peds proceures
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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 oralmedicationit 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.
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PREPRATION OF
Parent: -Explain about the action of medication.
Child: -A pos itive, kind, but firm approach wi 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
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1. Washhands
2 Read the physician order and compare it
with the medicine card
3 After reading the medication card take
the appropriate medicine from the shelf
compare the level with the medicine card
4. Omit the medications,
5. Take the required medicine from the shelf.
Compare the label with the medicine card. Read
the entire label. Before a medicine ticket
is written or a drug administered, the
nurse must calculate the safe dosage
range for the individual child and
compare it with the dosage
prescribed.
6 Take the suspension tablets and capsules first
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,
holding cork between ring and little finger. Holdbottle in the light to check for sediment etc.
8. Take a medicine glass in the left hand and place
thumbnail at the level which drug
9. Check drug with medicine chart again
and then pour into the glass.
10. Holding the medicine g1ass at eye level
again check dosages to see that the lower part of
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
1 To avoid crossinfection
2 To ensure safety in the
administration of the medication
3 the first safety check to prevent the
possibility of pouring the wrong
medicine
4 It help Prevent wrong dose
5 Recheck the medicine bottle
- It helps give correct medication
Prevent wrong dose
-It helps prevent wrong dose
6 It help to prevent contamination
7 It helps to administered the correct
dose
8. It helps prevent wrong dose
9 . It helps to administered the correct
dose
10 It help to prevent the
administrate the wronge medication
11 To prevent the contamination,
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bottle or container, discard it into the Sink.
12 Prepare separate medicationfor each
patient. Identify the patient with the
medicine card by-
- Reading the name on the case paper.
-Holding the child properly by doing the mimics.
13. First give little water to drink with the
help of spoon and then give Medicines
one at a time.
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.
12 Proper identification of each medication
assures accurate administration of
correct medication to correct patient
13 It help in the easy sallow wallowing of
the solid medication
14. Ensure the medication is taken
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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
PATIENTS NAME DIAGNOSIS
AGE/ SEX D.O.A.
WARD/BED NO. DR INCHARGE
DATE
TO
CALCULATE
THEPAEDIATRIC
DOSAGE: -
Most of the drugs
are available in
the adult dose.
The nurse needs
to know how to prepare the Paediatric dosage.
1) Youngs rule :- (for children over one year of age ) unto 12 years
Age of the child (in years) X Adult dose =Childs dose
Age of the child (years)+12
2) Clarks 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 Adults dose = Childs dose
150
S
r.N
o.
MEDICATION NAME DOSE TIME ROUTE SIGNATURE
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3)Frieds rule :- (For children under 1 year of age)
Weight of the child in pounds X Adults dose = Childs dose
150
CHECK LIST OF ADMINISTRATION OF ORAL MEDICATION
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 patients 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 patients identification asked the child name
her parents.
Yes No
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14.Told the childs 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.
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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 COLOSTOMY8
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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 faeca
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 laye
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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 wil
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 manag
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 childs 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.
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EQUIPMENT USE FOR COLOSTOMY CARE
A clean tray containing
Cover sheet
Protective sheet and towel
Glovesone 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 shee
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.
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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 pape
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 papebacking 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 the patient in a comfortable Position.
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.
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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 asepti
technique. Make him comfortable. Tidy up the unit.
Take all articles to the utility room. Clean all equipments immediately. Rinse them firs
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. Failureto 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.
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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 o
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 canthusthis 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 childs
movement and positioning
Assess the general condition of the childs ability to follow directions
Check the articles available in the patients unit.
ARTICLES REQURIED FOR THE EYE CARE
ARTICLES PURPOSE
A tray containing :-
Mackintosh and towel To protect the pillow and bed linen
Sterile bowl with sterile cotton swabs To clean the eye
Sterile normal saline or any ordered To clean the eye
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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 childs 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 RATINALE
1. Wash hand
2. Pour sterile saline into the bowl andwet the cotton swabs
3. Stand in front of the patient clean the
eyes with the sterile swabs. Discard
the swabs into the paper bag.
Continue cleaning till all discharge are
removed from the eyes
To prevent the cross infection
Take the following precaution
Area of the swab touched by the
fingers should not come in contact
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
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4. For crushed secretionplace a wet
warm gauze piece or cotton swab over
the closed eye. Leave it in the place
until the crust becomes soft.
