- Email: [email protected]
More Big Help from Little Tools
PEDIATRIC UPDATE
MORE BIG HELP
FROM
LITTLE TOOLS
Author: Joyce Foresman-Capuzzi, RN, BSN, CEN, CTRN, CPN, CCRN, SANE-A, EMT-P, Wynnewood, PA Section Editors: Donna Ojanen Thomas, RN, MSN, Joyce Foresman-Capuzzi, RN, BSN, CEN, CTRN, CPN, CCRN, SANE-A, EMT-P, and Michelle Tracy, RN, MA, CEN, CPN
Earn Up to 8 CE Hours. See page 271.
C
doi: 10.1016/j.jen.2009.01.001
a diversion and gain cooperation. For example, the nonrebreather oxygen mask can be called a Santa beard and the simple face mask can be called a space mask. Stickers can solve a myriad of problems, and if a scratch and sniff sticker is available, one can allow the child to pick the “flavor,” activate it, and place it on or in the mask. One of the easiest and most efficient ways to provide supplemental oxygen to the child is by using blow-by oxygen. While blow-by oxygen can be administered with the use of a simple mask using high-flow oxygen, it still is an unfamiliar object that the child might resist. Using oxygen tubing and a paper cup will provide the blow-by oxygen in an acceptable way. To use this method, one places one end of the oxygen tubing through the bottom of the paper cup and hooks the other end up to high-flow oxygen at 15 L. The cup now serves as a concentrator for the oxygen, and because it is a familiar object, the child likely will tolerate it being placed close to his or her face. Stickers also can be placed on the inside of the cup. This method should be used as a last resort only if all other methods fail because it does not deliver the highest concentration of oxygen available. To promote regular breathing, assist in providing breathing treatments, and create a diversion, the following items can be used: bubbles, a pinwheel, cotton balls and a straw, and a party blower. These items can be kept in a pediatric diversion box and may be purchased at a dollar store. A good bubble blower blows bubbles slowly though pursed lips, providing his or her own positive end expiratory pressure, and at the same time taking big breaths! The pinwheel can accomplish much of the same effect as bubbles, because it takes a gentle prolonged breath to make the wheels spin. One technique is to have a “race” across the tray table, stretcher, or counter, slowly using the straw to blow the cotton balls across the finish line. Is a chest radiograph needed? Do not forget to send the party blower with the child, who can be coached to take the deep breath needed to inflate the party blower and to hold that breathe so the radiograph can be taken. The child can then surprise the x-ray technician with the party blower noise! One must be careful to supervise children using these objects, because small parts on these objects may create a choking hazard. Use of the standardized color-coded tape system makes the job of caring for the critically ill child accurate and
260
JOURNAL OF EMERGENCY NURSING
aring for pediatric patients can present a challenge even for seasoned pediatric ED nurses. The challenge lies not only in knowing the developmental stages specific to the child but also in gaining trust and cooperation from both the child and his or her family. In a previous article in this column, the basic aspects of pediatric ED care were discussed, such as gaining trust, vital signs, and evaluation. In this article, tips and tricks for respiratory assessment and treatment, successful intravenous access, and medication administration will be presented. Oxygen Administration and Endotracheal Tubes
ED nurses are aware of the importance of the respiratory assessment, especially in the child. Knowing that the child’s condition can quickly deteriorate if respiratory conditions are not recognized, the ED nurse must act quickly to intervene to meet the needs of the child and at the same time gain the parents’ confidence. Here are some tips for administering supplemental oxygen. Because a younger child likely will not know what oxygen is, one can use the term “fresh air,” which is a concept they may understand. It can be described as “fresh air blowing like when the windows are open on a car ride,” which will prepare the child for the unusual sensation of the oxygen coming through the delivery device. Whatever method is ordered to provide supplemental oxygen to the child, the oxygen should be turned on before the device is placed on the child. If nasal prongs are used, the prongs should be lubricated with water-soluble jelly to protect the child’s tender nasal mucosa and make it more comfortable. Finding something playful about the equipment can create Joyce Foresman-Capuzzi is Clinical Nursing Educator, Emergency Department, The Lankenau Hospital, Wynnewood, PA. For correspondence, write: Joyce Foresman-Capuzzi, RN, BSN, CEN, CTRN, CPN, CCRN, SANE-A, EMT- P, Emergency Department, The Lankenau Hospital, 100 Lancaster Ave, Wynnewood, PA 19096; E-mail: [email protected]. J Emerg Nurs 2009;35:260-2. Available online 17 March 2009. 0099-1767/$36.00 © 2009 Emergency Nurses Association. Published by Elsevier. All rights reserved.
