INTRAMUSCULAR INJECTION

Introduction An intramuscular (IM) injection is the preferred route of administering medication when
fairly rapid-acting and long-lasting dosage of medication is required. Some medications that are irritating
to the subcutaneous tissue may be given into the deep muscle tissue. Injection of medication into muscle
tissue forms a deposit of medication that is absorbed gradually into the bloodstream. An intramuscular
injection is the safest, easiest, and best tolerated of the injection routes.

Definition

An intramuscular injection is an injection given directly into the central area of a specific muscle. In this
way, the blood vessels supplying that muscle distribute the injected medication via the cardiovascular
system.

Purpose

Intramuscular injection is used for the delivery of certain drugs not recommended for other routes of
administration, for instance intravenous, oral, or subcutaneous.

 The intramuscular route offers a faster rate of absorption than the subcutaneous route, and
muscle tissue can often hold a larger volume of fluid without discomfort.
 Medication injected into muscle tissues is absorbed less rapidly and takes effect more.
 slowly that medication that is injected intravenously.
 This is favorable for some medications which can’t be given by any other route.

Description of muscles:

Intramuscular (IM) injections are given directly into the central area of selected muscles. There
are a number of sites on the human body that are suitable for IM injections; however, there are
three sites that are most commonly used in this procedure.

Deltoid muscle

Originating from the Acromion process of the scapula and inserting approximately one-third of
the way down the humerus, the deltoid muscle can be used readily for IM injections if there is
sufficient muscle mass to justify use of this site.
 The deltoid's close proximity to the radial nerve and radial artery means that careful
consideration and palpation of the muscle is required to find a safe site for penetration of the
needle. There are various methods for defining the boundaries of this muscle.

Vastus lateralis muscle

The vastus lateralis muscle forms part of the quadriceps muscle group of the upper leg and can
be found on the anteriolateral aspect of the thigh. This muscle is more commonly used as the site
for IM injections as it is generally thick and well formed in individuals of all ages and is not
located close to any major arteries or nerves.

It is also readily accessed. The middle third of the muscle is used to define the injection site. This
third can be determined by visually dividing the length of the muscle that originates on the
greater trochanter of the femur and inserts on the upper border of the patella and tibial tuberosity
through the patella ligament into thirds. Palpation of the muscle is required to determine if
sufficient body and mass is present to undertake the procedure.

Gluteus medius muscle

The gluteus medius muscle, which is also known as the ventrogluteal site, is the third commonly
used site for IM injections. The correct area for injection can be determined in the following
manner. Place the heel of the hand of the greater trochanter of the femur with fingers pointing
towards the patient's head. The left hand is used for the right hip and vice versa. While keeping
the palm of the hand over the greater trochanter and placing the index finger on the anterior
superior iliac spine, stretch the middle finger dorsally palpating for the iliac crest and then press
 lightly below this point. The triangle formed by the iliac crest, the third finger and index finger
forms the area suitable for intramuscular injection.

Determining which site is most appropriate will depend upon the patient's muscle density at each
site, the type and nature of medication you wish to administer, and of course the patient's
preferred site for injections.

Articles used for intramuscular injection

S. no. Equipment Rationale

1. 1,3 & 5 cc disposable syringes

2. 22g-25g 7/8" & 1" needles *

3. Plastic aprons

4. Medication

5. Medication storage cold pack

6. Alcohol swabs

7. Barrier fields
Sharps container

8. Immunization health record

9. Personal record of immunization

10. Information sheets for specific

medications

11. Hand wipes

Procedure
 Steps of procedure Rationale

1) Check immunization record for name, date of Verifies identity of client and allows for
birth, address and telephone number. updating of information.

2) Explain the risks and benefits of immunization, Fulfills the requirement

including minor and serious reactions that may for informed consent. provides an
occur. opportunity for discussion of appropriate
treatment for any reactions.

3) Obtain and record the immunization history, and Provides the opportunity for reviewing
screen for the present procedure. medical history, including previous
immunization history.

4) Verify or obtain dated consent.

5) Arrange equipment on a barrier field, placed out

of child's reach.

6) Check anaphylaxis kit, noting appropriate doses Noting the appropriate dose of adrenalin
for person to be immunized. saves time if the dose is required.

7) Wash hands. if in a group setting a hand wipe or

sanitizer may be used.

8) Check medication product for expiry date, label, Medication that is outdated or that looks
amount and appearance. unusual in terms of color, clarity or
consistency may not be fully potent and
should not be used. medication without a
clearly marked lot number should not be
used.

9) Draw up medication as per specific product

instructions.

10) Select a site for injection. if this is not the first Rotating the injection site minimizes the
immunization, choose the limb opposite the site of trauma to muscle.
the previous injection.

 In a child aged up to and including eighteen
months, use the vastus lateralis muscle of
the anterior thigh.
 In a child of eighteen months the deltoid is
an alternate site.
 For older children, teens and adults,
the deltoidmuscle is a suitable site.
This muscle is large and well developed.
it is accessible, free of major nerves and
blood vessels and can readily adsorb
medication.
Deltoid muscle injection in this age
group may prevent pain that is associated
with walking after a vastus lateralis
injection.
AFTER-CARE

Monitor for signs of localized redness, swelling, bleeding, or inflammation at injection site. Observe the
patient for at least 15 minutes following the injection for signs of reaction to the drug.

COMPLICATIONS

Most complications of intramuscular injections are a result of the drug injected and not the procedure.
However, it is possible that localized trauma of the injection site may result as part of the process. Minor
discomfort and pain is common for a short period following the injection, but usually resolves within a few
hours.

Health care team roles

The health care provider is obliged to undertake the following when administering an intramuscular injection:

 Inform and educate the patient on the need and effect of the medication being delivered.
 Ensure the correct identification and verification procedures are followed.
 Provide privacy for the patient during the procedure.
 Understand the theory behind selecting appropriate injection sites.
 Demonstrate correct technique when undertaking the procedure.
 Monitor for complications.
 Document all relevant information and ensure safe disposal of equipment.

Resources

Elkin M.K., Perry A.G., and Potter P.A. Nursing interventions and clinical skills. Missouri: Mosby-inc.,1996.

Kozier B., et al. Techniques in clinical nursing. Canada: Addison-Wesley Nursing, 1993.

Dean Andrew Bielanowski, R.N.

 INTRAVENOUS INJECTION

DEFINITION:

Intravenous injection or iv injection is the giving of liquid substances directly into a vein. The word
intravenous simply means "within a vein", but is most commonly used to refer to iv therapy.

Compared with other routes of administration, the intravenous route is one of the fastest ways to deliver fluids
and medications throughout the body. Some medications, as well as blood transfusions and lethal injections,
can only be given intravenously.

PURPOSE:

 For instilling a single dose of medication

 For injecting a contrast medium,
 For beginning an iv infusion of blood, medication, or a fluid solution, such as saline or dextrose in
water.

ADVANTAGES

There are a variety of reasons why drugs would be injected rather than taken through other methods.

 Increased effect — injecting a drug intravenously means that more of the drug will reach the brain
quicker. This also means that the drug will have a very strong and rapid onset (or rush).
 More efficient usage — injection ensures that all of the drug will be absorbed.
 Bypasses the digestive system — some people with sensitive stomachs find it very unpleasant to
swallow drugs because of persistent cramps or nausea.
 Does not harm the lungs or mucous membranes — the mucous membranes can be permanently
damaged by habitual insufflation (snorting), and the lungs can be damaged by smoking.

Disadvantages

 Increased chance of blood-borne infection — This is generally a twofold problem. One is needle
sharing which transmits blood-borne diseases between users and the other is secondary infection of
injection sites caused by lack of hygiene and failure to rotate the injection site. In addition, the use of
cotton to filter some drugs can lead to cotton fever.
  Increased chance of overdose — Because iv injection delivers a dose of drug straight into the
bloodstream it is harder to gauge how much to use (as opposed to smoking or snorting where the dose
can be increased incrementally until the desired effect is achieved). In addition, because of the rapid
onset, overdose can occur very quickly, requiring immediate action.
 Scarring of the peripheral veins — This arises from the use of blunt injecting equipment. This is
particularly common with users who have been injecting while in jail and re-use disposable syringes
sometimes hundreds of times. Iv drug use for an extended period may result in collapsed veins.
Though rotating sites and allowing time to heal before reuse may decrease the likelihood of this
occurring, collapse of peripheral veins may still occur with prolonged iv drug use. iv drug users are
among the most difficult patient populations to obtain blood-specimens from because of peripheral
venous scarring. The darkening of the veins due to scarring and toxin buildup produce tracks along
the length of the veins and are known as track marks.
 Increased chance of addiction — The heightened effect of administering drugs intravenously can
make the chances of addiction more likely.
 Needle phobia — Quite a number of people have an intense aversion to needles which, in extreme
cases, is called trypanophobia and can make them feel nauseous or faint.
 Social stigma — In many societies there is a social stigma attached to iv drug use, in addition to the
more general stigma around illegal drug use and addiction. Many people feel that it is somehow
"unclean" to take drugs in such a manner, even though they may be perfectly comfortable taking them
by another route. This may be because of its common use in inner cities and with lower-income
people.

Articles:

S. no. Equipment Rationale

1. 1,3 & 5 cc disposable syringes

2. 22g-25g 7/8" & 1" needles *

3. Plastic aprons

4. Medication

5. Tournique

6. Medication storage cold pack

7. Alcohol swabs

8. Barrier fields
Sharps container

9. Immunization health record

 10. Personal record of immunization

11. Information sheets for specific

medications

12. Hand wipes

Procedure
S. no Steps of procedure Rationale
1. Wash hands and injection site with
antibacterial soap.

2. Clean injection site with isopropyl alcohol.

3. Wrap the tourniquet around your arm just

above the injection site.

4. Insert the needle at a 45 degree angle with the

vein. Inject with the flow of the vein (which
flows towards the heart). if you are hitting a
vein in your arm, the needle will point towards
the elbow

5. Pull back the plunger slightly to test for blood.

If there is no blood, pull it out - you missed. If
the blood is bright red, foamy, and has
considerable pressure behind it, pull out and
apply direct pressure - you hit an artery, you
don't want it there. (hitting an artery is
generally unlikely unless you are going for
deep veins.)
6.
If the blood is dark, you're there.

7. Remove the tourniquet. Injecting while a

tourniquet is tied will cause too much pressure
to build and may cause the vein to burst.

8 Slowly push in plunger and administer

chemical.

9. Pull out and apply pressure with clean gauze.

 10.
Keeping wound above heart will facilitate
clotting and minimize bruising.

References

1. Strang J, Keaney F, Butterworth G, Noble A, Best D (April 2001). "Different forms of heroin and
their relationship to cook-up techniques: Data on, and explanation of, use of lemon juice and other
acids". subst use misuse 36 (5): 573–88. Doi:10.1081/ja-100103561. pmid 11419488.
2. Helen Ogden-Grable; Gary W. Gill (2005-08-17). "Selecting the venipuncture site". American
Society for Clinical Pathology. 4. http://www.medscape.com/viewarticle/509098_4. Retrieved on
2008-12-22.
3. Mathers BM, Degenhardt I, Phillips B, et al. (November 2008). "Global epidemiology of injecting
drug use and HIV among people who inject drugs: A systematic review". Lancet 372 (9651): 1733–
45. doi:10.1016/s0140-6736(08)61311-2. pmid 18817968
 INSERTION OF PERIPHERAL IV LINE

Introduction:
This is the most common intravenous access method in both hospitals and pre-hospital services. A peripheral
iv line consists of a short catheter (a few centimeters long) inserted through the skin into a peripheral vein,
any vein that is not in the chest or abdomen.

Aims
1) To gain peripheral venous access in order to:
i. administer fluids
ii. administer blood products, medications and nutritional components
2) To minimize the risk of complications when initiating iv therapy through:
i. judicious choice of equipment
ii. careful choice of iv site
iii. good insertion technique
iv. aseptic preparation of infusions

Sites used for peripheral iv line:

 Arm and hand veins are typically

 Leg and foot veins are occasionally used.
 Veins in the arm are the common site in emergency
settings, commonly performed by paramedics and emergency physicians.
 On infants the scalp veins are sometimes used.

Key points
o Only nurses who have been certified as competent in the insertion of iv cannulla will perform
this procedure.
o Where the patient is less than 14 years of age, the iv cannulla will be inserted by a medical
practitioner. the exception will be in the case of neonates where neonatal trained nurses may
insert an iv cannulla if directed by a medical officer
o In the case of two unsuccessful attempts at insertion, the operator will seek the assistance of
 another experienced nurse for one additional attempt. after a total three unsuccessful attempts
the assistance of a medical practitioner will be sought.

Selection o*f equipment

1) Cannulla selection

1. Select cannula based on purpose and duration of use, and age of patient.
2. Consider risk of infection and extravasation.
3. Cannulae made from polyurethanes are associated with decreased risk of phlebitis2,3
4. Steel needles have higher risk of extravasation and should be avoided where tissue necrosis is likely if
extravasation occurs

2)Skin preparation
1. Antiseptic solution - 70% isopropyl alcohol, 0.5 - 1% chlorhexidine5
2. Use an aqueous based alternative if there is a known allergy to alcohol

3)Other required equipment

1. Intravenous solution as ordered
2. Tourniquet
3. Giving set
4. Iv stand/pole
5. Infusion pump
6. Transparent occlusive dressing (e.g. iv 2000®)6
7. Micropore, silk tape or similar to secure cannula
8. Gloves
9. Paper bag

4)Additional equipment which may be required

1. Syringe (5 ml)
2. Non bevelled drawing up needle
3. Needles (21g & 25g)
4. Sterile sodium chloride 0.9%
5. Local anaesthetic for use by medical officer (e.g. 1% lignocaine)
6. 3-way tap or triflow
7. Short extension tube

For pediatric patients

Splint and tape (to secure splint)
 Emla®*
  Burette
 Transparent tape for a child less than 12 months of age
Eutetic mixture of local anaesthetic* (emla®)
1. Emla cream can usually make the insertion of a central or peripheral intravenous cannulla or scalp
vein needle painless. The use of emla however requires planning as the cream must be applied at least
one hour and preferably one and a half hours before the proposed procedure. it is therefore suitable
for elective procedures but not for emergencies.
2. Emla will be effective for up to four hours from the time of application, and penetration may continue
for 30 minutes after removal.
3. Emla is not recommended for infants under 3 months of age. premature infants should be at least 52
weeks post conception before the use of emla cream is considered.