5. When the eye are clean, stop the
Procedure. Wipe the face with the face
towel
Warm compress makes the crusts to
become soft that it can be removed without
traumatizing the mucosa
AFTER CARE OF THE PATIENT AND ARTICLES:-
Instill any medications that is ordered if any
Remove the mackintosh and towel from under the patients head
Adjust the position of the patients 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 nurses record.
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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 Reyles 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.
TOProvide 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
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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 Rationale Scientific
Principles
Nursing
Principles
Wash hands with soap
and water.
To prevent cross-infection. Soap and water help
in checking the
microorganisms'
growth (principle of
Microbiology,
Physics).
Principle of safety
Spread the mackintosh
and the towel
To protect bed linen. Microbiology Safety and
comfort
Clean the nostril with a
cotton-lipped
applicator soaked in
saline.
To clean nostril. Microbiology Comfort and
safety
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Take the Ryles tube and
measure the distance for
insertion of the tube
from bridge of the nose
to earlobe plus distance
from ear lobe to the tip
of the xiphoid process of
the sternum and mark
with adhesive.
To determine
approximate length of
the tube to reach the
stomach.
Anatomy and Physics Safety and
individuality
Lubricate the tube for
about 2-4 inches with
thin coat of water
soluble jelly.
Lubrication reduces
friction between mucous
membrane and the tube.
Physics Safety
Hold the tube coiled in
the right hand to
introduce the tube.
Nasal septum is deviated
into the right side.
Anatomy Safety
Tilt back the child's head
before inserting the tube
into the nostril and
gently pass the tube into
the posterior
Nasopharynx quickly
backwards and
downwards.
Passage of the tube is
facilitated by following
the natural contours of
the body.
Anatomy and
Physiology
Safety and
therapeutic
effectiveness
When the tube reaches
the pharynx, the patient
may gag: allow him to
rest for a few moments.
Gag reflex is triggered
by the presence of the
tube. Helps to prevent
the aspiration of fluids or
passing the tube into
Trachea.
Anatomy and
Physiology
Safety
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Hold the child's head in
a partially flexed position
and advance the tube as
he swallows sips of
water.
Flexed head position
makes swallowing easier
and the tube less likely
to enter the trachea.
Swallowing facilitates
passage of the tube by
closing the epiglottis.
Helps in easy passing of
the tube and avoids
coiling it at Pharynx.
Anatomy and
Physiology
Safety
Continue to advance the
tube until it reaches the
previously designated
mark.
Mark on the tube
indicates that it has
reached the stomach.
Physics Safety
Aspirate for gastric
contents with a syringe.
Fluids cannot be freely
aspirated from the lungs.
Glands of mucous
membrane lining the
esophagus and stomach
produce mucus, and
gastric juices.
Anatomy and
Physiology
Safety and
therapeutic
effectiveness
Place the end of the tube
into a bowl of water and
note the rhythm of
escaping bubbles.
If the tube is in trachea
air bubbles will coincide
with the expiration of
each breath. Normal
respiration takes place in
lungs. As a result, air
will be expelled out with
expiration.
Anatomy and
Physiology
Safety
principles
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Ask the patient to speak. The patient will be
unable to speak or hum
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.
Physics Anatomy and
Physiology
Safety
principle
Confirmation of the
tube's place can be done
by using a stethoscope.
Take 5-10ml of air and
push in
distal end of the tube.
Hushing sound will be
heard on the stomach
while air is pushed. Air
pushed by force
produces a hushing
sound.
Physics Safety.
After the tube is in
place, tape it to the nose
/ forehead. Take 5cm of
tape, split length-wise
and only halfway, attach
up split end of the tape
to the nose / forehead
and cross split ends
around tubing.
Prevents the patient's
vision from being
disturbed, prevents
tubing from rubbing
against nasal mucosa
Psychology Individuality
and comfort
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Wait for some time
before giving the feed.
A few minutes rest will
help to subside the
peristalsis and prevent
nausea and vomiting.
Peristalsis is stimulated
by any irritation to
stomach or by a bolus of
food.
