APPLICATION OF ORO-PHARYNGEAL

AIRWAY
INTRODUCTION
Oropharyngeal (Guedel) airways are curved plastic devices that assist maintenance of an adequate
airway in the unconscious patient by keeping the airway clear and the tongue in place. The oropharyngeal
airway by itself does not replace correct airway management practices and should only be considered as a
tool to assist in the management of a patient’s airway.
This method is not recommended in infants or children under the age of 8 years.

CHARACTERISTICS OF AN AIRWAY
Oropharyngeal airways are a plastic device characterized by a rigid flange and a hollow
curved tube. The airways have a flange that, when properly fitted, rest against the patient’s
lips. This flange does not interfere with an adequate seal from a facemask.
The oropharyngeal airway comes in various sizes allowing for insertion into different sized
patients. In children, the length should be 40-80 mm (Guedel sizes 000 to 3).

CARE OF AN OROPHARYNGEAL AIRWAY

The oropharyngeal airway must be stored in an aseptic state, preferably in a clear plastic bag.
Oropharyngeal airway should be easily accessible in the first-aid kit, oxygen unit and first-aid
rooms.
The oropharyngeal airway should be checked for deformities such as cracks and scratches, if
such deformities exist, the oropharyngeal airway should be disposed of or used for training

1
 purposes. Oropharyngeal airways that are used specially for training purposes should be
marked with the words ‘Training use only’.
After training use, the oropharyngeal airway should be soaked in a solution of 70% alcoholic
chlorhexidine (or a suitable substitute) for at least two minutes. It should be then rinsed and
dried and then stored separately in a small clean clear plastic bag ready for use.
After use with a patient the contaminated oropharyngeal airway should be disposed of in a
safe manner preferably with attending ambulance or medical personnel in an infectious waste
bag. If this is not possible, the contaminated oropharyngeal airway should be placed in an
infectious waste bag and stored in a safe place until proper disposal can be organized –
usually this can be organized through the local hospital.

CHOOSING THE APPROPRIATE SIZED OROPHARYNGEAL AIRWAY

To obtain the correct size oropharyngeal airway, place the airway against the patient’s jaw
line. The flange, (top flattened end) of the airway will extend from the centre of the patient’s
lips. The curve of the airway is then run sideways along the patient’s jaw. The correct size
airway is the one that closely reaches the angle of the patient jaw.

INSERTING AN OROPHARYNGEAL AIRWAY

It is important to remember that oropharyngeal airways must be inserted only into deeply
unconscious or non-breathing patients. Insertion of an airway into a conscious patient may
induce vomiting, gagging and aspiration.
The oropharyngeal airway should be inserted into the unconscious breathing patient in the lateral position.
When a patient is not breathing the oropharyngeal airway can be inserted with the patient on their side or
back.
1. Tilt the patient’s head backwards; open the patient’s mouth with one hand using jaw support (or jaw
thrust, if necessary).
2. With the patient on their side, visually check the patient’s airway and manually clear if necessary.
3. Obtain correct size oropharyngeal airway.
4. Remove the oropharyngeal airway from the packet and lubricate using moisture on the lips of the
patient or with water.
2
 5. Hold the tongue forward with a tongue depressor and the airway via the flange and with the tip
pointing upwards towards the roof of the casualty’s mouth; insert the airway into the casualty’s
mouth to approximately one-third of its length.
6. Whilst gently pushing the airway further in, rotate it 180° until the tip points downwards, at the same
time sliding it over the patient’s tongue into the back of the pharynx until the flange is touching the
lips.
7. It should slip easily into place. If it is difficult, stop, re-position the patient’s lower jaw and tongue
before trying again. Never force it into position, as this may damage the mouth and airway and could
cause additional airway obstruction.

PRECAUTIONS WHILE INSERTING AN OROPHARYNGEAL AIRWAY

 Ensure lower lip is not pinched between teeth and oropharyngeal airway.
 Ensure that the oropharyngeal airway does not push the tongue backward and block the patient’s
airway.
 Ensure you have adequate head tilt prior to insertion of the airway.
 Don’t force the airway into the mouth, the airway should slide in easily.