Selection of catheter site

 Choose a suitable vein, use long straight veins in an upper extremity & away from the joints for
catheter insertion - in preference to sites on the lower extremities. If possible avoid veins in the
dominant hand and use distal veins first.
Do not insert cannula on the side of mastectomy or av shunts.Ttransfer catheter inserted in a lower
extremity site to an upper extremity site as soon as the latter is available.

In paediatric patients, it is recommended that the cannula be inserted into the scalp, hand, or foot site in
preference to a leg, arm, or ante cubital fossa site .

Procedure

Steps of procedure Rationale

1) Explain procedure to patient/parent Strict adherence to hand washing and
2) Wash hands with antiseptic soap. aseptic technique remains the
3) Don gloves cornerstone of prevention of cannulla
4) Apply the tourniquet above insertion site for related infections.
paediatric patient, an assistant's hand used both as a
tourniquet and restraint is often more acceptable to a
child than a tourniquet.
5) Disinfect the selected site with skin prep and allow to
dry.
6) Do not touch the skin with the fingers after
preparation solution has been applied.
7) If infiltration of local analgesia is required, inject
lignocaine 1% at the proposed site of entry of
cannula.lignocaine may only be injected by a medical
officer
8) Inspect the cannula before insertion to ensure that the
needle is fully inserted into the plastic cannula and
that the cannula tip is not damaged.
9) Do not touch the shaft or tip of the cannula.
10) Ensure the bevel of the cannula is facing upwards.
11) Facilitates the piercing of the skin by the bevel.
12) Insert the needle and the cannula into the vein.
13) Gentle traction on skin may stabilise the vein under
the skin
14) Partially withdraw the needle and advance the
cannula.
15) Release the tourniquet
16) Secure the hub of the cannula with clean adhesive
tape.

17) Do not cover the puncture site. cut tape immediately

prior to use only.
18) Flush the cannula with normal saline ensures the line
is patent and accessible
19) Cover the intravenous and surrounding area with a
sterile transparent dressing.
20) Ensure that the insertion site and the area proximal to
the site are visible for inspection purposes.
21) If infusion ordered, prime the line and connect the
intravenous giving set to the cannulla
22) Note the date and time of insertion in the patient's
medical record.
23) Record date of line change and secure to iv line
24) Intravenous lines used for intermittent infusions must
be labelled with the patient’s name, and the date and
time of commencement
25) If the site needs to be immobilised, use a well
padded splint and strapping if necessary. for infants
<12 months, a transparent tape must be used.
If a bandage is used, apply it at each end of splint so
that the central area is lightly covered for easy
inspection.
conform bandages to secure the splint are available
for paediatric patients if required
26) Dispose of equipment safely
DOCUMENTATION

On insertion of each peripheral iv, the name of doctor inserting the iv, documents the following in the
progress notes:

o insertion date
o time
o site

Check and document the following on the fluid balance chart hourly:

o peripheral iv site - document any signs of phlebitis in the progress notes or clinical pathway
o pump pressures for each iv line
o infused volume
o syringe pumps are checked at the syringe and the pump

Changing cannulas:

 There is no evidence to recommend regularly re-setting iv cannulas in children as is the practice in

adults.
 Cannulas only need to be replaced when they fall out, show signs of phlebitis or become blocked.

Removal of iv cannulla:

 Wearing non-sterile gloves, carefully remove the dressing and cannula;

 If scissors are required to remove the dressing, only blunt-end scissors may be used.
 Apply gauze or cotton wool to prevent bleeding;
 Cover site with cotton wool and tape or band-aid;

COMPLICATIONS

Phlebitis
 Contributing factors
• catheter material
• catheter size
• site of insertion
• skill of operator
• duration of cannula
• type of infusion
• rate of infusion
• dilution of solution
• frequency of dressing change
• presence of infection
• type of skin prep
 • host factors

Infection
 Contributing factors
• contaminated infusions
• inadequate skin preparation
• poor technique
• host factors

Extravasation
 Contributing factors
• age
• site of cannulla
• type of cannulla
• duration of cannulla
• iv drug infusions

REFERENCES
 Maki DG. Ringer M. 1991. Risk factors for infusion-related phlebitis with small peripheral venous
catheters. A randomized controlled trial. Annals of Internal Medicine. 114:10:845- 54.
 Dougherty, SH. 1988. Pathobiology of infections in prosthetic devices.Rev.Infect.Dis.10:1102-17
 Sheth, NK; Rose, HD & Franson TR et.al. 1983. Colonization of bacteria on polyvinyl chloride and
Teflon catheters in hospitalized patients. J.Clin.Microbiol.18:1061-63
 Tully JL. Friedland GH. Baldini LM. Goldmann DA. 1981. Complications of intravenous therapy
with steel needles and Teflon catheters. A comparative study. American Journal of Medicine.
70(3):702-6
 Cobbett, S. Le Blanc, A. 2000. Minimising IV site infection while saving time and money.
Australian Infection Control 5:2:8-14
 Maki DG. Ringer M. 1987. Evaluation of dressing regimens for prevention of infection with
peripheral intravenous catheters. Gauze, a transparent polyurethane dressing, and an iodophor-
transparent dressing. JAMA. 258(17):2396-403
 McCafferty DF. Woolfson AD. Boston V. 1989. In vivo assessment of percutaneous local anaesthetic
preparations. British Journal of Anaesthesia. 62:1:17-21
 Taddio A. Ohlsson A. & Einarson TR. et.al. 1998. A systematic review of lidocaineprilocaine cream
(EMLA) in the treatment of acute pain in neonates. Pediatrics. 101:2:E1
 Garland JS. Dunne WM Jr. & Havens P. et.al.1992. Peripheral intravenous catheter complications in
critically ill children: a prospective study. Pediatrics. 89: 6(2):1145-50.
 McNair, TJ & Dudley, HA. 1959. Local complications of intravenous therapy. Lancet. 2:365- 368.
 Feldstein A. 1986. Detect phlebitis and infiltration before they harm your patient. Nursing. 16(1):44-
7.
 Centers for Disease Control 1996. Guideline for the prevention of intravascular device related
infections. Am.J.Infect.Control 24:262:293
 Strand, CL; Wajsbort, RR & Sturmann, K. 1993. Effect of iodophor vs iodine tincture skin
preparation on blood culture contamination rate. JAMA. 269:8:1004-1006
 ORAL MEDICATION

Introduction

Medications now come in multiple forms for administration via multiple routes. The prescribed route will
depend on availability, cost, speed and mode of action, the condition being treated and the child’s
ability/tolerance of the chosen route.

The oral route is the most common route of administration in children. this is for several reasons:

 It is associated with less pain and anxiety than other routes such as intramuscular injections
 It is often cheaper than other preparations such as intravenous
 Less equipment is required and the procedure is often less time-consuming and more convenient.
The majority of oral medications for infants are available in liquid form. These drugs often include a sweet
flavor to make them more palatable to youngsters.

The three main areas of medicine management in children are; health education, administering the prescribed
medicine safely.

Devices for giving oral medication

 In case of infants: a syringe, dropper or calibrated spoon

 In case of elder children: cylindrical dosing spoon (which resembles a long test tube with a small
spoon at the top) or cup, silverware spoon.

Basic principles

Child development considerations are important in the administration of medicines. some basic principles
include :

 Be confident and firm

 Approach the child/family with a positive attitude
 Be honest and understanding
 Allow the child to have control where appropriate
 Use appropriate language that the child understands
 Discuss with the child what they might taste/smell/see/hear/feel
 Listen to all involved
 Explain the benefits of compliance with the medicine taking
Drug calculations

Pediatric dose calculation is usually based on either body surface area (mg/m²) or body weight (mg/kg) of the
child. Body weight is used more frequently for ease of calculations.

To calculate drug doses, use the following formula:

What you want / what you have x what it is in (dilution)

For example: a child is prescribed 90mg of paracetamol and the medication supplied is 120mg of paracetamol
in 5mls:

90 / 120 x 5 = 3.75mls

Medication errors arising from poor mathematical skills of nurses are an ongoing problem.

To enhance safety:

 Take time working out calculations

 Recheck answers
 Do not be rushed by colleagues/patients/parents/ careers
 Answers that look wrong probably are wrong and an initial mental estimate of the dose may be
useful.

Special considerations

 If the volume of the suspension is large, consider using an alternative preparation (e.g. soluble
tablets).

 Crushing tablets or opening capsules generally makes the medication unlicensed for use. Any harm
caused by this practice is a shared responsibility between the nurse administering the drug and the
prescriber who has a legal requirement to authorize this practice.

 Some tablets are not suitable for crushing. For example, slow release capsules should not be crushed
as the coating prevents the release and absorption of the drug until it has reached the small intestine.

 Soluble tablets/capsules should not be crushed but dissolved in water.

 Some capsules should not be broken or opened as the preparation inside the shell is coated in a matrix
 (e.g. vancomycin tablets).

 It is good practice to avoid crushing tablets or dissolving the contents of capsules. However, if this is
unavoidable, care should be taken to ensure the dose drawn up is as accurate as possible. Liaising
with pharmacy and referring to manufacture guidelines are a part of this process.

 Tablets should not be broken in half unless they are scored and an appropriate tablet cutter should be
used.

 Personal protective equipment (ppe) should be considered whenever there is a risk of inhalation of
history of allergies for the person administering the medicine or at the recommendation of the
manufactures guidelines.

Contraindications

 Unconscious child
 Absent gag reflex
 Inability to swallow
 Vomiting
Cautions to prevent worsening of the child's condition

 Digestive tract trauma/illness

 Post gastro-intestinal surgery
 Nil-by-mouth
 Nausea
 Diarrhoea

Preparation of equipment

 Prescription chart
 Medication formulary (eg british national formulary (bnf), medicines for children, guys formulary or
refer to the gos intranet pharmacy home page). Ensure appropriates formulary is checked.
 Manufacturers drug information (if required)
 Disposable medication tray
 Medication
 Medicine spoon/pot (with measured volumes) or
 Purple oral syringe
  Cup/beaker/teat (if required)
 Tablet splitter/tablet crusher
 Sterile water (for dissolving medication)
 Non-sterile gloves (if required)

‘Must do’s’: areas that are in bold should be read aloud

 Systematic check of chart

 Allergies
 Weight/age/surface area
 Right patient
 Right medicine
 Right time
 Right route
 Right dose
 Signed by a prescriber
 Drug commence date completed
 Expiry
 Double checking –this must occur from start to finish

Preliminary assessment:

 Check the prescription is clearly and correctly written and is signed and dated by the prescribing
practitioner.

 Check the medication is required and has not already been given. Ensure any preliminary checks and
observations have been carried out if necessary prior to administration (e.g. blood pressure
monitoring prior to administration of anti-hypertensives).

 Check the child does not have any known allergy or contra-indication to the prescribed medication.
Inform the prescribing practitioner immediately if the child does and do not give the medicine.

 Check that a recent weight has been recorded and dated on the prescription chart

 on admission
  weekly as an inpatient

 Check in an approved drug formulary that the dose, route and frequency of prescribed medication are
accurate.

 Check the medication supplied is suitable for oral administration

 If more than one medicine is prescribed, check for compatibilities and drug interactions. if they are
not, inform the prescribing practitioner.

 Check if it is necessary for the medication to be given before or after food/fluid because the
administration of some medications on an empty stomach can cause gastric irritation whilst the effect
of other medication may be inhibited by the presence of food.

Inform child and family

 Negotiate with the parent/caregiver and child regarding mixing the medication with food to disguise
the taste. nb: the nurse and parent/guardian should consider the potential benefits and risks of covert
administration of medications in food/fluid carefully.

 Identify if the child has any previous experience of taking medications and if so what this experience
was like for them.

 Using age and /or developmentally appropriate language, explain to the child what medication is due
and why. Explain this to the parent/caregiver as well. Negotiate roles for the administration of the
medication with the child/caregiver/parent.

 Where possible, allow the child as much control and choice as possible in the procedure.

 Be firm but fair with the child.

 If a choice is available, identify the child‘s preference for the form of oral medication (e.g. tablet or
suspension) and the type of vessel to be used.

Procedure

Steps of procedure Rationale

1. Ensure treatment room door is closed.
2. Wash hands according to the trust
guidelines.
3. Remove the medication from the box and
1. To minimize disruptions and reduce the
risk of a mistake.
2. To reduce the risk of cross infection.
3. To prevent a medication error occurring if
the medication bottle or tablet strip has
been put in the incorrect box.
 check the name, dose and expiry date of the 4. To reduce the risk of cross infection.
medication’s original container (e.g. bottle
label, tablet strip, vial).

4. Dispense medication into the appropriate 5. To prevent tampering of medication.

vessel without directly touching the
medication with your hands.
5. Check the child is available to take the
medication.
6. Take the medication directly to the child for
administration.
6. To prevent accidental ingestion of
medication by others.
7. To ensure trust policy is adhered to and
that the medication is not given via the
wrong route.
8. To minimize the risk of administering
medications via the wrong route.

7. Do not leave the medication in a room for 9. To reduce risk of drug error occurring
the parent/carer to administer later.