Anatomy and
Physiology
Comfort
Before giving the feed
connect tunnel and
syringe, pour some
water through it and
lower the funnel slowly
so as to expel air.
Expelling air from the
tube before the feed is
given docs not allow the
fluid to run. Air is lighter
than water, liquid exerts
pressure because of
their weight.
Physics Safety
Hold the funnel or
syringe 8 inches above
the bed.
To prevent the damage
of mucus membrane in
stomach. The height of a
column of fluid
determines the amount
of pressure exerted at
the point of application.
Physics Safety
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Slowly introduce feeding
into the funnel or
syringe barrel, keep it
full until total amount
has been introduced.
To prevent distension,
nausea and excessive
peristalsis and to
prevent air entry into
the stomach. Helps in
preventing injury to
gastric mucosa by
reducing pressure.
Physics Safety
When the quantity of
feed is over, clear the
tube by introducing a
small amount of water.
To prevent the blockage
of tube. As the food
remains in tube, it
blocks the lumen and
causes obstruction to
flow.
Physics Safely
Disconnect funnel or
syringe barrel and clamp
the tube to prevent
leakage of fluids.
To prevent the leakage
of gastric fluids back
from the tube. Fluid
flows only when there is
a difference in pressure,
the direction is to the
area of lower pressure.
Physics Safety
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Tube may be removed or
left in the place. To
remove the tube pinch it
b/pulling it out
continuously with a
moderate rapid motion.
To prevent aspiration of
contents into trachea.
Physics Safety
Offer a mouth wash,
clean face and hands.
To clean mouth and
prevent tartar formation
and to moisten the
mouth. As the patient isnot taking food by
mouth there will be less
secretion of saliva and
dryness.
Microbiology Comfort and
safety
Remove the mackintosh
and the towel.
To keep the unit clean Psychology Comfort and
safety
Make the patient
comfortable in bed.
To give a sense of well-
being, comfort.
Comfort
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To take the articles to
the utility room. Discard
water and clean with
soap and water. Dry
them and replace in
their proper place.
To clean them
thoroughly. To prevent
cross-infection. Helps in
checking growth of the
micro-organisms.
Microbiology Safety
Wash hands To prevent cross-
infection.
Microbiology Safety
Record the time, date,
amount of feed, nature
of feed, reaction of the
patient, if any, in the
nurse's notes and
intake-output chart.
To have good
communication in team
and to maintain fluid
balance for future
reference.
Psychology Safety
Therapeutic
effectiveness
If the tube is reusable,
clean it with cold water
first then with a warm
soapy solution. Pushingwater several times
through the lumen boil
it, dry it and replace.
Disposable tubes to be
discarded.
Usually disposable ones
can be discarded.
Rubber tubes arc kept
ready for the next use.
Microbiology and
Physics
Safety and
comfort
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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.
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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 50to 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 thestomach 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.
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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 andthe length passed and the amount of feeding given.
Methods of tube feedings :
Nasogastric (NG) feeding Nasoduodenal feeding Nasojejunal feeding
Jejunostomy (JT) feeding Gastrostomy (GT) feeding
RELATED LITERATURES TO THE NEXT PAGE:
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COLLEGE OF NURSING BHARATI VEEDYAPEETH, PUNE.
Final Year Msc Nursing [Pediatric Specialty]
STUDENTS NAME:-___________________________DT:__
CHECKLIST FOR NASOGASTRIC TUBE FEEDING
SR.
NO
PARTICULARS YES NO N.A
* BEHAVIORAL GUIDES
1. APROACHES THE CHILD/PARENT WITH CONFIDENCE.
2 GIVES A RELAVANT EXPLAINATION INWAYS THATCHILD OR PARENT CAN UNDERSTAND.
3. ORIENTS THE CHILD/PARENT THE POSIBLEDICOMFORT AND TO HIS ROLE DURING THE
PROCEURE.
4. ANTICIPATES CHILDS EMBARSEMENT AND
PROTECTS PRIVACY.
5. MAKES ALLOWANCES FOR INDIVIDUALDIFFERENCES IN TOLERANCE OF TREATMENT.
6. SHOW PATIENCE.
7. NOTICES CUES INDICATING CHILDS DISCOMFORT
AND ATEMPTS TO ALLEVIATE IT.
