’s nursing care of infants and children (10th ed.). St Louis MO: Mosby Elsevier.

2. NSW Health, Sydney, Australia, Guideline on Infants and Children: Management of Acute and Procedural Pain in the Emergency Department, [Internet, last updated 7 March 2016; cited YOU6 November 2017], Available from: http://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2016_009.pdf

3. Royal Children's Hospital, Melbourne, Australia, Clinical Practice Guideline on Sucrose (oral) for procedural pain management in infants, [Internet, last updated November 2015; cited 6 November], Available from: http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Sucrose_oral_for_procedural_pain_management_in_infants/

4. Royal Children's Hospital, Melbourne, Australia, Fact Sheet – “Reduce children's discomfort during tests and procedures” [Internet, last updated November 2010; cited 6 November 2017], Available from: https://www.rch.org.au/kidsinfo/fact_sheets/Reduce_childrens_discomfort_during_tests_and_procedures/

5. Royal Children's Hospital, Melbourne, Australia, Clinical Practice Guideline on Procedural Pain Management, [Internet, last updated May 2016; cited 6 November 2017], Available from: https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Procedural_Pain_Management/

6. The United Nations. “Convention on the Rights of the Child.” Treaty Series 1577 (1989): 3. Print

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Definition of Terms

Kangaroo Care refers to a neonate lying on the bare skin of their mother or father, upright at a 40-60 degree angle and covered by parent’s shirt/ gown with an additional blanket as required.

Swaddling - neonates can be wrapped in a cloth or blanket to make them feel secure.

Non-Nutritional Sucking (NNS) - refers to the use of a dummy to promote sucking without breast milk or infant formula.

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Search Terms

Pain, procedure, venepuncture, cannulation, analgesia, infant, child

Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Policy Team ONLY to complete the following:Date Amended Section Amended Divisional Approval Final Approval 10/01/2018 Complete Review Karen Faichney A/g ED,

WY&CCHHS Policy Committee

This document supersedes the following: Document Number Document NameCHHS12/070 Paediatrics – Oral Sucrose Administration to InfantsCHHS12/066 Paediatrics – Preparation and Care of Children During Procedures

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