8. Do not take medication that requires 10. Tto adhere to trust policy.
administration via different routes into
the room at the same time (i.e. oral and
intravenous medication)

9. Follow administering medication- ‘must

do’s’)areas in bold should be read aloud

10. identify patient – the electronic

prescription must be taken to the patient for
this check. outpatients to follow their policy
for patient identification.

witness. have you seen the patient take the

drugs? 11. To ensure safe administration to correct
patient.
sign the chart

remember: check the name, date of birth

and hospital number on the medication
chart corresponds with the details on the
child’s name band.
11. All children should have a name band in
situ or a photograph to confirm the child’s
identity. both people checking the drug
should check this. students must double-
12. To promote development of a trusting
relationship between child and nurse and
to reduce the risk of aspiration.
13. To promote ingestion of medication.
14. To reduce risk of spillage and to reduce

check the name band with the staff nurse
who checked the drug.
12. Do not attempt to administer the medicine
while the child is asleep/crying.
13. Assist the child if necessary in
repositioning for administration of
medicines.
14. Unless contraindicated by condition or
treatment the child should be in an upright
position. a baby can be positioned in a
semi-reclined position with the head
elevated on your/the parent/carer’s lap.
15. Allow time for the child to take the
medicine.
16. Do not force the vessel/medicine into the
child’s mouth).
17. Oral syringe/spoon can be inserted into the
side of the mouth between the cheek and
the gum or can be placed on the tip of the
tongue.
18. Encourage older children to use a medicine
pot or spoon to take medication.
19. ensure the medication is given slowly and
use a medicine spoon to retrieve any
medicine that has been spilt or spat out.
20. Stroke a baby’s cheek or under the chin.
21. Encourage older children to use a spoon or
medicine pot rather than a syringe.
22. Unless contraindicated offer the child a
flavored drink/ice cube between and after
medicines.
23. Provide positive reinforcement as
the risk of aspiration.
15. To decrease feelings of anxiety at being
rushed and aid compliance
16. To reduce exposure to syringes and
unnecessary medicalisation of the
procedure.
17. To ensure the child has the ability to
maintain the airway in the presence of
fluid.
18. To ensure child receives an accurate dose.
19. To ensure child receives an accurate dose
20. To encourage the sucking reflex.
21. To make the procedure seem a less
“medical” one.
22. To eliminate the taste of medicines.
23. To encourage the child to take this and
further medicines.
24. To promote the child’s comfort.
25. To enable the responsible practitioner to
make a decision regarding the child’s
treatment.
26. To maintain accurate records.
27. To prevent the misuse of medicines by
others.
28. To reduce the risk of cross infection.
29. To reduce the risk of drug error where the
medication is given twice.
30. To adhere to nmc guidelines. (nmc 2004,
griffith 2003, nmc 2002)
31. To adhere to nmc guidelines. (nmc 2004,
griffith 2003, nmc 2002)
 appropriate during and after the procedure.
32. To facilitate early detection and action of
24. Assist the child in re-positioning if required any adverse effects of the medication.
after the procedure. (watt 2003)
33. To facilitate a risk assessment as trust
25. If the child refuses or is unable to take the policy.
prescribed medicine inform the responsible
prescriber.

26. Document the incident in the appropriate

section of the drug chart and in the child’s
health care notes.

27. Discard any unused medicine according to

trust policy (refer to gosh medication
policy).

28. Dispose of equipment according to trust

waste policy. wash hands.

29. Sign for the administration of the

medication on the child’s prescription chart
once administration is complete.

30. If the process required double- checking

ensure both signatures’ are on the
medication chart.

31. Monitor the effects of the medicine

administered and document in the nursing
records.

32. Observe for and report immediately to the

nurse in charge and responsible prescriber
any adverse effects of the medication.

33. Stabilize child’s condition. complete

incident form.

References/Bibliography

1) Nursing and midwifery council (nmc) (2004) guidelines on the administration of medicinces.
london, nmc
 2) Watt s (2003) safe administration of medicines to children: part 2. paediatr nurs 15 (5): 40-4.
3) Kanneh a (2002c) paediatric pharmacological principles: an update. part 3. pharmacokinetics:
metabolism and excretion. paediatr nurs 14 (10): 39-43.
4) Griffith r, griffiths h, jordan s (2003) administration of medicines. part 1: the law and nursing.
nurs stand 18 (2): 47-53; quiz 54, 56.
5) Nursing and midwifery council (nmc) (2004) code of professional conduct. london, nmc
6) Cope j (2006) administration of medicinces operational policy. london, great ormond street
hospital
7) Gibson f (2003) nurse prescribing: children's nurses' views. paediatr nurs 15 (1): 20-5.

STEAM INHALATION

Introduction :

Inhalation of warm, moist air into the mucous membranes and respiratory tract.
Steam Inhalation is an easy and affective natural healing remedy.

Indications:

 Headaches
 Sinus congestion
 The common cold
 Infections and Sinus pain
 Asthma
 Influenza
 Bronchitis
 Respiratory ailments which are due to allergies

Contradiction:
This treatment is best avoided in case of high blood pressure

Effects:
1. Relieves inflammation and congestion of the mucous membranes of the upper respiratory tract.
2. Relieves irritation (throat tickle) by moistening the air.
3. Loosens secretions and stimulates expectoration.
4. Relieves spasmodic breathing.
5. Relaxes muscles and thus relieves coughing.
6. Prevents excessive dryness of the mucous membranes.

Articles Needed:
1. Boiling water in a kettle with spout. An empty juice-can may serve the purpose.
2. Hot plate of gas stove or local stove using charcoal.
3. Vicks Vaporub ointment or tincture of Benzoin or Camphor oil for good smelling sensation.
4. Old newspaper.
5. Umbrella.
6. Sheets.
7. Paper Bag

Procedure:
1. Fill kettle with water just below the level of the spout, and bring the water to boiling point. Add 1 tsp of
medication (Vicks or Benzoin) into the boiling water.
2. Carry the stove and the kettle with caution near the bedside of the patient, if the patient is unable to stand or
sit on the chair.
3. If croup tent is indicated, open an umbrella over the head of the patient and cover it with a sheet to form a
tent.
4. With the newspaper make a cylindrical tube direct to the steam into the tent away from the patient’s face.
5. If the patient is able to sit on the chair, he may sit near the stove in the kitchen. With the cylindrical tube of
paper the steam is directed into the patient’s face for inhalation.
6. Treatment time: 30 minutes to one hour, morning and evening, as tolerated.

Precautions:
1. Avoid all risks of burning.
2. Avoid drafts during time of treatment. Close windows near the patient.
3. Extra care must be observed when giving treatment to children and restless patients to avoid scalding.

References :
 OXYGEN ADMINISTRATION

Definition

Oxygen may be classified as an element, a gas, and a drug. Oxygen therapy is the administration of oxygen
at concentrations greater than that in room air to treat or prevent hypoxemia (not enough oxygen in
the blood). Oxygen delivery systems are classified as stationary, portable, or ambulatory. Oxygen can be
administered by nasal cannula, mask, and tent. Hyperbaric oxygen therapy involves placing the patient in an
airtight chamber with oxygen under pressure.

Purpose

The body is constantly taking in oxygen and releasing carbon dioxide. If this process is inadequate, oxygen
levels in the blood decrease, and the patient may need supplemental oxygen. Oxygen therapy is a key
treatment in respiratory care. The purpose is to increase oxygen saturation in tissues where the saturation
levels are too low due to illness or injury. Breathing prescribed oxygen increases the amount of oxygen in the
blood, reduces the extra work of the heart, and decreases shortness of breath. Oxygen therapy is frequently
ordered in the home care setting, as well as in acute (urgent) care facilities.

Some of the conditions oxygen therapy is used to treat include:

 documented hypoxemia
 severe respiratory distress (e.g., acute asthma or pneumonia)
 severe trauma
 chronic obstructive pulmonary disease (COPD, including chronic bronchitis, emphysema, and
chronic asthma)
  pulmonary hypertension
 cor pulmonale
 acute myocardial infarction (heart attack)
 short-term therapy, such as post-anesthesia recovery

Indications

Oxygen may be administered to any patient, particularly including patients with the following:

i. Respiratory problems

ii. Altered Mental Status

iii. Chest Pain

iv. Indications of shock

v. Trauma patients

vi. Seizure patients

Contraindications:

 Oxygen should never be used in explosive environments, and its use is cautioned against when there
is a risk of sparks or materials combusting as oxygen accelerates combustion. Smoking during
oxygen therapy is a fire hazard and a danger to life and limb, especially with home oxygen if
compliance is poor.
 Exercise caution with oxygen administration in chronic obstructive pulmonary disease (COPD)
patients

Types of oxygen delivery systems:

The types of oxygen delivery systems include:

 Compressed oxygen—oxygen that is stored as a gas in a tank. A flow meter and regulator are
attached to the oxygen tank to adjust oxygen flow. Tanks vary in size from very large to smaller,
portable tanks. This system is generally prescribed when oxygen is not needed constantly (e.g., when
it is only needed when performing physical activity).
 Liquid oxygen—oxygen that is stored in a large stationary tank that stays in the home. A portable
tank is available that can be filled from the stationary tank for trips outside the home. Oxygen is
liquid at very cold temperatures. When warmed, liquid oxygen changes to a gas for delivery to the
 patient.
 Oxygen concentrator—electric oxygen delivery system approximately the size of a large suitcase.
The concentrator extracts some of the air from the room, separates the oxygen, and delivers it to the
patient via a nasal cannula. A cylinder of oxygen is provided as a backup in the event of a power
failure, and a portable tank is available for trips outside the home. This system is generally prescribed
for patients who require constant supplemental oxygen or who must use it when sleeping.
 Oxygen conserving device, such as a demand inspiratory flow system or pulsed-dose oxygen
delivery system—uses a sensor to detect when inspiration (inhalation) begins. Oxygen is delivered
only upon inspiration, thereby conserving oxygen during exhalation. These systems can be used with
either compressed or liquid oxygen systems, but are not appropriate for all patients.

Oxygen Administration

Oxygen kit showing a demand valve and a constant flow mask

METHOD OF ADMINISTRATION

The equipment used to convey oxygen from the cylinder or pipeline to the patient consists of a pressure
gauge, regulator (optional), flow meter, tubing, mask or nasal cannulae and humidifier (if required).

1. MASKS

a) Venturimask :- These masks have colour coded adapters which by stating the flow rate to be used enable a
given concentration of oxygen (as prescribed) to be administered eg 8L per minute of oxygen delivered via a
yellow adapter will enable the patient to breath an atmosphere containing 35% oxygen.

Oxygen enters the mask through a narrow jet opening, thereby increasing the speed of the flow. Room air is
drawn through the ports, mixing with the steam of oxygen giving the desired oxygen concentration.
c) M C Mask:- This is a soft plastic mask with a central bore and is connected via oxygen tubing to the
oxygen supply. Vent holes are incorporated into the design to allow the clearance of expired carbon
dioxide and to prevent the development of high pressures. This mask MUST NOT be used if accurate
percentages are required. This mask delivers an oxygen concentration between 40 and 60%, but
concentration is not always accurate.

High Concentration Mask / Non re breathing (trauma mask)

This mask delivers an oxygen concentration of between 60 and 90%

2. NASAL CANNULAE

These consist of a pair of tubes approximately 2cm long, placed in the patients nostrils and the tubing
connected directly to the oxygen flow meter. They may be used as an alternative to masks, especially
 if used in patients who require a low supplement of oxygen. However, they do not deliver as
predictable a percentage of oxygen as the ventimask. They may also be used for patients who cannot
tolerate facial masks. Nasal cannulae are the preferred choice for patients receiving long term oxygen
therapy.

3. AMBU BAG

A self inflating rubber bag. One end is fitted with a one way air valve and a connection for attaching tubing to
the oxygen supply. The other end is connected either via an angle mount to a face mask , or a catheter mount
to a tracheal tube. The percentages of oxygen delivered will depend on the flow rate and volume of bag. This
method is usually used for resuscitation procedures.

4. WATERS CIRCUIT

Usually consists of a 2 litre rubber bag fitted to an adjustable release valve attached to the oxygen supply and
to the patient via a catheter mount and tracheal tube, or angle mount and face mask. This will deliver 100%
oxygen and require additional training in it use.

5. MECHANICAL VENTILATION

This is a specialised area, and has therefore not been covered by this procedure.

6 HUMIDIFICATION

Humidification of oxygen is desirable as the administration of oxygen without humidification can result in the
retention of secretions with small areas of the lung collapsing.

Humidification can be achieved using either a hot or cold water system or in some cases a heat and moisture
exchanger (HME). Advice should be sought from either the Respiratory Nurse Specialist or Medical staff on
which option is the preferred system to be utilised.

Nasal Cannula

The nasal cannula is a thin tube with two small nozzles that protrude into the victim's nostrils. It can only
provide oxygen at low flow rates: 2-6 liters per minute, delivering a concentration of 28-44%. Use of the
nasal cannula at higher flow rates than 6 liters per minute can cause discomfort by drying the nasal passages
and pain from the force of the oxygen.
Bag-Valve-Mask

The task of administrating oxygen with bag-valve-mask (BVM) is not very demanding, and requires only one
hand to squeeze the bag and one to maintain a good seal with the mask. Thus, this task can advantageously be
achieved by one rescuer, who will then keep their mind free and, being at the head of the victim, have a good
view of the overall situation. The head of the victim can be secured between the knees of the BVM operator.
The bag-valve-mask (BVM) is used for victims in critical condition who require pure oxygen. A reservoir bag
is attached to a central cylindrical bag, attached to a valved mask that administers 100% concentration oxygen
at 8-15LPM. The central bag is squeezed manually to ventilate the victim.

Non-rebreathing Mask

Caution

Do not allow grease or oils to come in contact

with or be near oxygen tanks at ANY time. This
can cause explosive combustion!

The non-rebreathing mask (NRB) is utilized for patients with multiple trauma injuries, chronic airway
limitation/chronic obstructive pulmonary diseases, smoke inhalation, and carbon monoxide poisoning, or any
other patient that requires high-flow oxygen, but does not require breathing assistance. It has an attached
reservoir bag where oxygen fills in between breaths, and a valve that largely prevents the inhalation of room
or exhaled air. This allows the administration of high concentrations of oxygen, between 65-85%. This device
is set to 10-15 lpm, or at least enough to keep the reservoir inflated between breaths. Due to the poor seal on a
patient's face, it is exceedingly difficult to obtain anything approaching 100% oxygen with this device. While
some patients with Chronic Obstructuve Pulmonary Disease (COPD) rely on what is called hypoxic drive,
high flow oxygen should never be witheld from COPD patients who require it.

Pocket Mask

The pocket mask is a small device that can be carried on one's person. It is used for the same victims that the
BVM is indicated for, but instead of delivering breaths by squeezing a reservoir, the first aider must actually
exhale into the mask. Pocket masks normally have one-way valves built into them to protect against cross-
contamination. Many masks also have an oxygen intake built-in, allowing for administration of 50-60%
oxygen.