WHEN TO INSERT AN AIRWAY

The use of an oropharyngeal airway is optional during patient management. Rescuers should
take less than 15 seconds to correctly size and insert the airway into a patient’s mouth.
Ideally, the oropharyngeal airway should be inserted into the unconscious patient’s mouth
after the patient has been rolled onto their side and their airway cleared. However if an
airway is not available, it can be inserted later while the unconscious breathing patient is on
their side.
The airway can also be inserted during CPR while the patient is on their back. Rescuers
should cease CPR and quickly insert the airway and then continue with CPR. While the
airway is being inserted the time could also be used to access a patient’s pulse and or call for
assistance.

WHEN NOT TO USE AIRWAYS

 If the patient is conscious or semi-conscious. Insertion of an airway into a conscious patient may
induce vomiting, gagging and aspiration.
 If a correct size airway is not available.
 If there is a large amount of vomit.
 The insertion of oropharyngeal airways by the ‘rotation method’ should not be used in children due
to the risk of damage to the mouth and pharynx.

3
INSERTION OF OROPHARYNGEAL AIRWAY FLOWCHART
Yes
Danger Present? Manage Danger
Check for danger
No
Check for Response Yes
Response Present?
Manage Patient
No
Prepare patient  Patient rolled onto side
 Head tilt
 Manual airway clearance
Prepare Oropharyngeal airway
 Select appropriate size
(Guedel)
 Remove from packet
 Lubricate with patients saliva or with
saliva
 Hold by flange
Insert Oropharyngeal Airway
 Natural curve upside down. (Tip towards
roof of mouth)
 Pass tip first and insert halfway into
mouth.
 Rotate 180° whilst continuing to insert.
 Insert until flange rests against patient’s
lips.
Check  Ensure lower lip is not pinched between
 Check for gag reflex.
teeth and oropharyngeal airway.
 Maintain Head tilt and jaw support.
 Maintain position of airway.
 Look, feel and listen for air movement.

Continue resuscitation as  Continue Patient Management.

necessary

REMOVAL OF THE AIRWAY

If casualty shows any signs of rejecting the oropharyngeal airway, remove it immediately. In most
cases the patient may spit it out. The airway can be easily removed by sliding the airway out of the
mouth with its natural curve. Clean the airway by rinsing it with hydrogen peroxide and water, and
use a pipe cleaner to remove any secretions from the side channels or central lumen.

NURSING CARE OF THE PATIENT IN OROPHARYNGEAL AIRWAY

 After the airway is successfully inserted, frequently check its position to be sure of proper placement.
Suction excess secretions as necessary, and monitor the patient's respiratory status. The presence of

4
 stridor, gasping, or snoring may be an indication of displacement of the airway or be a sign of increasing
respiratory distress.
 Perform lip and mouth care at least every four hours, and more frequently if needed. Check for any
lacerations or ulcerations. Tissue irritation and ulceration of the mucous membranes of the mouth can
occur if the airway is left in place for prolonged use.
 That's why you'll want to remove the airway intermittently, according to your facility's policy and the
patient's condition. Intermittent removal will give you an opportunity to thoroughly inspect the oral
cavity and provide complete mouth care.
 To remove the device, gently pull the airway outward and downward, following the mouth's natural
curvature.
 Remember to thoroughly document all of your care. Following insertion, document the type of device
and size used, and if you encountered any difficulties during the procedure. Include methods employed
to verify placement and your respiratory assessment findings post insertion. Record ongoing assessments
of the patient's respiratory status and skin integrity around the airway and inside the oral cavity.
 As an emergency measure, the oropharyngeal airway is a quick and effective intervention that nurses can
employ without an order. Making sure that your skills are as sharp as they can be will go a long way
toward potentially saving a life.

5
 OXYGEN THERAPY
CLINICAL GUIDELINES
 Oxygen therapy may be administered by a respiratory therapist, registered nurse (RN), licensed
practical nurse (LPN), or appropriately trained parent.
 Oxygen may be administered by use of a nasal cannula, nasopharyngeal catheter, mask, or hood
when the oxygen level is below normal or the demand is increased.
 Nasal cannulas and nasopharyngeal catheters are contraindicated in children with nasal obstruction
(e.g. nasal polyps and choanal atresia).
 Nasopharyngeal catheters are contraindicated in those who have sustained a maxillofacial trauma,
children in whom a basal skull fracture is present or suspected, and in children with coagulations
problems.
 Nasopharyngeal catheters are not appropriate for oxygen administration in the neonatal population.
 Partial rebreathers or non-rebreather masks are not appropriate for use in the neonatal population.