35:3 May 2009
PEDIATRIC UPDATE/Foresman-Capuzzi
safe. All ED nurses should be sure they know how to use it and where to look on the tape for specific help. It helps to remember the saying “red to the head” when placing the tape next to the patient. The insertion length of the endotracheal tube (ETT) is 3 times its size. If the ETT is 3 mm, than the insertion length is 9 cm, and if the ETT size is 4 mm, than the insertion length is 12 cm. Equally as important is knowing what size suction catheter will fit down that small ETT. To determine what catheter to use, the size of the endotracheal tube should be doubled, which provides the size of the suction catheter needed. For example, a 5-mm ETT will require a 10-French suction catheter, and a 3-mm ETT will require a 6-French suction catheter. Intravenous Access
One of the most challenging procedures nurses are asked to perform on a child is to obtain intravenous access for infusion. Because some medical terminology is unfamiliar to even the adult, the medical language may need to be translated into something the child and family can understand. One should keep in mind that the active and creative mind of the child allows for misinterpretations to abound (Table). Because “IV” may sound like the ivy out in the garden, one can describe it as “a little straw” and show the patient the catheter without the needle in it. Before starting the intravenous line, one should determine which is the dominant hand, so the child is still able to use that hand; this determination is especially important in children who suck their thumbs, because they will use that hand to comfort themselves. When it is necessary to find that illusive vein, one technique is to use a dry washcloth that has been kept in the blanket warmer: Wrap the extremity in the warm washcloth, place a disposable pad or diaper around it, and observe carefully. When it is necessary to gauge if something is too hot for use on a child, apply this rule of thumb: If you cannot hold it in your hand and wring it out without discomfort, it is too hot for a child. Commercial transillumination devices also are very helpful (but expensive) in finding a vein. Because the child’s vein has such a small diameter, inserting the needle bevel down may help prevent it from going through the opposite side of the vein wall. One must remember to advance the catheter very slowly and pause when entering the vein. The small size of the intravenous catheter and the small size of the vein chosen may preclude an immediate flash of blood. It is necessary to be patient before deciding that repositioning is needed. One rule should be to never allow someone to try more than 2 unsuccessful sticks. It is better to let someone else try than
May 2009 35:3
TABLE
ED words that can confuse children Word
Possible interpretation
Shot
A shot has to do with guns, and they kill! Sticks are out in the yard and can poke! My grandpa is gonna die. Ivy grows in our yard. My doggie got put to sleep and didn’t come back. I don’t want to lie on the floor. That stuff makes our car run. My kitty scratches me. I don’t want to pick you. I don’t want her to pick me. Why do they want to take little seats from me? You’re in test? I don’t like tests. I didn’t study! I don’t want you to take anything of mine. Will you give it back?