Dosage
a. Nasal Cannula 2-61pm

b. Non Rebreather Mask 12-15 Ipm

c. Blow By 12-15 Ipm

d. Bag Valve Mask 12-15 Ipm

Administration Procedure

a. Patients should receive oxygen via non-rebreather mask (NRB) at a rate of 12-15 Ipm in the following
circumstances:

i. Patient has an altered mental status

ii. Patient experiencing shortness of breath or any respiratory problem

iii. Patients with oxygen saturation level below 94% as determined by a pulse oximeter device

IV. Any other circumstances where EMTs feel that a high concentration would benefit the patient

Take the following precautions when using oxygen:

 Always make sure that oxygen is flowing before placing the delivery device over the victim’s mouth
and nose.
 Do not use oxygen around flames or sparks. Oxygen causes fire to burn more rapidly. Do not smoke
or let anyone else smoke around oxygen in transport, in use or on standby.
 Do not use grease, oil or petroleum products to lubricate or clean the pressure regulator or any fitting
hoses, etc. This could cause an explosion.
 Do not stand oxygen cylinders upright unless they are well secured.
 If the cylinder falls, the regulator or valve could become damaged or cause injury.
 Do not drag or roll cylinders.
 Do not carry a cylinder by the valve or regulator.
 Do not hold onto protective valve caps or guards when moving or lifting cylinders.
 Do not deface, alter or remove any labeling or markings on the oxygen cylinder.
 Do not attempt to mix gases in an oxygen cylinder or transfer oxygen from one cylinder to another.
 Never use oxygen without a safe regulator that fits properly.
 When the tank is not in use keep vavlves closed even if thetank is empty. Store oxygen tanks below
125°F.
 If defibrillating, make sure that no one is touching or is in contact with the victim or the resuscitation
equipment.
 Do not defibrillate someone when around flammable materials, such as gasoline or free-flowing
oxygen.
  Never drag or roll cylinders.
 Carry a cylinder by both hands and never by the valve or regulator.
 Do not store oxygen cylinders near flammables or hot water heaters, near electric or phone boxes,
where they can have something heaby fall on them, where they could be tipped over or exposed to
heat or direct sunlight.
 When transporting oxygen cylinders: do not store them in the trunk; secure then in case of a sudden
stop, acceleration or sharp turn, when they could become a serious projectile hazard; immediately
remove them from the vehiole rather than risk heat exposure which could cause a potentially
hazardous relearse of gas.

References :

1. The Royal Marsden Hospital (2000). Manual of Clinical Policies and Procedures. Blackwell Science.

2. The why, where and how of Oxygen Therapy, Lifecare Hospital Supplies.

NEBULIZATION

Definition

Nebulization is a process of adding fine drops of moisture or fine particles of medication to inspired air.

Purposes

 Nebulization will help to improve the clearance of pulmonary secretions.

 The water or medication is usually broken up by gas under pressure or by high-frequency vibrations
(ultrasonic mucosa nebulization).

Equipment:

 Pulmo-Aide®
 Connecting tubing
 Nebulizer manifold
 Normal saline
 Medication as per doctor order

Preperation

1. Gather all required equipment. Check to ensure that all medications are available and expiration dates are
current.

2. Provide privacy and wash hands.

3. Place person in a comfortable sitting position in Diaphragmatic expansion and lung compliance

a wheelchair or semi-fowler's position on a bean are greater in this position. This ensures
bag. maximal effectiveness of medication(aerosolized particles) to the basilar areas of the lungs.

4. Wash hands.

5. Take person's heart rate before and after the Broncho-dialators may cause tachycardia

treatment. palpitations, dizziness, nausea, or nervousness.

Procedure

 Add the prescribed amount of medication and saline to the nebulizer. Connect the tubing to the
Pulmo-Aide®
 Place the face mask on person and verbally encourage him to breath deeply. Observe for person's
chest expansion.
 Turn Pulmo-Aide® on. A fine mist from the device should be visible.Nebulization will normally take
15-20 minutes.
 On completion of the treatment, there may be The medication may dilate airways, facilitating
increased secretions and coughing. Encourage expectoration of secretions.
 several deep breaths.

After care

 Assess for need to suction.

 Record medication used, description of secretions Note tolerance of the treatment.
and amount suctioned

 Change nebulizer filters every 6 months

 PALADI FEEDING

Feeding Young Children

Parents and care givers influence the eating habits of children through the foods they serve and the examples
they set.
Planned snacks can be an excellent way to get needed nutrients into a child’s diet.
Children triple their weight during their first year, then add approximately one birth weight every year until
they reach puberty.
Give children ample time to finish eating, but never force them to eat or finish everything on their plates.

Developing Children's Eating Habits

Our food habits begin to develop the day we are born and each one of us learns at an early age which foods
we like and dislike. Young children learn by watching others and this applies to their eating habits as well. A
child often looks to someone else to model the appropriate behavior. Through the foods we serve and the
examples we set, parents and care givers can help children form sound eating habits.

Tips to Follow

Serve nutritious foods in an attractive environment. When planning meals, either for your own child or
child care home/center, provide a wide variety of nutritious foods served in an attractive manner.

Serve foods that are flavorful and colorful. Consider the flavor of the foods you serve. Generally, young
children reject strong flavors, although many children like pickles and some spicy sauces. Children also do
not like their foods to be too hot or too cold.

Children have a natural interest in color. Green, orange, yellow, and pink are some of the more popular colors
that children like. Presenting food on colorful plates or in colorful ways can help make eating fun.

Encourage participation in meal preparation. Young children often have a limited number of foods they
like and their likes can change often and unexpectedly. Eating only one type of food is what we sometimes
call a food jag. One way to help children over food jags is to involve them in planning and preparing meals
and snacks. If they feel like they have a part in selecting, preparing, and serving foods, they're more likely to
try different foods. If you have a garden, involve your children in picking food from the garden.

Offer children choices in foods. Give children some control over what they're eating by offering them
choices. For example, ask which vegetable they would like for supper and follow through on their
suggestions.

Introduce new foods with old favorites. When introducing new foods, it's best to start with small changes.
Introduce new foods with old favorites and serve them at the beginning of the meal when children are most
hungry.

Provide small portions to encourage appropriate food habits. To accommodate varying appetites, it is best
to offer small portions and encourage preschoolers to ask for second helpings, if desired. Because preschool
children are not growing as rapidly as they were as infants, their appetites tend to decrease. Also, due to
growth spurts and competing interests, a preschooler's appetite varies from day to day.

Provide a clean, comfortable environment with appropriate utensils. It is important for the child to have a
place at a table that is appropriate for his or her size. If available, child-size furniture is desirable. Provide
children with utensils that they can handle. Many children are slow in learning how to handle eating utensils
correctly. Children learn to eat with utensils through encouragement, praise, and practice, not force or
punishment.

Plan regular meal and snack times and eat together. Because of their small stomachs and short attention
spans, preschool children like to snack. Most preschoolers eat four to five snacks or meals each day. Plan
snacks as you do meals, as snacks can be an excellent way to get needed nutrients into a child's diet. As a
parent or care giver, join children at mealtimes whenever possible. Have a pleasant conversation and set a
good example for proper eating behavior at the table. Eating together helps children learn that eating can and
should be a pleasurable and enjoyable experience.

Planning Healthy Meals Using the Dietary Guidelines

The Dietary Guidelines for Americans provide a framework for planning nutritious meals for children. Here
are some ways to incorporate the Dietary Guidelines into meal planning.
Offer and eat a variety of foods. Offering a variety of foods, prepared in different ways, makes meals and
snacks more interesting for children. It also makes good nutrition sense. Everyone needs many different
nutrients for good health and some foods provide more of one nutrient than another. For example, milk is a
good source of calcium while meats, beans and some breads are important sources of iron.

Serve meals and snacks that help promote a healthy body and weight, and encourage physical
activity. Children need food and the calories it contains for growth and normal development. Actual calorie
needs of children will vary depending on body size, growth spurts and physical activity.

Because children have high nutrient needs, it's important to focus on foods that are good sources of nutrients.
This doesn't mean, however, that children can't have desserts.

Encouraging children to be active also helps promote good health. Regular physical activity burns calories,
helps with weight control, improves coordination, helps build muscles, and is important in preventing some
chronic diseases. Children who are not active are at higher risk of becoming overweight. One of the best ways
to help an overweight child grow into his or her weight is to encourage physical activity like playing games
and going for walks. According to the Dietary Guidelines for Americans, children and adolescents should aim
for at least 60 minutes of moderate to vigorous activity on most, preferably all, days of the week.

Serve plenty of grain products, vegetables, and fruits. Grains such as breads, cereals, pastas, and rice as
well as vegetables and fruits add color and variety to the diet. These foods are also good sources of complex
carbohydrates, dietary fiber, and a number of vitamins and minerals.

Encourage foods that are low in fat. For most people, it is sensible to eat less fat, saturated fat and
cholesterol. It is important to often introduce children to foods that are low in fat, especially saturated and
trans fats. The Dietary Guidelines for Americans recommend keeping total fat intake between 30 and 35
percent of total calories for children 2 to 3 years of age and between 25 to 35 percent of calories for children
and adolescents 4 to 18 years of age.

After age two, families should begin thinking about the amount of saturated fat and total fat that's in their
child's diet. The fat in most foods contains a blend of saturated, polyunsaturated, monounsaturated fats, and
sometimes trans fats. Saturated fats usually are solid at room temperature. Examples of foods that are high in
saturated fats include animal products like meat and lard, and dairy products such as whole milk, cream and
butter.

Polyunsaturated and monounsaturated fats are liquid at room temperature. Corn and safflower oils are good
sources of polyunsaturated fats. Canola and olive oils are high in monounsaturated fats. Replacing solid,
saturated fats with liquid, unsaturated ones will be healthier for you and your children.

Trans fats are unsaturated fats that have been modified to make them more solid at room temperature. While
small amounts of trans fats occur naturally meat and dairy products, most are created as a side effect of the
partial hydration of plant oils. Because trans fats are neither required nor beneficial for health, and in fact
increase the risk of heart disease, health authorities recommend limiting the consumption of trans fats to trace
levels.

Changes to reduce the level of fat in meals must be practical and acceptable. For example, if you're used to
buying whole milk, buy a half gallon of whole and a half gallon of 2% milk and mix the two together. Slow
change is more likely to be accepted and adjusted to than a dramatic change.

The amount of fat you use in meal preparation can easily be reduced without losing much of the food's appeal
or flavor. For example, if a muffin recipe calls for 1 cup of oil, you can easily reduce the amount of oil to 3/4
cup without changing the flavor and quality of the end product.

Lowering the fat content also lowers the calories in meals. When fat is lowered in a meal, other foods such as
grains, vegetables, and fruits may need to be added to replace lost calories.

Moderate the use of sugar and foods high in sugar. There are two main reasons to offer children sugar in
moderation. First, sugars and foods high in sugar supply calories but may be limited in vitamins and minerals.
Second, too much sugar can lead to tooth decay.

Baby bottle tooth decay, also known as nursing bottle syndrome, is characterized by rapid decay of the
primary upper front teeth and some of the lower back molars. Baby bottle tooth decay is associated with
inappropriate bottle feeding, such as giving infants a sweet pacifier or bottle containing milk, formula, or a
sugary liquid when they go to bed. Decayed baby teeth affect mouth formation and the health of permanent
teeth later on.

Serve salt and processed foods only in moderation. The preference for salty foods is learned. Teaching
children to enjoy food without adding salt may help reduce problems with high blood pressure later in life.
Most children actually prefer less salty food. Avoid adding salt to recipes when possible. Experiment with
spices and the flavors of lemon or lime juice.

Salt is added during the processing and manufacturing of food products in the form of sodium. Some
examples of foods that contain high amounts of salt are processed meats and cheeses, canned soups, salad
dressings, and prepared frozen entrees and dinners. Look for sodium in the list of ingredients on a food's
packaging as well as on the food label. You'll be surprised to learn just how much sodium is added to the
foods we eat.

More information on the 2005 Dietary Guidelines for Americans is available

at www.healthierus.gov/dietaryguidelines.

Planning Healthy Meals Using MyPyramid

MyPyramid is an outline of what to eat each day. It's not a rigid prescription, but a general guide that lets you
choose and plan a healthful diet that's right for you and your family. The overall message of the Food Guide
Pyramid is to select foods that together give you all the nutrients you need to maintain health without eating
too many calories or too much fat.

MyPyramid is arranged with colored stripes radiating from the base to the top of the pyramid. Each stripe
represents one of the five main food groups: grains, vegetables, fruits, milk, meat and beans. A thin line
representing oils is also included. Some stripes are thicker than others and all are wider at the bottom,
indicating that you should eat more of some foods and from some food groups than others. Each of the food
groups provides some, but not all, of the nutrients you need. No one food group is more important than
another - for good health, you need them all.

Food intake amounts are given in cups and ounces for a given total calorie level. For 2 to 3 year olds, 1,000 to
1,400 calories per day are recommended, depending on activity level. For 4 to 8 year olds, the recommended
range is 1,200 to 1,800 calories. At the 1,200 calorie level, the daily amounts of food are: 4 ounces of grains,
1.5 cups vegetqables, 1 cup fruit, 2 cups of milk and 3 ounce equivalents of meat or beans. For more
information, go to mypyramid.gov.

Using MyPyramid in planning meals for preschool children will help ensure that they are getting a variety of
foods and the right amounts from each food group. It also will help ensure that foods high in fat and added
sugars are kept in moderation.

See fact sheet 9.306, A Guide for Daily Food Choices, for more information on the Food Guide Pyramid.

The Nutrition Facts Food Label

Now that we know how to plan healthy meals, how do we know that what were buying is nutritious? The
Nutrition Facts food label can help.

This label tells you the total calories in one serving of the food and the number of calories that are coming
from fat. It also tells you about the different types of fats and carbohydrates in the food. It tells you about the
vitamin A, vitamin C, iron and calcium content of the food; these are all nutrients that are important for
children. The nutrition label tells you about the cholesterol, fiber and sodium in that food.

Labels can assist meal planners in making more knowledgeable purchases based on the nutrient content of
each food. Look for nutrient content claims such as "free," "low," or "reduced" on the front of the label to
help identify foods that are low in calories, fat, saturated fat, cholesterol, and sodium.