 Restrict use of ignition sources in child’s room (e.g., sparking toys, cigarettes, candles) when oxygen
is in use.
 Secure cylinders of oxygen in upright position.
 During oxygen administration, the child should not wear clothing made of synthetic fabric that can
build up elastic electricity.
 Oils and oil-based petroleum products should not used on the child when oxygen is in use. These
products are known to ignite spontaneously when used around oxygen (e.g. petroleum jelly should
not be used around the child’s face).
 The need for oxygen, the type of delivery system, and the amount of oxygen administered are
determined by the physician.

EQUIPMENT

6
  Nasal cannula, nasopharyngeal catheter, or masks.
 “No smoking” sign
 Oxygen flowmeter
 Oxygen tubing
 Oxygen hood
 Paper tape
 Water-soluble lubricant (for catheter insertion)
 Disposable gloves
 Goggles (if needed)
 Humidification attachment (if ordered)
 Waterproof pad
 Extra baby blankets or bath blankets
 Warm sleepwear and hat for child
 Humidifier and sterile water
 Stimulating pictures to place on outside of hood. (optional)
MODES OF OXYGEN DELIVERY
Method of Delivery Percentage of Liter flow Nursing care considerations
O2 delievered
Nasal cannula 21% O2 plus 0.5 – 6 Dries mucosa; give with humidification.
3% per liter L/min Provides limited O2 delivery. Easy to use
and well tolerated. Child can eat and talk
without altering FiO2. Contraindicated in
children with nasal obstruction.

Nasopharyngeal catheter FiO2 varies <3 L/min Improper insertion can cause gagging and
with the child’s nasal or pharyngeal trauma.
inspiratory Contraindicated in children with nasal
flow. obstruction and in presence of
maxillofacial trauma. Not appropriate for
the neonatal population.
Venturi mask 24-50% FiO2 3-15 Adjustable to control percentage of
L/min oxygen delivered. Eating disrupts oxygen
delivery. Air containment ports can
become occluded.

7
Simple face mask < 40% FiO2 4-8 L/min Not a stable delivery system of FiO2 >
40%; good for short-term use (e.g. during
procedures, for transport, in emergency
situations). Eating disrupts oxygen
delivery.

Partial rebreathing mask 50-60% FiO2 6-10 Allows greater concentration of O2 to be

L/min delivered. Eating disrupts oxygen delivery.
Not appropriate for the neonatal
population.
Non-rebreathing mask 90-95% FiO2 6-10 Allows greater concentration of O2 to be
L/min delivered. Eating disrupts oxygen delivery.
Child inhales only from gases in the bag,
thus, kinks in the tubing may cause
hypoxia. Not appropriate for the neonatal
population.

Bag-valve mask 65-95% FiO2 10-15 Excellent method for assisted ventilation.
L/min Mask in selected to fit over the child’s
mouth and nose.
Air-entrainment mask 24-60% FiO2 3-15 FiO2 are changed by selecting or changing
(AEM) and nebulizers L/min the jet adapter or entrainment holes.
Humidification of O2 not required with
mask use. Air-entrainment nebulizers
share most features of AEMs but provide
additional humidification and heat control
and produce high noise levels in enclosed
environments (e.g. hoods, incubators).
Monitor child’s temperature if heated
nebulizer is used.
O2-powered device - - Never use in children.

8
 O2 hood Can deliver 2-3 Easy visibility and access to child. Need to
FiO2 up to L/kg/min remove infant for feeding and care. Need
100% oxygen analyzer to gauge percentage of
oxygen delivered. Temperature in hood
needs to be monitored. High gas flows
may produce harmful noise levels.