Little stick Dye IV Go to sleep Go to the floor You’ll be given gas CAT scan PICU Stool sample Urine test Test Take your ____
to lose one’s confidence after being unsuccessful. It also is helpful to keep in mind that certain intraosseous devices, such as the drill type, can be used on conscious patients of any age when intravenous access is difficult.1 Securing the intravenous line is crucial after successfully gaining access. When extra protection may be needed to protect the site from being bumped and a commercial device is not available to provide a firm covering on top, one can be made by using scissors to cut a plastic medicine cup in half lengthwise. The edges should be taped for comfort and the halved cup placed over the top of the intravenous line. This device will provide protection while allowing the site to be visualized and can be described as a little “house for the straw.” A clear dressing may be used to secure the intravenous line. Coverings or dressings that do not permit checking the site for infiltration or redness should never be used. Medication and Oral Fluid Administration
How many ED nurses wish that Mary Poppins were available with her spoonful of sugar to help the medicine go down? Here are some tips that can be pulled out of your carpetbag that might even rival Mary Poppins’ tricks. If the
JOURNAL OF EMERGENCY NURSING
261
PEDIATRIC UPDATE/Foresman-Capuzzi
child is not on “nothing by mouth” status and it is cleared with the ordering practitioner, taste buds can be numbed prior to administration with ice water or a Popsicle and the medication followed with a chaser of the same. If cleared by pharmacy, medications can be served cold to help hide the bad taste. Conversely, eye drops and ear drops are better tolerated when warmed, because even room-temperature drops can feel uncomfortable when instilled. If this order is anticipated early, the eye or ear drops can be carried in a pocket to help to warm them to a comfortable temperature. Drops should never be warmed in a microwave—one’s hands can be used to warm them. Safe nursing care is important when caring for all patients. When preparing to administer a suspension or elixir, an oral syringe specifically designed for this purpose should be used both to measure and administer the medication. A standard parenteral syringe should never be used because of the danger of inadvertently administering it intravenously. A parent should never be given a syringe meant for intravenous or intramuscular medication to take home because the cap of the syringe can easily be aspirated. The syringes designed for oral medication usage should always be used. A supply of crazy straws can make a “by mouth” challenge easier. What child wouldn’t enjoy watching their juice or electrolyte solution come through the silly shape and likely increase their intake? These fun straws also make it easier when giving medication or computed tomography contrast. Having a timed contest to beat the clock by drawing lines on the drinking cup may help motivate the reluctant drinker. If a small reward is not available to provide to the child, allowing the child the pleasure of assigning something extra silly for his or her ED nurse to do might just prove to be the needed motivator. It may not be out of the realm of possibility for the nurse and patient to even share a little tea party to get that liquid into the child’s belly. Sometimes the nurse just has to have the mantra, “whatever it takes”! Psychobiologist Roger W. Sperry developed the concept of right and left brain thinking.2 The right brain is considered visual and processes information in an intuitive and simultaneous way, looking first at the whole picture and then the details. Many artists and musicians possess dominance in this area. The left side of the brain is considered verbal and processes information in an analytical and
262
sequential way, looking first at the pieces then putting them together to get the whole; many scientists and lawyers fall into this category (see the Web site NobelPrize.org). ED nurses must develop and foster both hemispheres of their brain to provide holistic care and meet the needs of all patients. While the precise and logical nurse is crucial to provide swift and accurate care to the child, the creative and playful nurse is equally as important to meet the smallest patients in a way that gains their trust and develops that unique and special relationship distinctive to the emergency department. (As always, check with your nursing department, medical director, and the hospital’s policies and procedures before using any of these tips and tricks). REFERENCES 1. Vidacare. IO access in the hospital setting. Available at: http:// www.vidacare.com/ez-io/hospital/ed-critical-care.html. Accessed December 8, 2008. 2. Sperry RW. Some effects of disconnecting the cerebral hemispheres. Available at: http://nobelprize.org/nobel_prizes/medicine/ laureates/1981/sperry-lecture.html. Accessed November 15, 2008.
SUGGESTED READING Aehlert B. Comprehensive pediatric emergency care (revised reprint). St. Louis: Mosby/JEMS; 2006. Emergency Nurses Association. Emergency nurse pediatric course. 3rd ed. Des Plaines (IL): The Association. Hockenberry MJ. Wong’s nursing care of infants and children. St. Louis: Mosby; 2006. Thomas DO. Core curriculum for pediatric emergency nursing. Sudbury (MA): Jones and Bartlett; 2003.