Take the time to read food labels. You can use labels to help you plan healthy meals and budget your intake
of calories and fat over several days.
 NASOGASTRIC TUBE FEEDING / GASTROSTOMY FEEDING

Introduction

A nasogastric (NG) tube is a small tube that goes into the stomach through the nose. Breast milk, formula, or
liquid food is given through the tube directly into the stomach, giving a child extra calories.

Definition
Gavage feeding is a means of providing food via a catheter passed through the naries or mouth, passed
through the pharynx, down the esophagus, and into the stomach, slightly beyond the cardiac sphincter.

Objectives:
 To provide a method of feeding or administering medication that requires minimal patient’s
effort, when the infant is unable to suck or swallow.
 To provide a route that allows adequate calories or fluid intake.
 To prevent fatigue or cyanosis that is apt to occur from nipple feeding.
 To provide a safe method of feeding a limp and listless patient.

Contraindication:

 Absent bowel sounds: Tube feeding are contraindicated to patients without bowel sounds.
Administration of feeding solution into an improperly placed tube may cause aspiration of the feeding
into the lungs.

Types of nasogastric tube:

Short-term tubes are made of polyvinylchloride (pvc). The length of time the tube can remain in place
depends on the manufacturer's guidance; this also applies to cleaning and storage of the tube.

Long-term tubes are made of polyurethane and usually have a guide wire to help with passing the tube. The
wire is removed when the tube has been passed but should be kept in case the tube has to be re-passed. The
length of time the tube can remain in place again depends on the manufacturer's guidance; this also applies to
cleaning and storage of the tube.

Articles required:

 Sterile rubber or plastic catheter/ Nasogastric tube,

 stethoscope,
 feeding fluid,
 rounded tip, size 5-10 french clear calibrated reservoir for feeding fluid,
 50 ml syringe,
 water for lubrication and to flush,
 pacifier
 ph indicator paper,
 tape to secure,
 glass of water/juice

Inserting a nasogastric tube

It takes time and practice to learn how to insert the tube, so be patient with yourself.

s. no Steps of procedure Rationale

1) 1.Position the infant on his side or back with a
diaper roll placed under his shoulder, a mummy
restraint may be necessary to help maintain this
position.
2) Measure feeding catheter and mark with tape;
measure distance from tip of nose to ear to
xiphisternum.
3) have suction apparatus readily available.
4) Lubricate catheter with a sterile water or saline.
5) Stabilize the patient’s head with one hand; use
the other hand to insert catheter.
Push nose up to widen nostril.
a.Insertion through nares slip the catheter into
nostril and
This position allows for easy passage of the
catheter, facilitates observation, and helps
avoid constriction of the air way.
Premeasuring the catheter provides a
guideline as to how far to insert the catheter.
Suctioning clears the air way and prevent
aspiration if vomiting occurs.
Do not use oil because of danger of
aspiration..
This direction will follow the nares passage
way into the pharynx. Do not direct the
catheter upward. Positioning in nares may
cause partial airway obstruction, therefore,
observe for respiratory distress. Avoid this
route if there is critical airway compromise.

6) If the patient swallows, passage of the catheter Swallowing motion will cause esophageal
may be synchronized with swallowing. Do not peristalsis which opens the cardiac sphincter
push against resistance. and facilitates passage of the catheter.
7) If there’s no swallowing, insert the catheter
smoothly and quickly.
8) In the infant, especially, observe for vagal
stimulation (i.e. bradycardia and apnea)
9) + Once the catheter has been inserted to the
premeasured length, tape the catheter to the
patient’s face.
10) Test for the correct position of the catheter in
the stomach.
a. Inject 5.5 ml air into the catheter and the
stomach. At the same time listen to the typical
growing stomach sound with a stethoscope
placed over the epigastric region.
b.Aspirated injected air from the stomach.
c.Aspirate small amount of stomach content and
test acidity by pH tape.
d.Observe and gently palpate abdomen for the
tip of the catheter. Avoid inserting catheter into
the infant’s trachea.
11) The feeding position should be right side-lying
with head and chest slightly elevated. Attached
reservoir to catheter and fill with feeding fluid.
Allow infant to suck during feeing. Hold infant
if possible.
12) Aspirate tube before feeding begins.
: Because of cardiac sphincter spasm,
resistance may be met at this point, pause a
few seconds, then proceed.
: The vague nerve pathway lies from the
medulla through the neck and thorax to the
abdomen. Above the stomach, the left and
right branches unite to form the esophageal
plexus. Stimulation of the nerve branches
with the catheter will directly affect the
cardiac and pulmonary plexus
: This prevents movement of catheter from the
premeasured, preestablished correct position.
Alternative method loop narrow cloth tape
amount tube just below the nostril, then
secure it above tip or nose with tape. Some
movement of tube may be seen with
swallowing.
Aids in ensuring proper location of catheter.
This prevents abdominal distention.
Failure to obtain aspirate does not indicate
improper placement; there may be any
stomach content or the catheter may not be in
contact with the fluid.
If improper placement occurs and the catheter
inserts the trachea the patient may cough,
fight and become cyanotic. Remove the
catheter immediately and allow the patient to
rest before attempting intubation again
This position allows the flow of fluid to be
aided by gravity. The use of the pacifier will
relax the infant, allowing for easier flow of
fluid as well as provide for normal sucking
needs. Sucking will help develop muscles and
provide a positive association between
sucking and relief of hunger.
 a.If over ½ the previous feeding is obtained,
withhold the feeding.
b.If small residual of formula is obtained, return
it to stomach and subtract that amount from the
total amount of the formula to be given.
This is done to monitor for appropriate fluid
intake, digestion time, and over feeding that
can cause distention. Note an increase in
gastric residual content.

13) The flow of feeding should be slow. Do not
apply pressure. Elevate reservoir 15-20cm,
above the patient’s head.
The rate of flow is controlled by the size of
feeding catheter: the smaller the size, the
lower the flow. If the reservoir is too high the
pressure of the fluid itself increases the rate of
flow.

14) Food taken too rapidly will interfere with The presence of food in the stomach
stimulates peristalsis and causes the digestive
peristalsis, causing abdominal distention and process to begin. Also, when tube is in place,
regurgitation. incompetence of the esophageal-cardiac
sphincter may result in regurgitation.
15) Feeding time should last approximately as long
as when a corresponding amount is given by
nipple 5ml/5-10 minutes or 5-20 minutes total
time.

16) When the feeding is completed, the catheter
may be irrigated with clear water. Before the
fluid reaches the end of the catheter clamp it off
and withdraw it quickly.
Clamp the catheter before air enters the
stomach and causesabdominal distention.
Clamping also prevents fluid from dripping
from the catheter into the pharynx, causing
the patient to gag and aspirate.

17) Discard feeding tube and any feeding solution.

Note: Intermittent gavage is often preferred to indwelling gavage feeding. An indwelling catheter may coil
and know, perforate the stomach, and cause nasal airway obstruction, ulceration, irritation of the mucous
membrane, incompetence and esophageal-cardiac sphincter, and epistaxis. However, if intermittent intubation
is not well tolerated and the indwelling method is used, the catheter should be clamped to prevent loss of
feeding or entry of air and changed every 48-72 hours (use alternate side of the nares. Constant alertness to
the above problem should be stressed. Indwelling method may be preferred with older infant or child.

Positioning during feeding

• Where possible the child should be positioned with their head above the level of their stomach, preferably
sitting or supported at an angle of approximately 30°
• Babies may be fed in baby seats offering firm support, such as car eats, in preference to bouncy chairs which
can induce vomiting

• If the child shows any signs of shortness of breath (more than usual), sudden pallor, vomiting or coughing
stop the feed immediately and seek medical attention

Giving the feedings Bolus feeding:

It may be helpful to have 2 people to do this type of tube feeding. One person can hold and comfort the child
while the other gives the feeding.

1. Wash your hands.

2. Measure the correct amount of formula and warm it to the desired temperature.

3. Check tube placement as above.

4. Clamp the tube.

5. Attach a syringe to the feeding tube.

6. Pour the formula into the syringe.

7. Unclamp the tube.

8. Allow the formula to run for the same amount of time as it would take the child to drink it by mouth, or as
prescribed by the doctor.

9. Ways to help the feeding flow: Try to start the feeding when the child is calm. You may have to “push” the
feeding to get it started. To do this, place a plunger into the syringe and push slightly. Remove the plunger
gently and allow the formula to flow in by gravity. If your child is crying, you may need to repeat the push
several times. A pacifier may help calm a young child and also helps to connect sucking with stomach-filling.
For older children, use activities to distract them, or involve the child with the feeding, such as holding the
syringe.

10. During the feeding, keep the bottom of the syringe no higher than 6 inches above the child’s stomach.

11. Continue adding formula into the syringe until the prescribed amount is given.

12. When the syringe is empty, flush the tube with the prescribed amount of warm water.

After the feeding:

Clamp the tube.

Leave the tube open to air. Tape a piece of gauze over the syringe to keep fluids from splashing out.

Burp your child.

Infants and young children may be most comfortable with their head and upper body raised, or lying on their
left side.

Older children may be up and playing.

Continuous feeding with a feeding pump

1. Wash your hands.

2. Measure enough formula for 4 hours and warm it if needed.

3. Pour formula into the feeding bag. Run formula to the end of the pump tubing.

4. Set up the pump and pump tubing according to the directions from the medical supply company. Be sure
the rate is set correctly.

5. If a new feeding tube is to be inserted, see “Getting ready to insert the tube” and “Inserting the tube.”

6. Check placement (see “Checking the tube placement.”

7. Connect the pump tubing to the child’s feeding tube.

8. Turn on the pump. Check to make sure the formula is dripping.

9. As the bag empties every 4 hours, add more formula.

10. Hold and/or talk to your child often during waking hours. Have your child’s head raised during the entire
feeding.

11. Watch your child carefully to make sure there is no change in breathing or behavior. Make sure the mark
on the tube is still at the nostril. It is also a good idea to measure it every few hours, because sometimes the
tube can slip under the tape.

12. After the feeding period, flush the tube with the prescribed amount of warm water.

13. After the feeding: Plug or clamp the tube. Leave the tube open to air. Tape a piece of gauze over the
syringe to keep fluids from splashing out Burp your child. Have child’s head raised for about 30

minutes after the feeding is done.

Removing the feeding tube

(if ordered)

1. Remove the tape.

2. Pinch the tubing and pull the tube out in one quick motion.

3. Hold, cuddle, and comfort the child. If child is an infant, burp him or her.
Skin care

• Most children benefit from using a barrier product such as hydrocolloid dressings and transparent films to
protect the skin under strong adhesive tapes

• Replace the tape only if dirty or peeling off

• When tape is removed, cleanse face and dry thoroughly. Clean child’s skin around the tube often with warm
water, removing any secretions.

• If the nostril is reddened or the skin is irritated, remove the tube and replace it in the other nostril, if
possible. If you have used a transparent dressing on your child’s face, remove it by loosening it with mineral
oil and gently working the dressing off. If you use adhesive remover to loosen the dressing, be sure to wash
the skin with water to remove all residue, as this can be very irritating.

If there is difficulty in obtaining aspirate:

• To attempt to push the tube’s port away from the stomach wall insert -5ml of air via syringe down the
nasogastric tube and then try again o aspirate tube and test with ph indicator paper

• Lie the child on their left side and then try again and/or encourage the child to take a small amount of oral
fluid (if allowed) and then try to aspirate the tube

• Try advancing or retracting the tube slightly

• If unsure if tube is correctly positioned then seek further advice from community or hospital professionals

Bolus feeding

• Prepare feed and equipment in a clean area

• Check feed (including feed type and expiry date; if the feed is curdled do not use)

• Wash hands before and after the procedure

• Explain to the child that they are going to have their feed

• Check feeding tube position (if nasogastric tube in situ)

• Ensure the child is positioned correctly for feeding

• Flush the feeding tube

• Attach syringe without the plunger to the feeding tube

• Slowly pour the amount of feed required into the syringe

• If the feed is running to quickly or slowly alter the height of the syringe slightly, a feed should take between
15-30 minutes

• When feed finished, remove the syringe

• Flush the feeding tube at least 10mls of cool boiled water (unless otherwise indicated); replace the end cap

Caring for gastrostomy tube

Skin care

For the first 10 days post gastrostomy tube insertion:

• Leave external fixation device in situ

• Clean skin around stoma site and under retention device with sterile water using gauze and ensure the skin is
then dried thoroughly

• Avoid using creams and talcum powder as they can irritate the skin and cause infection; creams can reduce
the effectiveness of the device and effect the tube material itself

• Avoid occlusive dressings as they can encourage and trap moisture

After 10 days:

• Loosen the external fixator device as advised by the manufacturer’s guidelines in order that the skin around
the stoma site can be cleaned thoroughly; note the original position so it can be returned to the same point on
the tube after cleaning

• Clean site with a mild solution of soap and water, rinse and dry thoroughly

• Retighten the external fixator so that it lies approximately 2mm from the skin surface, this may need to be
loosened or tightened as thec hild loses or gains weight

• Loosen the external fixator and push the tube in a little way and turn tube 360° on a daily basis and then pull
tube back to original place(this depends on tube manufacturer’s guidelines)

• Inspect the skin for signs of redness, swelling, irritation, skin breakdown and leakage

• The use of a dressing will depend on the child’s skin condition and will require individual assessment of the
child’s needs checking balloon inflation

This should be done on a weekly basis.

• Wash hands before and after the procedure

• Attach a syringe onto the inflation valve of the balloon gastrostomy

• It is advisable to hold on to the tube, ensuring it remains in the child’s stomach

• Gently draw back the plunger on the syringe until no more water comes out of the internal balloon

• Check the recommended volume of the balloon as stated on the inflation valve

• Using cool boiled water, reinsert recommended volume through the inflation valve to re-inflate balloon

Replacing gastrostomy tube

• If the child has a peg tube that falls out medical attention must besought as soon as possible

• If a gastrostomy tube falls out then it should be replaced as soon as possible, preferably within 1-2 hours, or
the stoma will start to close

• The procedure for changing the gastrostomy tube will depend onindividual manufacturer's guidelines

• Guidelines for the frequency of changing tubes should be provided bythe manufacturer

• Staff/parents and carers involved in changing gastrostomy tubesshould have received appropriate training

• A replacement tube should be kept with the child (e.g. at school)

Problems/ Complications :

Clogged or plugged feeding tube (follow only the checked instructions):

 Flush tube with warm water.