8. PLACES THE PROCEDURE APROPRIATELY TOTOLERANCE AND/OR CONDITION OF CHILD.
9. FOCUSSES ATTENTION ON THE PROCEDURE TOTHE EXTENT THAT READINESS TO RESPOND
TO OTHER EVENTS IS LIMITED.
10. INDICATES AWARENESS OF RESPONSIBILITY TO
THE CHILD FOLLOWING THE PROCEDURE.
* FEEDING OBSERVED NOT
OBSERVED
11. ENSURE 30-45DEGREE UPRIGHT POSITION OF
CHILD IF UNLESS CONTRAINDICATED.
12. ENSURE TUBE IS CORRECTLY POSITIONED.
13. CHECK THAT PRESCRIBED FLUID IS ATAPPROXIMATELY NORMAL BODY TEMPERATURE.
14. INTRODUCED ORDER AMMOUNT OF FLUIDTHROUGH THE TUBE.
15. INSERTS MININMUM 10 ML OF WATER FOLLOWING
FEED TO FLUSH THE FEED.
TOTAL
N.A = NOT APPLICABLE. POINTS: /15
COMMENTS:
STUDENTS SIGN:-
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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 o
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 acolorless, 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: sometimes 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: Nursemust aware of mental status of the child and his parents to provide
anxiety free procedure.
20. INDICATION./ REASON FOR PROCEDURE:
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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. Articles Rationale
1. Oxygen cylinder with stand ,or
central supply oxygen with a
flow meter, humidifier /Wolffs
bottle and connecting.
2. A tray containing:
To deliver oxygen.
To humidify oxygen
3. a) Nasal catheter / canula /
oxygen /flow meter & mask of
an appropriate size clean /
disposable type in a covered
container.
To check the amount of oxygen going
to the patient.
4. b) Water and soluble
lubricating jelly
To lubricate the nasal catheter.
5. c) Adhesive tape To attach the nasal catheter.
6. d) A bowl of water To check oxygen flow.
7. e) Swab sticks and normal
saline in a container.
For cleaning nostrils.
8. 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
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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 Rationale Scientific
PrinciplesNursingPrinciples
Wash hands Reduces transmission of micro-organisms.
Soap and water reduce surface tension
and thus remove dirt and check the
growth of micro-organisms.
Microbiology Safety
Attach canula / catheter mask
to oxygen tubing and
humidified oxygen source
adjusted to the prescribed
flow rate.
Prevents drying of nasal and. oral
mucous membranes and airway
secretions. Use of a humidifier prevents
drying of mucus membranes.
Physics Safety, comfort
Place lips of canula into the
patient's nares. If mask,
apply snuggly to face.
Directs flow of oxygen into the upper
respiratory tract. Prevents loss of
oxygen.
Therapeutic
effectiveness.
Safety,
economy of
Check cannula/equipmcntevery eight hours.
Ensures patency of canula and oxygenflow. Also ensures safe delivery of
prescribed oxygen.
Safety
Keep the humidification jar
filled al all times.
Prevents inhalation of dehumidified
oxygen. Prevents drying of mucus
membranes.
Safety and
therapeutic
effectiveness.
Observe the patient's nares
and superior surface of both
ears and skin breakdown.
Oxygen therapy can dry nasal mucosa.
Pressure on ears from canula
tubing/elastic can cause skin irritation.
Safety, comfort
Check the oxygen flow rate
and the physician's orders
every eight hours.
Ensures delivery of the prescribed oxygen
flow rate.
Safety Therapeutic
effectiveness.
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Wash hands before removing
the oxygen mask pr tube.
Reduces transmission of microorganisms Microbiology. Safely
Inspect the patient for relief
of symptoms associated with
hypoxia.
Indicates that hypoxia is
reduced/treated.
Anatomy and
Physiology
Therapeutic
effectiveness.
Record procedure in the
nurse's notes.
Documents correct use of oxygen therapy
and the patient's response.
Safety, good
workmanship
14. AFTER CARE OF PATIENT AND ARTICLE.
Stay with the child ti ll he/she is at ease.
Keep the child warm and comfortable.
Evaluate the childs 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 withclean 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.
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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.