Submissions to this column are encouraged and may be sent to Donna Ojanen Thomas, RN, MSN [email protected] or Joyce Foresman-Capuzzi, RN, BSN, CEN, CTRN, CPN, CCRN, SANE-A, EMT-P [email protected] or Michelle Tracy, RN, MA, CEN, CPN [email protected]
JOURNAL OF EMERGENCY NURSING
35:3 May 2009
MORE BIG HELP
FROM
LITTLE TOOLS
Author: Joyce Foresman-Capuzzi, RN, BSN, CEN, CTRN, CPN, CCRN, SANE-A, EMT-P, Wynnewood, PA Section Editors: Donna Ojanen Thomas, RN, MSN, Joyce Foresman-Capuzzi, RN, BSN, CEN, CTRN, CPN, CCRN, SANE-A, EMT-P, and Michelle Tracy, RN, MA, CEN, CPN
Earn Up to 8 CE Hours. See page 271.
C
doi: 10.1016/j.jen.2009.01.001
a diversion and gain cooperation. For example, the nonrebreather oxygen mask can be called a Santa beard and the simple face mask can be called a space mask. Stickers can solve a myriad of problems, and if a scratch and sniff sticker is available, one can allow the child to pick the “flavor,” activate it, and place it on or in the mask. One of the easiest and most efficient ways to provide supplemental oxygen to the child is by using blow-by oxygen. While blow-by oxygen can be administered with the use of a simple mask using high-flow oxygen, it still is an unfamiliar object that the child might resist. Using oxygen tubing and a paper cup will provide the blow-by oxygen in an acceptable way. To use this method, one places one end of the oxygen tubing through the bottom of the paper cup and hooks the other end up to high-flow oxygen at 15 L. The cup now serves as a concentrator for the oxygen, and because it is a familiar object, the child likely will tolerate it being placed close to his or her face. Stickers also can be placed on the inside of the cup. This method should be used as a last resort only if all other methods fail because it does not deliver the highest concentration of oxygen available. To promote regular breathing, assist in providing breathing treatments, and create a diversion, the following items can be used: bubbles, a pinwheel, cotton balls and a straw, and a party blower. These items can be kept in a pediatric diversion box and may be purchased at a dollar store. A good bubble blower blows bubbles slowly though pursed lips, providing his or her own positive end expiratory pressure, and at the same time taking big breaths! The pinwheel can accomplish much of the same effect as bubbles, because it takes a gentle prolonged breath to make the wheels spin. One technique is to have a “race” across the tray table, stretcher, or counter, slowly using the straw to blow the cotton balls across the finish line. Is a chest radiograph needed? Do not forget to send the party blower with the child, who can be coached to take the deep breath needed to inflate the party blower and to hold that breathe so the radiograph can be taken. The child can then surprise the x-ray technician with the party blower noise! One must be careful to supervise children using these objects, because small parts on these objects may create a choking hazard. Use of the standardized color-coded tape system makes the job of caring for the critically ill child accurate and
260
JOURNAL OF EMERGENCY NURSING
aring for pediatric patients can present a challenge even for seasoned pediatric ED nurses. The challenge lies not only in knowing the developmental stages specific to the child but also in gaining trust and cooperation from both the child and his or her family. In a previous article in this column, the basic aspects of pediatric ED care were discussed, such as gaining trust, vital signs, and evaluation. In this article, tips and tricks for respiratory assessment and treatment, successful intravenous access, and medication administration will be presented. Oxygen Administration and Endotracheal Tubes
ED nurses are aware of the importance of the respiratory assessment, especially in the child. Knowing that the child’s condition can quickly deteriorate if respiratory conditions are not recognized, the ED nurse must act quickly to intervene to meet the needs of the child and at the same time gain the parents’ confidence. Here are some tips for administering supplemental oxygen. Because a younger child likely will not know what oxygen is, one can use the term “fresh air,” which is a concept they may understand. It can be described as “fresh air blowing like when the windows are open on a car ride,” which will prepare the child for the unusual sensation of the oxygen coming through the delivery device. Whatever method is ordered to provide supplemental oxygen to the child, the oxygen should be turned on before the device is placed on the child. If nasal prongs are used, the prongs should be lubricated with water-soluble jelly to protect the child’s tender nasal mucosa and make it more comfortable. Finding something playful about the equipment can create Joyce Foresman-Capuzzi is Clinical Nursing Educator, Emergency Department, The Lankenau Hospital, Wynnewood, PA. For correspondence, write: Joyce Foresman-Capuzzi, RN, BSN, CEN, CTRN, CPN, CCRN, SANE-A, EMT- P, Emergency Department, The Lankenau Hospital, 100 Lancaster Ave, Wynnewood, PA 19096; E-mail: [email protected]. J Emerg Nurs 2009;35:260-2. Available online 17 March 2009. 0099-1767/$36.00 © 2009 Emergency Nurses Association. Published by Elsevier. All rights reserved.