 Use Clog-Zapper® if instructed to do so.
 Remove and replace the tube.

Coughing while tube is inserted:

 If your child gags or coughs during the feeding, pinch the tube and pull it out.
 Comfort your child until calm, and try again.
 Before starting the feeding, be sure to check the placement of the tube (see “Checking the tube
placement”).

Diarrhea and cramping:

 Check to see if the formula concentration is correct.

 Allow formula to hang a maximum of 4 hours.
  Do not mix new formula with formula that has been hanging.
 Slow the feeding rate or stop for awhile. Be sure to flush the tube with warm water to prevent
clogging.
 Warm the formula if it is cold.
 Call doctor if this continues.

Nausea (upset stomach) or vomiting (throwing up):

 Slow feeding rate or stop feeding for a while. Be sure to flush the tube with warm water to prevent
clogging.
 Start feeding again when the child feels better.
 Call doctor if this continues.

Skin around the nose is irritated:

 Keep the area around the nostrils clean and dry.

 Tape down, not up over the nose (ask the nurse show you how to tape the tube).
 Alternate nostrils when replacing tube.

References

 Anderton,A. (1999) microbal contamination of enteral tube feeds –how can we reduce the risk?
nutricia clinical carebax,m. (1989) eating is important, developmental medicine and child eurology,
31, 285-286
 Colagiovanni,l. (1999) taking the tube, nursing times supplement,95 (21), 63-66
 Elia,M. Russell,C. Stratton, R. (2001) trends in artificial nutrition supportin the uk during 1996 –
2000.
 A report by the British Artificial Nutritionsurvey a committee of the british association for parenteral
andenteral nutrition. bapen: berkshire.
 Estoup,M. (1994). approaches and limitations of medication delivery in patients with enteral feeding
tubes. critical care nurse. 14(1), 68-81
 COLOSTOMY CARE

Guidelines:
Helpful hints

• Eat a well-balanced diet including vegetables and fresh fruits. Eat on a regular schedule. Drink at least 6 to 8
glasses of fluids daily.

• Eat slowly in a relaxed atmosphere. Chew your food thoroughly. Avoid chewing gum, smoking, and
drinking from a straw. This will help decrease the amount of air you swallow, which may help reduce gas.

• Eating yogurt or drinking buttermilk may help reduce gas.

• To control gas at night, do not eat after 8 p.m. this will give your bowel time to quiet down before you go to
bed.

• If gas is a problem, use beano. Sprinkle beano on the first bite of food before eating to reduce gas. It has no
flavor and should not change the taste of your food.

• Limit the use of foods like fish, onions, garlic, broccoli, asparagus, and cabbage to prevent stronger odor
from the pouch.

Applying the pouching system

To apply your pouch, follow these steps:

1. Place all your equipment close at hand before removing the pouch.

2. Wash your hands.

3. Provide standing or sitting position to the child. Remember to must keep the skin around the stoma
wrinkle-free for a good seal.

4. Gently remove the used pouch (1-piece system) or the pouch and old wafer (2-piece system). Empty the
pouch into the toilet. Save the closure clip to use again.

5. Wash the stoma itself and the skin around the stoma. Stoma may bleed a little when being washed, this is
normal. Rinse and pat dry. Use a wash cloth or soft paper towels (like bounty), mild soap (like dial, safeguard,
or ivory), and water. Avoid soaps that contain perfumes or lotions.

6. For a new pouch (1-piece system) or a new wafer (2-piece system), measure stoma using the stoma guide
(fig. 1) in each box of supplies.

7.Trace the shape of stoma onto the back of the new pouch or the back of the new wafer (fig. 2). Cut out the
opening fig. 3). Remove the paper backing and set it aside.

8.Optional: Apply a skin barrier powder to surrounding skin if it is irritated (bare or weeping), and dust off
the excess.

9. Optional: Apply a skin-prep wipe (such as skin prep) to the skin around the stoma, and let it dry. Do not
apply this solution if the skin is irritated (red, tender, or broken) or if you have shaved around the stoma.

10. Optional: Apply a skin barrier paste (such as stomahesive, coloplast, or premium) around the opening cut
in the back of the pouch or wafer. Allow it to dry for 30 to 60 seconds.

11. Hold the pouch (1-piece system) or wafer (2-piece system) with the sticky side toward your body. Make
sure the skin around the stoma is wrinkle-free. Center the opening on the stoma, then press firmly to your
abdomen (fig. 4). Look in the mirror to check if you are placing the pouch, or wafer, in the right position. For
a 2-piece system, snap the pouch onto the wafer. Make sure it snaps into place securely.

12. Place your hand over the stoma and the pouch or wafer for about 30 seconds. The heat from your hand
can help the pouch or wafer stick to your skin.

13. Add deodorant (such as super banish or nullo) to your pouch. Other options include food extracts such as
vanilla oil and peppermint extract. Add about 10 drops of the deodorant to the pouch. Then apply the closure
clamp.

Note: Do not use toxic chemicals or commercial cleaning agents in your pouch. these substances may
harm the stoma.

14. Optional: For extra seal, apply tape to all 4 sides around the pouch or wafer, as if you were framing a
picture. You may use any brand of medical adhesive tape.

15. Change your pouch every 5 to 7 days. Change it immediately if a leak occurs.

16. Wash your hands. if you are wearing a 2-piece system, you may use 2 new pouches per week and
alternate them. Rinse the pouch with mild soap and warm water and hang it to dry for the next day. Apply the
fresh pouch. Alternate the 2 pouches like this for a week. After a week, change the wafer and begin with 2
new pouches. Place the old pouches in a plastic bag, and put them in the trash.

Tips for colostomy care

Applying your pouch

• You may stand or sit to apply your pouch.

• Keep the skin where you apply the pouch wrinkle-free. If the skin around the pouch is wrinkled, the seal
may break when your skin stretches.

• If hair grows close to your stoma, you may trim off the hair with scissors, an electric razor, or a safety razor.

• Always have a mirror nearby so you can get a better view of your stoma.

• When you apply a new pouch, write the date on the adhesive tape. This will remind you of when you last
changed your pouch.

Changing your pouch

• The best time to change your pouch is in the morning, before eating or drinking anything. Your stoma can
function at any time, but it will function more after eating or drinking.

Emptying your pouch

• Empty your pouch when it is one-third full (of urine, stool, and/or gas). If you wait until your pouch is fuller
than this, it will be more difficult to empty and more noticeable.

• When you empty your pouch, either put toilet paper in the toilet bowl first, or flush the toilet while you
empty the pouch. This will reduce splashing. You can empty the pouch between your legs or to one side while
sitting, or while standing or stooping. if you have a 2-piece system, you can snap off the pouch to empty it.
Remember that your stoma may function during this time.

• If you wish to rinse your pouch after you empty it, a turkey baster can be helpful. When using a baster,
squirt water up into the pouch through the opening at the bottom.with a 2-piece system, you can snap off the
pouch to rinse it. After rinsing your pouch, empty it into the toilet.

• When rinsing your pouch at home, put a few granules of dreft soap in the rinse water. This helps lubricate
and freshen your pouch.

• The inside of your pouch can be sprayed with non-stick cooking oil (pam spray). This may help reduce stool
sticking to the inside of the pouch.

Bbathing

• You may shower or bathe with your pouch on or off. Remember that your stoma may function during this
time.

• The materials you use to wash your stoma and the skin around it should be clean, but they do not need to be
sterile.

Reducing odor

• Limit foods such as broccoli, cabbage, onions, fish, and garlic in your diet to help reduce odor.

• Each time you empty your pouch, carefully clean the opening of the pouch, both inside and outside, with
toilet paper.

• Rinse your pouch 1 or 2 times daily after you empty it (see directions for emptying your pouch and going
away from home).

• Add deodorant (such as super banish or nullo) to your pouch.

• Use air deodorizers in your bathroom.

• Do not add aspirin to your pouch. even though aspirin can help prevent odor, it could cause ulcers on your
stoma.

COLONIC IRRIGATION

Definition

Colonic irrigation (also known as colonics, colonic lavage, colon irrigation, high colonic or colon
hydrotherapy) is the practice of cleansing the colon using filtered and temperature regulated water via a rectal
catheter.

Current best practice guidelines for colonic irrigation recommend:

The procedure room should:

• Be as hygienic as possible to avoid and protect both the client and operator from disease transmission.

• Have a hands-free basin with hot and cold running water supplied through a single outlet, liquid soap and
paper towels.

• Have a toilet and shower for the exclusive use of the client located in the procedure room or as an ensuite.

• Have paper towel on the client couch.

• Have paper towel for each client to clean themselves after the irrigation procedure.

• The clinic should provide clean and comfortable facilities for you to change. Clean gowns, robes and towels
should be provided.

• Care should be taken that the systems tubing does not become blocked during the procedure.

• A water-based lubricant in a single use sachet is recommended to assist catheter insertion. Single use gloves
should be worn by the operator when assisting a client to insert a catheter and discarded immediately after
use. If the client is positioning the catheter they should be provided with single use wipes.

• Water temperature must be regulated to normal body temperature to prevent thermal shock or scalding. The
temperature of the water delivery should be between 34 and 40°C and should never exceed 40°C. Normal
body temperature should be the guide and this is 37.6°C. If you have concerns about the temperature of the
water before or during the procedure, you should discuss this with the operator.
• The controls should be placed so that clients are unable to alter settings once the procedure commences.

• Operators should have clean clothes and no exposed cuts, abrasions or wounds. Hands must be washed and
thoroughly dried immediately before putting on new gloves before the procedure and on completion of the
procedure.

• Colonic irrigation equipment should have an Australian Register of Therapeutic Goods (ARTG) inclusion
number. Policies and procedures for safe operation should be in place, and the manufacturers’ instructions,
including maintenance, strictly followed.

• Under no circumstances should the colonic irrigation equipment be connected directly to a potable
(drinking) water supply system. A direct connection could result in (a) a serious (and possibly fatal) injury to
a client due to application of mains pressure; and (b) under abnormal conditions such as a sudden drop in
mains pressure, the potable water supply could become contaminated with faecal matter.

• The tubing and catheters used in this process should be single use only.

Risks

People with acute or chronic illnesses, who aresuffering from diarrhoea, or who are immunocompromised
should seek medical advice prior to undertaking any colonic irrigation procedure. Potential risks for any client
include:

• Infection due to unsterile equipment that permits backflow of faecal material to the water system.

• Injury to the colon, such as ulceration or perforation.

• Exacerbation of chronic bowel disease such as diverticulitis, Crohn’s Disease or haemorrhoids.

• Scalding if water temperature regulating controls fail.

• Reduced capacity to control bowel movements for a period of time after the procedure.

• Removal of normal intestinal flora may lead togastrointestinal infections.

The procedure

The first stage of the colonic irrigation procedure involves massage of the lower abdominal area. A sterile
single use catheter is then gently inserted into the rectum by either the operator or the client. Filtered and
temperature regulated warm water, and occasionally herbs or oxygen (ozone therapy), is gradually introduced
into the colon and natural evacuation of faeces occurs. If you have any allergies you should let the operator
know before the introduction of additives.
After care

If you develop an infection, feel weak, or have any other unusual symptoms following therapy, stop treatment
and check with your doctor. You should also report these symptoms to the operator.

Reference:

www.health.vic.gov.au/ideas

ASSISTING IN RESUSCITATION

DEFINITION

Resuscitation is an emergency or crisis-oriented care provided to patients with serious potentially life
threatening injuries or illness.

PURPOSE

1. To preserve and restore life

2. To prevent deterioration before more definitive treatment can be given

3. To restore the patient to useful living

EQUIPMENT

1. Resuscitation Bay / Trolley

2. Crash trolley with complete emergency drugs

3. Defibrillator

4. Cardiac Monitor

5. E.C.G Machine

6. Suction Apparatus

7. Oxygen mask/Oxygen supply

8. Cardiac board

9. Oro/Naso-pharyngeal airways

10. Hard/Soft cervical collars

11. Sandbags

12. Diagnostic set

13. Torch

14. B.P Apparatus with stethoscope

15. Intubation Instruments-laryngoscope, Magill forceps, swivel connectors

16. ET tubes of different sizes

17. Urinary catheters with drainage bags

18. Doppler machine

19. Scoop

20. Splints or traction kit

21. Identity bands

22. Minor procedure sets-suturing sets, D.P.L, I.C.D, cut down sets, catheterization set and the Tracheostomy
set.

PROCEDURE

S. no. Steps of procedure Rationale

1. Check the resuscitation area To ensure proper functioning of all
 Crash trolley equipped and ready to use equipments and availability of all
 Cardiac monitors, Ventilators, Defibrillators required sources every shift and after
are in good working condition every resuscitation.
 Oxygen and suction available
 I.V.F (crystalloids/colloids) available
 Emergency intubation drugs available in a
separate tray
 Minor procedure sets (sterile) ready
- Suturing sets
- DPL
- Tracheostomy set
- Cut down sets
- ICD sets
2. Place the patient in supine position. For proper management
3. Ensure patient’s privacy. To avoid unnecessary embarrassment
4. Assess the level of consciousness and initiate To determine the neurological
 the primary survey
* Apply a hard/soft collar or sandbags
* Insert an oral or nasopharyngeal airway
* Initiate cardiac monitoring or obtain V/S
5. Start 100% oxygen inhalation
6. Ensure two peripheral IV lines by using
cannula G 14 or 16 and commence two pints
of Normal Saline.
7. Assist the trauma team in performing the
secondary survey, a systematic 2-3 minute
examination of the patient from head to toe
assessment.
8. Expose / undress the patient.
9. Apply pressure bandage on wounds.
Immobilize any fractures.
10. Ensure that blood samples are sent to the
laboratory for investigations.
11. Prepare and assist for any surgical or diagnostic
procedure such as C.T scan, ultra sound, D.P.L,
I.C.D, X-rays and E.T.C.
12. Escorting the patient to OT, ICU, or other
respective wards.
13. Document the procedure appropriately including
the response of the patient.
status of the patient.
To immobilize cervical spine or
any suspected spine with cord
injuries.
To maintain a patent airway.
To determine base line data for
comparison.
To improve circulation and
prevent hypervolemic shock.
To detect additional injuries and
prioritize the treatment or detect
underlined medical conditions.
To look for clues for injuries such
as wounds, fractures, abrasions or
lesions.
To avoid bleeding.
To prevent further displacement.
To detect abnormalities and provide
base line data for comparison.
To detect abnormalities and for
diagnostic purposes.
To perform the definitive stage or
care.
For accurate evaluation of the
progress of the patient.
 INCENTIVE SPIROMETERY

Definition

Simple, inexpensive, and noninvasive, spirometry is a versatile measure of lung function and is the most
objective, reproducible test for COPD. Spirometry measures the volume of air forcefully exhaled from the
point of maximal inspiration and the amount of time (in seconds)taken to complete.