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Match the correct delivery device with your assessment of the patient:
Device F
low
Concentration Indications Considerations
Cannula 1-6
liters
Low flow
24% -
44%
Use in infants who are
obligatory nose breathers or if
you do not have a correct size
mask
Simple
mask
6-10
liters
Moderate
flow 35% -
60%
Must maintain a minimum of 6
liter flow
Blow by 6-15
liters
Mod. - High
flow Depends
on flow rate
and proximity to
face
Can be used in
all
patients
Use for infants and young
children. Use a simple mask,
corrugated tubing, or 02
tubing threaded through the
bottom of a paper (not
Styrofoam) cup.
Non-
rebreather
--mask
12-15
liters
High flow
80% -
90%
Partial airway
obstruction
Respiratory distress
Inhaled poison
Altered mental
status Shock
Trauma
Bag
Valve Mask
15
liters
High flow
= 90%
Be familiar with the pop-off
valve and manometer port if
present
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NEBULIZATION IN CHILDREN24. INTRODUCTION.
The simplest and most natural route of drug delivery to the lungs is the inhaled one. From the historica
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 ofDaturaferoxto 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.
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d) Physics: Compressor of Nebulizer works on principles of physicsand the nurse here also must
use the body mechanics.
e) Psychology: Nursemust 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 Privacy2. 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.
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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. PREPARE MEDICATION [ Eg. Albeterol 0.3mgto 0.5mg/kg/hour.]
J. 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.
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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. Re-evaluate patient after initial 2 hours for possible decrease in drug dosage level.
l. 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 aithrough a reservoir containing a solution of the bronchodilator drug. Younger children who may find i
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
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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.
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NOTES: Nebulization to emptymay 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. I
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 tha
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 o
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, congenita
anomalies.
PREPARATION OF PATIENT
Anticipation and preparation are very important for effective resuscitation. Anticipation of likelihood o
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
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Supplies
Keeping a newborn baby in a warm environment saves the babys 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 syringeBag 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
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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 mothers abdomen while drying. Keep the baby in direct skin to skin contact maintains warmth and
prevent hypothermia. Clear the airway by wiping the babys 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 babys 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
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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 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 preventaspiration 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 infants 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 infants back
Slapping in back
Squeezing the rib cage
Forcing thigh on abdomen
Using hot or cold compress
Shaking
Using free flow oxygen
Free flow oxygen refers to blowing oxygen over the nose of the baby to enable the baby to breath
oxygen enriched air. This can be done by holding the end of an oxygen tube close to the nose, within a
cupped hand or by holding the oxygen mask over the mouth and nose.
Free flow of oxygen is used when an infant has established regular respirations and the hear
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. Icyanosis persists despite 100% free flow oxygen , a trial of bag and mask ventilation may be
indicated.
Bag and Mask Ventilation
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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 infant with apnea. However, if the infant remains apneic , tactile
stimulation should be abandoned and bag and mask ventilation initiated immediately.
Continued use of tactile stimulation in an infant who does not respond is not warranted and may
be harmful, since valuable time is being wasted.
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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 newborns 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 babys 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 6-
8 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: Dont 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 particula
newborns depends on how well the mask fits to the newborns face will achieve a tight seal between
mask and newborns 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 ai
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 babys 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 babys 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 isindicated 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 neonates
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. Othe
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 breas
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 babys 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
water & warm 30 ml.
3. Take boiled Wati spoon with boiled
water & warm 30 ml
4. Add 1 spoon powder in 30 ml of water
and mix it with spoon evenly.
5. Hold the baby gently in lap. To
stimulation just tap the sole of feet.
6. Elevate 30degree head of baby on our
left hand.
7. Give small quantities & spoon feed to
baby to prevent vomiting
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
by holding in an upright position &
support the head and neck while
gently patting or rubbing the back.
1. To prevent infection
2. Boiled articles to prevent
gastrointestinal infection to baby.
3. Boiled articles to prevent
gastrointestinal infection to baby.
4. to avoid lump of powder becoming &
to prepare proper milk
6. To prevent aspiration & milk while
swallowing
7. to prevent vomiting
8. this provides comfort to the child
9. It helps to prevent the regurgitation
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10. Clean the mouth lips & neck.
11. Place the baby in a bed on the left
lateral si