35:3 May 2009
PEDIATRIC UPDATE/Foresman-Capuzzi
safe. All ED nurses should be sure they know how to use it and where to look on the tape for specific help. It helps to remember the saying “red to the head” when placing the tape next to the patient. The insertion length of the endotracheal tube (ETT) is 3 times its size. If the ETT is 3 mm, than the insertion length is 9 cm, and if the ETT size is 4 mm, than the insertion length is 12 cm. Equally as important is knowing what size suction catheter will fit down that small ETT. To determine what catheter to use, the size of the endotracheal tube should be doubled, which provides the size of the suction catheter needed. For example, a 5-mm ETT will require a 10-French suction catheter, and a 3-mm ETT will require a 6-French suction catheter. Intravenous Access
One of the most challenging procedures nurses are asked to perform on a child is to obtain intravenous access for infusion. Because some medical terminology is unfamiliar to even the adult, the medical language may need to be translated into something the child and family can understand. One should keep in mind that the active and creative mind of the child allows for misinterpretations to abound (Table). Because “IV” may sound like the ivy out in the garden, one can describe it as “a little straw” and show the patient the catheter without the needle in it. Before starting the intravenous line, one should determine which is the dominant hand, so the child is still able to use that hand; this determination is especially important in children who suck their thumbs, because they will use that hand to comfort themselves. When it is necessary to find that illusive vein, one technique is to use a dry washcloth that has been kept in the blanket warmer: Wrap the extremity in the warm washcloth, place a disposable pad or diaper around it, and observe carefully. When it is necessary to gauge if something is too hot for use on a child, apply this rule of thumb: If you cannot hold it in your hand and wring it out without discomfort, it is too hot for a child. Commercial transillumination devices also are very helpful (but expensive) in finding a vein. Because the child’s vein has such a small diameter, inserting the needle bevel down may help prevent it from going through the opposite side of the vein wall. One must remember to advance the catheter very slowly and pause when entering the vein. The small size of the intravenous catheter and the small size of the vein chosen may preclude an immediate flash of blood. It is necessary to be patient before deciding that repositioning is needed. One rule should be to never allow someone to try more than 2 unsuccessful sticks. It is better to let someone else try than
May 2009 35:3
TABLE
ED words that can confuse children Word
Possible interpretation
Shot
A shot has to do with guns, and they kill! Sticks are out in the yard and can poke! My grandpa is gonna die. Ivy grows in our yard. My doggie got put to sleep and didn’t come back. I don’t want to lie on the floor. That stuff makes our car run. My kitty scratches me. I don’t want to pick you. I don’t want her to pick me. Why do they want to take little seats from me? You’re in test? I don’t like tests. I didn’t study! I don’t want you to take anything of mine. Will you give it back?