Purposes

In obstructive lung disease, such as COPD, lung volume may be normal, but air flow is diminished.

Conversely, in restrictive lung disease, such as pulmonary fibrosis, lung volume is reduced, but air flow may
be normal. Postbronchodilator spirometry can be used for the differential diagnosis of COPD and asthma
because it can confirm the partially reversible airway limitation that is characteristic of COPD.

SPIROMETRY IN PRIMARY CARE

Primary care physicians who want to conduct in-office spirometry need to have staff specially trained in
spirometry to perform the test and maintain the equipment

PROCEDURE

Spirometry can be performed in the primary care setting, provided that good skills training and an ongoing
quality assurance program are available.

To ensure a meaningful test result, patients should be fully instructed as follows

• Explain or demonstrate how the procedure works to aid compliance and ease anxiety

• Make sure patients are seated upright rather than bent over

• Place and adjust nose clips to prevent air leakage

• Instruct patients to breathe in as deeply as they can and exhale as forcefully as they can. For a COPD
diagnosis, an expiratory time of at least 6 seconds generally is recommended

References:

Mannino DM, Homa DM, Akinbami LJ, et al. Chronic obstructive pulmonary disease surveillance—United
States,1971–2000. MMWR Surveill Summ.2002;51(SS- 6):1-16. 2.

Lethbridge-Çejku M, Rose D, Vickerie J. Summary health statistics for U.S. adults: National Health
Interview Survey, 2004.

National Center for Health Statistics. Vital Health Stat. 2006;10(228). 3. National Heart, Lung,and Blood
Institute. Morbidity & Mortality: 2004 chart book on cardiovascular, lung,and blood diseases. May 2004.

Bethesda, Md: U.S. Department of Health and Human Services, Public Health Service, National Institutes of
Health; 2004.
 CHEST PHYSIOTHERAPY

Introduction

Chest Physiotherapy is the removal of excess secretions (also called mucus, phlegm, sputum) from inside the
lungs, by physical means. It is used to assist a cough, re-educate breathing muscles and to try to improve
ventilation of the lungs.

What are the excess secretions and what causes them?

The lungs are kept moist with a thin film of fluid to stop them drying out. When there is a chest infection or
occasionally in other situations, this fluid increases and becomes thick and putrid. In the normal situation,
these secretions are removed by coughing but in the presence of weakness, or in chronic lung disease, this is
not always possible. Although antibiotics can control the infection, they do not remove the secretions that
occur. Some will be reabsorbed into the body but very thick ones will remain.

Why is it important to remove the secretions?

It is important to remove the secretions to allow more effective breathing and increase the amount of oxygen
getting into the body.

How is chest physiotherapy done?

The first way of trying to remove the secretions is by postural drainage. This uses gravity and correct
positioning to bring the secretions into the throat where it is easier to remove them. The lungs are divided
into segments called lobes and at times, certain lobes can be more affected than others.

If the bottom lobes have more secretions, then the child/adult will be tipped head down. If one lung is more
affected than the other, then they will be positioned on the opposite side.

Many children with SMA do not like lying on their front because they find it difficult to move and breathe. It
is important for your physiotherapist to be aware of this and to adapt the positions accordingly. Some also do
not like to be on their back for the same reason. When tipping the child over pillows to get them 'head down',
the pillows should be placed under the pelvis, NOT under the chest.

In babies, it may be more usual for the upper lobes to be affected and then the baby will be propped in sitting
position to try and clear some of the secretions.

Another technique is percussion. This involves a form of 'patting' the chest to vibrate the lungs and help the
secretions move. It is not hitting! 'Vibrations' and 'patting' do what they say, to try and clear the airways.

Assisted coughing is a very important adjunct to chest physiotherapy and when done well is effective and
comfortable. It assists the work of the diaphragm to increase the cough pressure and try and force the
secretions out.

Some physiotherapists prefer a technique called active cycle of breathing which involves taking deep breaths
and trying to 'Huff' the air out. Huffing is that funny thing we all do if we feel we have something in the back
of our throat. The problem with this sort of treatment in SMA is that often the children cannot take a big
enough breath for this to be effective.

Manual hyperinflation or bagging: this is a technique most often used in intensive care but some
physiotherapists do use this in a ward or home situation. It involves the use of a facemask attached to a
special rubber or plastic 'bag'. By pressing the bag, air can be pushed into the chest to help it expand. This is
not as easy as it sounds. There are machines that can do this, the 'Bird' or 'Cough Machine' (see below)

When should chest physiotherapy be done?

Chest physiotherapy should never be done straight after a meal or drink. For a meal wait one hour and after a
drink wait ½ hour. Chest physiotherapy should be done when secretions need removing and this may be once
a day or it may be 4-5 times a day. It is often useful to do physio first thing in the morning before getting out
of bed. The chest will have been relaxed at night and the secretions may be easier to remove.

Are breathing exercises and breathing exercise equipment helpful?

Many studies have been done in different muscle disorders to try and find out if breathing exercises are
useful. Unfortunately they do not all agree and some studies are not as well done as others. The important
thing is that breathing exercises will not do any harm and like all exercises, the strongest muscles will benefit
most from exercise. This means that in the weakest children, they are unlikely to be very helpful. Devices
like PEP masks, 'Flutters' and 'Cornets' again have conflicting evidence about their effectiveness in helping to
strengthen either the inspiratory muscles (for breathing in) or expiratory muscles (for breathing out and
coughing) but none have been shown to do any harm.

Other exercises that will help to build up stamina and breathing reserve include: swimming/hydrotherapy,
singing, playing a light wind/toy instrument. Games like blow football and a jolly good tickle are all good for
the chest!
 ASSISTING IN LUMBER PUNCTURE

Introduction:

Lumbar puncture is a procedure that is often performed in the emergency department to obtain information
about the cerebrospinal fluid (CSF). Although usually used for diagnostic purposes to rule out potential life-
threatening conditions such as bacterial meningitisor subarachnoid hemorrhage, lumbar puncture is also
sometimes performed for therapeutic reasons, such as the treatment of pseudotumor cerebri. CSF fluid
analysis can also aid in the diagnosis of various other conditions, such as demyelinating diseases and
carcinomatous meningitis. Lumbar puncture should be performed only after a neurological examination and
should never delay potentially lifesaving interventions such as the administration of antibiotics and steroids to
patients with suspected bacterial meningitis.

Indications

 Suspected CNS infection

 Suspected subarachnoid hemorrhage
 Therapeutic reduction of cerebrospinal fluid (CSF) pressure
 Sampling of CSF for any other reason

Contraindications

 Local skin infections over proposed puncture site (absolute contraindication)

 Raised intracranial pressure (ICP); exception is pseudotumor cerebri
 Suspected spinal cord mass or intracranial mass lesion (based on lateralizing neurological findings or
papilledema)
 Uncontrolled bleeding diathesis
  Spinal column deformities (may require fluoroscopic assistance)
 Lack of patient cooperation

Articles reqired:

 Lumbar puncture tray (to include 20 or 22 gauge Quinke needle with stylet, prep solution,
manometer, drapes, tubes, and local anesthetic)

Universal precautions materials

Preprocedure patient education

 Obtain informed consent

 Inform patient of possibility of complications (bleeding, persistent headache, infection) and their
treatment
 Explain the major steps of the procedure, positioning, and postpocedure care

Procedure

o Assess indications for procedure and obtain informed consent as appropriate

o Provide necessary analgesia and/or sedation as required
o Position patient: lateral decubitus position with “fetal ball” curling up, or seated and leaning
over a table top; both these positions will open up the interspinous spaces (see Figure 1)
ASSISTING IN ICD
 ASSISTING IN BONE MARROW ASPIRATION

Bone Marrow Aspiration

The bone marrow is usually regarded by the public and physicians as a brutal, extremely painful procedure
which is difficult to master. However, with knowledge and some experience, successful marrow procedures
can be repeatedly performed with minimal discomfort to the patient.

Definition

A bone marrow examination is a critical part of the evaluation of patients with a variety of hematopoietic and
non-hematopoietic diseases. It is performed for diagnostic purposes in patients with splenomegaly,
dysproteinemias, suspected lysosomal storage disease,an unexplained deficiency or excess of peripheral blood
leukocytes or platelets, or the presence of immature or morphologically atypical cells in the peripheral blood.

Purpose

Peripheral blood examination and other routine laboratory assays do not always provide enough information
for the diagnosis of hematologic disease. In some patients direct microscopic examination of the bone marrow
is required for confirmation of a suspected clinical diagnosis or monitoring the course of medical therapy.
Occasional patients also require bone marrow collection for special studies, such as cytogenetic analysis, flow
cytometry, molecular studies, or microbiologic cultures.
Indication

 Anemia
 Leukopenia
 Thrombocytopenia
 Pancytopenia
 Non-Hodgkin's Lymphoma
 Hodgkin's disease
 Metastatic carcinoma
 Acute leukemia
 Myeloproliferative disease
 Myelodysplastic syndrome
 Lymphoproliferative disease
 Plasma cell dyscrasia
 Fever of unknown origin
 Hepatosplenomegaly

Preperation for procedure

1.Obtaining Patient Medical Information

A successful bone marrow evaluation requires knowledge of the patient and the reason(s) the study was
requested. The following information should be obtained when the laboratory is first contacted to schedule the
marrow study:

 Patient name
 Patient age and gender
 Patient location/requested time of examination
 Primary diagnosis
 Clinical indication(s) for examination
 Allergies (especially to povidone iodine and lidocaine)
 Recent chemotherapy, radiation therapy, bone marrow transplantation, or blood transfusions
 Dietary, racial, and family history
 Medications (iron, B12/folate, G-CSF, aspirin, coumadin,heparin, antibiotics, etc.)
 Special studies requested (immunophenotypic analysis,cytogenetic analysis, culture, etc.)
 Special medical problems that may preclude procurement or written consent or complicate the
procedure (i.e.,unresponsive or mentally incompetent patient, adversity to medical procedures,
anxiety, pain intolerance, disease or recent surgery involving the pelvic bone, hemophilia or other
bleeding disorder, severe cardiac or pulmonary disease, morbid obesity etc.)
 Name/pager #/telephone # of person requesting examination
 Name of attending physician

2.Reviewing the Patient’s Medical Record

The patient’s chart should be reviewed upon arriving at the location of the marrow procedure to verify the
information previously provided to the laboratory. Do not assume that this information is complete or correct.
The following facts should be verified:

 Is the patient identification correct? Use hospital numbers in addition to names.

 Is the request for a marrow procedure justified?
 Can the patient give written consent for the procedure? If not,obtain the name and telephone number
of the person giving consent
 Does the patient have special medical problems which may complicate the procedure? These may
include disease or recent surgery involving the pelvic bone, bleeding, severe cardiac or pulmonary
disease, unusual sensitivity to pain,adversity to medical procedures, allergies to iodine or lidocaine,
extreme obesity
 Once the chart review is completed, the nurse caring for the patient should be notified of the
procedure and necessary assistance

3.Meeting the Patient

 The identification of the patient must be absolutely confirmed,preferably by verifying the hospital
number and name from a wrist band or identification card. If such is not available, the patient should
be asked to state their name and asked whether they were expecting to have a marrow performed.
 The marrow team should be introduced to the patient. The procedure must be explained to the patient,
all questionsanswered to the satisfaction of the patient and family members, and written consent
obtained from the patient.If the patient cannot provide written consent, it should be obtained from the
next-of-kin. In the rare circumstance of an incapitated patient without a family, a court order must be
obtained. Under no circumstances should a bone marrow be obtained without written permission.
 Individuals performing a bone marrow procedure must also be thoroughly familiar with and follow all
institutional policies regarding consent for medical procedures.
 All questions should be answered completely and the patient should then be given the opportunity to
sign the written consent form. Some patients are reluctant at first to grant consent and require further
persuasion or time to consult with their family or attending physician.The attending physician should
be notified if the patient refuses to grant written consent.
 Although the vast majority of patients do not require pharmacologic intervention other than local
anesthesia, the procedure may need to be delayed until the proper type of sedation can be arranged.

General Considerations

Hematopoietically active bone marrow is distributed throughout the skeleton in children, but it is restricted to
the axial bones of adults Of the potential sites to obtain the bone marrow, the posterior iliac crest is optimal
for reasons of safety and ease of performance.

Alternative sites should be considered if the posterior iliac crest is diseased or inaccessible because of morbid
obesity or inability to position the patient correctly. These alternative sites include the tibia (infants only),
anterior iliac crest (children and adults), and sternum(adults only, aspiration only). Sternal marrow
examination should be considered only if other sites are unacceptable, and is completely contraindicated in
patients with diseases associated with bone resorption, including multiple myeloma (Foucar, 1995).There is a
continuing debate about adequate marrow sampling for various purposes. Most studies of multiple marrow
sites have revealed marrow cellular content, cellular composition, and pathologic esions to be rather
uniformly distributed through the bone marrow.Therefore, most hematopathologists today consider an
adequate sample from a single site acceptable in most patients.