Little stick Dye IV Go to sleep Go to the floor You’ll be given gas CAT scan PICU Stool sample Urine test Test Take your ____
to lose one’s confidence after being unsuccessful. It also is helpful to keep in mind that certain intraosseous devices, such as the drill type, can be used on conscious patients of any age when intravenous access is difficult.1 Securing the intravenous line is crucial after successfully gaining access. When extra protection may be needed to protect the site from being bumped and a commercial device is not available to provide a firm covering on top, one can be made by using scissors to cut a plastic medicine cup in half lengthwise. The edges should be taped for comfort and the halved cup placed over the top of the intravenous line. This device will provide protection while allowing the site to be visualized and can be described as a little “house for the straw.” A clear dressing may be used to secure the intravenous line. Coverings or dressings that do not permit checking the site for infiltration or redness should never be used. Medication and Oral Fluid Administration
How many ED nurses wish that Mary Poppins were available with her spoonful of sugar to help the medicine go down? Here are some tips that can be pulled out of your carpetbag that might even rival Mary Poppins’ tricks. If the
JOURNAL OF EMERGENCY NURSING
261
PEDIATRIC UPDATE/Foresman-Capuzzi
child is not on “nothing by mouth” status and it is cleared with the ordering practitioner, taste buds can be numbed prior to administration with ice water or a Popsicle and the medication followed with a chaser of the same. If cleared by pharmacy, medications can be served cold to help hide the bad taste. Conversely, eye drops and ear drops are better tolerated when warmed, because even room-temperature drops can feel uncomfortable when instilled. If this order is anticipated early, the eye or ear drops can be carried in a pocket to help to warm them to a comfortable temperature. Drops should never be warmed in a microwave—one’s hands can be used to warm them. Safe nursing care is important when caring for all patients. When preparing to administer a suspension or elixir, an oral syringe specifically designed for this purpose should be used both to measure and administer the medication. A standard parenteral syringe should never be used because of the danger of inadvertently administering it intravenously. A parent should never be given a syringe meant for intravenous or intramuscular medication to take home because the cap of the syringe can easily be aspirated. The syringes designed for oral medication usage should always be used. A supply of crazy straws can make a “by mouth” challenge easier. What child wouldn’t enjoy watching their juice or electrolyte solution come through the silly shape and likely increase their intake? These fun straws also make it easier when giving medication or computed tomography contrast. Having a timed contest to beat the clock by drawing lines on the drinking cup may help motivate the reluctant drinker. If a small reward is not available to provide to the child, allowing the child the pleasure of assigning something extra silly for his or her ED nurse to do might just prove to be the needed motivator. It may not be out of the realm of possibility for the nurse and patient to even share a little tea party to get that liquid into the child’s belly. Sometimes the nurse just has to have the mantra, “whatever it takes”! Psychobiologist Roger W. Sperry developed the concept of right and left brain thinking.2 The right brain is considered visual and processes information in an intuitive and simultaneous way, looking first at the whole picture and then the details. Many artists and musicians possess dominance in this area. The left side of the brain is considered verbal and processes information in an analytical and
262
sequential way, looking first at the pieces then putting them together to get the whole; many scientists and lawyers fall into this category (see the Web site NobelPrize.org). ED nurses must develop and foster both hemispheres of their brain to provide holistic care and meet the needs of all patients. While the precise and logical nurse is crucial to provide swift and accurate care to the child, the creative and playful nurse is equally as important to meet the smallest patients in a way that gains their trust and develops that unique and special relationship distinctive to the emergency department. (As always, check with your nursing department, medical director, and the hospital’s policies and procedures before using any of these tips and tricks). REFERENCES 1. Vidacare. IO access in the hospital setting. Available at: http:// www.vidacare.com/ez-io/hospital/ed-critical-care.html. Accessed December 8, 2008. 2. Sperry RW. Some effects of disconnecting the cerebral hemispheres. Available at: http://nobelprize.org/nobel_prizes/medicine/ laureates/1981/sperry-lecture.html. Accessed November 15, 2008.
SUGGESTED READING Aehlert B. Comprehensive pediatric emergency care (revised reprint). St. Louis: Mosby/JEMS; 2006. Emergency Nurses Association. Emergency nurse pediatric course. 3rd ed. Des Plaines (IL): The Association. Hockenberry MJ. Wong’s nursing care of infants and children. St. Louis: Mosby; 2006. Thomas DO. Core curriculum for pediatric emergency nursing. Sudbury (MA): Jones and Bartlett; 2003.
Submissions to this column are encouraged and may be sent to Donna Ojanen Thomas, RN, MSN [email protected] or Joyce Foresman-Capuzzi, RN, BSN, CEN, CTRN, CPN, CCRN, SANE-A, EMT-P [email protected] or Michelle Tracy, RN, MA, CEN, CPN [email protected]
JOURNAL OF EMERGENCY NURSING
35:3 May 2009