Equipment

 A compartmentalized plastic or wooden tray

 equipment may be carried in
 a wheeled cart with a flat work surface for preparing the marrow slides.
 Adequate routine supplies to perform several bone marrow
 examinations should be carried in the tray, as well as any special
 tubes, preservative solutions

Positioning the Patient

The patient is positioned as follows, depending on the location of the procedure:

1) Posterior iliac crest (PIC) – The patient is placed in a right or left lateral decubitus position
with their knees flexed, a pillow under their head, and their eyes away. The posterior iliac
crest may be used in patients over one year of age.

2) Anterior iliac crest (AIC) - The patient is placed in a supine position, with their hips and
knees flexed, and eyes averted away. This site is appropriate only in adults when the posterior
iliac crest is inaccessible because of obesity, infection, injury, or inability to position the
patient in the lateral decubitus position. The thick, hard cortical layer of the anterior iliac
crest.
3) Sternum - Supine position, head and eyes away, light towel over face “to keep things sterile”
and cover eyes.

4) Tibia – Marrow aspiration from the anteromedial surface of the tibia is performed only in
children less than 18 months of age.The tibia is an unsatisfactory site in older individuals
because of variable cellularity and the hardeness of the cortical bone.

The skin surrounding the procedure site should be cleaned as follows:

 Use three sterile, disposable swabs soaked with 10% povidone-iodine solution (Betadine Solution,
Purdue Frederick Company). For individuals allergic to iodine,chlorhexidine gluconate, 4% (Betasept
Surgical Scrub may be utilized.
 With each of the three swabs, wash the skin in a circular motion beginning with the marked site and
working outward approximately four inches.
 Remove the povidone-iodine in the center of the washed area with a single swipe of a sterile
 isopropyl-soaked swab.
 Most patients who are anxious at first are adapting well to the experience by this time, but the anxiety
level actually increases in a few patients. occasional patients may. Drugs commonly used for the bone
marrow procedure are listed in Tabl require conscious sedation to permit proper marrow
procurementeI.
 Administering Local Anesthesia
 Once a sterile site has been achieved, a local anesthetic is utilized to “numb” the skin and periosteum
over the chosen area of the posterior iliac crest. Lidocaine or a similar local anesthetic can be
used,providing the patient has no history of an allergic reaction to this medication (BE SURE TO
ASK!). During this process, local anesthetic is first infiltrated into the skin and subcutaneous tissue to
anesthetizean area approximately 1 cm. in diameter.
 Determine the adequacy of local anesthesia after several minutes by gently tapping the periosteum
with the sharp point of the numbing needle. If sharp pain is stilled experienced,the injection of
additional lidocaine is required. Unbuffered lidocaine is used for this purpose.

PROCEDURE

Marrow aspiration from the posterior or anterior iliac crest is performed as follows:

1. Fill the necessary number of 10 mL syringes with heparin solution or other anticoagulant as required.
Regardless of the suspected diagnosis or purpose of the study, it is best to obtain at least one heparin-
anticoagulated tube of marrow aspirate, “just in case” it is needed for special studies
(i.e.,microbiologic culture, immunophenotypic analysis, cytogenetic analysis, molecular biology
studies, etc.).
2. Obtain the desired marrow aspirate needle from the assistant and inspect for signs of manufacturing
defects. Remove the plastic guard from the needle (if one is present).
3. Loosen and remove the obturator to make certain that it can be removed with ease. Insert obturator
and relock. Hold the needle with index finger near needle tip to control the depth of penetration.
4. Hold needle horizontally (for a patient lying on their side) or vertically (if supine) to puncture the
anesthetized skin. If the skin is tough, make a small incision with a sterile scalpel.
5. Advance the needle with steady pressure and a slight twisting motion to the center of the posterior
iliac prominence (PIC) or to the bone (AIC). Angle the needle 15 degrees caudad (PIC) or cephalad
(AIC).
6. A 16 gauge Illinois sternal/ Iliac aspiration needle has been placed into the marrow cavity. The
obturator is being removed.
7. Rotate the needle back and forth (90o-180o) and carefully apply pressure to advance the needle
through the cortical bone. The consistency of the bone varies considerably from patient to patient, but
may have significance as follows:Soft (“Swiss cheese”) consistency = osteoporotic bone(elderly
patient, multiple myeloma, renal failure, some postchemotherapypatients), firm (“pine board”)
consistency =Normal for young athletic individuals, very hard (“oak board”)consistency = possible
hyperostosis.
8. Decreased resistance (Usually!) indicates penetration of cortex and entry into the marrow cavity.
9. Advance needle about 1 cm into the marrow cavity. Unlock and slowly remove the obturator. Some
patients may notice pain if the obturator is not removed carefully.
10. The obturator of the Illinois sternal/Iliac aspiration needle has been removed and a 10 mL syringe
 attached to the hub. Suction is being applied to the syringe, with successful aspiration of marrow.
11. Preparing aspiration smears. An experienced medical technologist is preparing smears from small
drops of the bone marrow aspirate placed on glass microscope slides. Attach a 10 ml syringe to the
aspirate needle. Quickly (<5 seconds) aspirate 1.0 mL marrow into the 10 mL syringe (more than this
dilutes the specimen with peripheral blood).
12. BEWARE! The sudden sharp pain may cause the patient to shout, move suddenly, or even try the
strike you! Remain alert, try to maintain sterility, and calm the patient quickly if this happens.
13. Quickly give the syringe to the technical assistant to prepare specimen slides. Hold a finger over
needle opening to prevent blood flow while the technician prepares slides and evaluates for the
presence of spicules.
14. If spicules are present, extra marrow specimen(s) for special studies can be obtained. Aspirate
approximately 2 mL of marrow into a syringe containing 1 mL of heparin solution.
15. If a “dry tap” (no fluid, no sharp pain) occurs, then reposition needle (depth, angle or location) and try
again. As a “last resort” touch preparations can be prepared from the core
16. Remove aspiration needle and apply pressure with a sterile sponge until bleeding ceases. Apply a
pressure bandage, and have patient lie supine for at least 30 minutes (see “Finishing Up” below).
17. Aspirate marrow specimen

After care

 After procurement of the marrow specimens, bleeding must be stopped, the procedure site must be
cleaned up, needles properly disposed of in a Sharps container, and the site bandaged. A procedure
note must be placed on the patient’s chart.
 Apply pressure with thumb or fingers to procedure site until bleeding has completely ceased. Gently
remove and dispose of the fenestrated drape.
 Completely remove povidone-iodine from the skin with alcohol swabs. Residual povidone-iodine
may cause itching and lead to a future allergic response. Double gauze square an place over the
procedure site. Cover the area with at least two pieces of surgical tape approximately 2-3 inches in
length. Pressure tape should benused if unusual oozing was encountered during the procedure, and in
patients with thrombocytopenia or a history of ahemostatic disorder.
 Advise the patient to remove the dressing the following day, after first wetting the tape to make
removal easier. Have the patient lie supine, putting pressure on the procedure site for at least 30
minutes. Advise the patient to contact their physician if tenderness or bleeding is noted at the
procedure site during the next few days. Thank the patient for their cooperation.Carefully dispose of
the syringes and needles in a sharps container. Advise the patient’s nurse or physician that you have
completed the procedure and remind them to keep the patient supine for 30 minutes.
 Place a note on the patient’s chart. This is required for medicolegal and billing purposes, as well as to
alert the patient care team to the performance of the procedure and any complications that were
encountered.

Reference:
 1. Bearden, J.D., Ratkin, G.A., et al.. Comparison of the diagnostic value of bone marrow biopsy and
bone marrow aspiration in neoplastic disease. J. Clin. Pathol. 27(9): 738-740, 1974.
2. Birch, C.D., Fischer, S. et al. Diagnostic bone-marrow studies extended routinely by iliac crest
biopsy, using the method of Schaadt- Fischer. Acta. Pathol. Microbiol. Immunol. Scand. [A] 90(4):
229-234,1982.
3. Bird, A.R. and Jacobs, P. Trephine biopsy of the bone marrow. S. Afr. Med. J. 64(8): 271-276, 1982.
4. Block, M. Bone marrow examination: aspiration or core biopsy,smear or section, hematoxylin-eosin
or Romanowsky stainwhich combination? Arch. Pathol. Lab. Med. 100(9): 454-456, 1976.
5. Brook, M.G., Ayles, H. et al. Diagnostic utility of bone marrow sampling in HIV positive patients.
Genitourin. Med. 73(2): 117-121,1997.

ASSISTING IN KIDNEY BIOPSY

What is a kidney biopsy?

A biopsy is a diagnostic test that involves collecting small pieces of tissue, usually through a needle, for
examination with a microscope. A kidney biopsy can help in forming a diagnosis and in choosing the best
course of treatment. A kidney biopsy may be recommended for any of the following conditions:

 hematuria, which is blood in the urine

 proteinuria, which is excessive protein in the urine
 impaired kidney function, which causes excessive waste products in the blood

A pathologist will look at the kidney tissue samples to check for unusual deposits, scarring, or infecting
organisms that would explain a person’s condition. The doctor may find a condition that can be treated and
cured. If a person has progressive kidney failure, the biopsy may show how quickly the disease is advancing.
A biopsy can also help explain why a transplanted kidney is not working properly.
Patients should talk with their doctors about what information might be learned from the biopsy and the risks
involved so the patients can help make a decision about whether a biopsy is worthwhile.

What are the preparations for a kidney biopsy?

Patients must sign a consent form saying they understand the risks involved in this procedure. The risks are
slight, but patients should discuss these risks in detail with their doctors before signing the form.

Doctors should be aware of all the medicines a patient takes and any drug allergies that patient might have.
The patient should avoid aspirin and other blood-thinning medicines for 1 to 2 weeks before the procedure.
Some doctors advise their patients to avoid food and fluids before the test, while others tell patients to eat a
light meal. Shortly before the biopsy, blood and urine samples are taken to make sure the patient doesn’t have
a condition that would make doing a biopsy risky.

PURPOSE: To provide guidelines for preparing the patient for a kidney biopsy.

PROCEDURE:

I.Pre-Procedure:
Nursing personnel will obtain:
a. Consent per physician’s order (Percutaneous Kidney Biopsy and moderate sedation). Physicians must
specify the exact procedure, site, and side. Refer to Corporate Policy (00.PAT.79) Correct Patient, Procedure,
and Site Verification.
b. Blood work as ordered. If patient is on anticoagulants, have a PT/INR drawn. If the patient is on Heparin,
draw a PTT. Results need to be charted and the physician notified of any abnormalities.
2. Positive patient identification is required prior to performing the procedure/labeling. Refer to Corporate
Policy (00.PAT.80) Patient Identification: Inpatient/Outpatient.
3. The patient will be NPO (clear liquids for 4 hours and 6 hours for solid foods or per physician’s order) if
they are to receive moderate sedation.
4. The patient will be transported to the CT Room in Radiology via stretcher at the appropriate time.

II. Radiology CT Guided Kidney Biopsy:

1. The nurse will check the medical record for the following:
a. The patient has been NPO as addressed above.
b. The consent form is signed for Percutaneous Kidney Biopsy (including side-right or left as per Policy
00.PAT.79) and moderate sedation.
c. Any allergies.
d. Baseline vital signs.
e. Any blood work results are present and the physician is aware of the results.
f. Pre-procedure medication administered.

2. The patient will be placed in the prone position with blankets at the level of the umbilicus to facilitate
accessibility to the kidneys.

3. Wash hands. A sterile field will be prepared.

4. Blood pressure, respirations, pulse and pulse ox will be taken before and monitored during the procedure.

5. A “timeout” will be performed per policy (00.PAT.79) to re-verify correct patient, procedure, and site. If
procedure is done at the bedside, documentation of the “time-out” will be done on section 2A of the Nursing
Procedure Checklist/Moderate Sedation Record.

6. The physician will explain the procedure to the patient, practice breathing exercises with the patient, prep
area for biopsy and insert needles for the biopsy purposes.

7. At the conclusion of the biopsy, a dry sterile dressing will be applied over the biopsy site. Minimal
bleeding is expected.

8. All equipment will be cleaned and returned to Central Service.

9. Correctly labeled specimens (date/time/collectors Initials and specimen type ie. “kidney biopsy”{right or
left)} will be taken to laboratory.

POST PROCEDURE:
1. The patient will go to the Radiology Nursing Unit. If an inpatient, the patient will be transported back to
their room once they meet transfer criteria. (Refer to policy 00.PAT.38, “Moderate Sedation”).

2. Vital signs will be checked and recorded and the biopsy site will be assessed immediately, then every 15
minutes x 2, every ½ hour x 2 and then hourly until stable. Check for specific MD orders pertaining to the
frequency of vital signs. Monitor for signs and symptoms of hemorrhage or shock.

3. The patient will remain supine on bed rest as per MD order.

4. Urine output will be monitored, if ordered. The first voided specimen may be tinged with blood.

DOCUMENTATION:
1. Medication Administration Record (MAR): Document preprocedure medication and those given during the
procedure.

2. Moderate Sedation Form/Nursing Reassessment: Document the following:

a. Time
b. Vital signs
c. Procedure and Physician
d. Patient reactions and tolerance to procedure and medications
e. Disposition of specimens
f. Post-procedure assessments, vital signs, and nursing care as provided.

Points to Remember

 A biopsy is a diagnostic test that involves collecting small pieces of tissue, usually through a needle,
for examination with a microscope.
 A kidney biopsy can help in forming a diagnosis and in choosing the best course of treatment.
 Before the kidney biopsy, patients should
o talk with their doctors to make sure they understand the need for a biopsy
o sign a consent form
o tell their doctors about any allergies they have and medicines they take
 o follow their doctors’ orders for food restrictions

 After the kidney biopsy, patients should

o lie on their backs—or stomachs if they have a transplanted kid-ney—for a few hours
o report any problems, such as

 bloody urine more than 24 hours after the test

 inability to urinate
 fever
 worsening pain
 faintness or dizziness

REFERENCE (S):
 SMHCS Corporate Policy. (00.PAT.38). Moderate Sedation. (2007). SMH: Author.
 SMHCS Corporate Policy. (00.PAT.79). Correct Patient, Procedure, and Site Verification. (2006).
SMH: Author.
 SMHCS Corporate Policy. (00.PAT.80). Patient Identification: Inpatient/Outpatient. (2006). SMH:
Author.
 SMH Policy. (2005). Specimen Label: “STOP” Procedure. (01.LAB.12). SMH: Author.