CHILD AND FAMILY ASSESSMENT AND PREPARATION

 Assess child’s history to determine rationale for oxygen administration (e.g. chronic or acute
pathologies).
 Determine whether there are any contraindications or concerns related to a particular method of
oxygen delivery or level of oxygen concentration, inappropriate oxygen flow can result in
hypoxemia or hyperoxemia.
 Use the parents to demonstrate how the equipment is placed on the child’s face.
 Explain the procedure to the child/family. Use developmentally appropriate language (e.g., “This is
to help you breathe better”). If access to the child is limited because of hood use, discuss with the
family alternative methods to provide stimulation to the child and to engage in physical contact with
the child.
NASAL CANNULA, NASOPHARYNGEAL CATHETER, OR MASK
STEPS RATIONALE/POINTS OF EMPHASIS
1. Perform hand hygiene. Gather all Reduces transmission of microorganisms. Promotes
necessary supplies. efficient time management and provides an
organized approach to the procedure.
2. Select proper size of cannula, or mask. Improper sizing of the equipment can lead to nasal
obstruction.
3. Remove all friction toys or open flames Sparks or static electricity will ignite the oxygen.
from the area and display “no smoking”
signs.
4. Connect the flowmeter to either the Allows for the oxygen to flow from source at the
oxygen unit or the freestanding tank. prescribed rate.
5. Connect the humidifier to the oxygen Provides for moisture in the system. Humidified air
setup. is less drying to the nares and to the lungs.
6. Following instructions for the particular Use of sterile water decreases the incidence of
oxygen setup, fill reservoir with sterile bacterial growth and mineral buildup within the
water. system.
7. Attach tubing to the oxygen source. Allows oxygen to flow from source to child.

9
 Check all electrical equipment in area to
ensure that it is grounded. Decreases chance of electrical sparks igniting the
Connect the distal end of oxygen tubing to oxygen.
the delivery device (cannula, catheter, or Completes the cycle of supplying oxygen from the
mask). source to the patient.
8. Turn on the flowmeter to the prescribed Ensures the child actually receives the amount of
amount and check to see whether you feel oxygen the physician demand necessary.
oxygen flowing through the system. Flow
rates should be as follows:
 Nasal cannula: In newborns and
infants, flows should be limited to a
maximum of 2 L/min. older children
and adolescents can be maintained up
to 6 L/min.
 Nasopharyngeal catheter: 0.5 L/min
through and 8F catheter in infants with
pneumonia and 1 L/min in infants up
to 12 months of age.
 Masks: Flow rates can vary from 5 to
10 L/min. Rebreathing of CO2 may
occur if total O2 flow is inadequate.
9. Don disposable gloves. If child is Gloves and safety equipment protect against transfer
coughing or has copious secretions, a of pathogens.
mask and goggles may also be worn.
10. Place child in supine semi-Fowler’s Raising the head of the bed helps protect the airway
position. The neonate’s and infant’s head if the child should vomit following airway
should be placed in a midline “sniffing placement. Maintains proper alignment of the
position”. mouth, pharynx, and trachea.

For nasal cannula:

11. Place the nasal prongs just inside the Allows the oxygen to flow in closest proximity to
external meatus of the nares. Either loop the respiratory system of the child. The means of
the head attachment around the child’s securing the nasal cannula in place vary based on
ears and tighten it under the chin or loop it manufacturer. The result should be the same: a
around and behind the child’s head and secure nasal cannula. The restless child can easily
tighten. Paper tape or other adhesive dislodge the nasal cannula. Displacement can lead to

10
 materials may be used sparingly to secure loss of oxygen delivery. Care should be taken to
the tubing to the child’s face. keep cannula tubing and straps away from the neck
to prevent airway obstruction in infants.
12. Instruct child to breathe through his or her Provides the prescribed oxygen.
nose.
For nasopharyngeal catheter:
13. Lubricate the tip of the catheter with Protects the mucosa as the catheter is glided in
water-soluble lubricant. place.
14. Gently insert the properly sized catheter to Improper insertion can cause gagging and nasal or
a depth equal to the distance from the side pharyngeal trauma.
of the nose to the front of the ear, so that Improper sizing can lead to nasal obstruction and
the tip of the catheter is just visible in the irritation. Catheter sizes less than 8F are less
pharynx below the soft palate when the effective in oxygen delivery and may easily obstruct
mouth of the infant is open. In infants, this with mucus. Use may be limited by excessive
distance is about 7 cm. mucous drainage, mucosal edema, the presence of a
deviated septum.
15. Secure the tubing to the child’s face using Prevents dislodgement of the catheter when the child
paper tape or other adhesive material. moves.
16. Turn on flowmeter, providing humidified Oxygen given with this method is bypassing the
oxygen to the child. humidifying and warming properties of the nose,
thus requiring humidification to avoid drying of the
pharyngeal mucosa and to reduce the likelihood of
producing thick dry secretions.
17. Place nasogastric tube through nares not The nasopharyngeal catheter can become displaced
being used. downward into the esophagus and cause gastric
distention. Passage of the nasogastric tube permits
rigid decompression of the stomach.
18. Alternate the site of the catheter between Prevents occlusion of distal holes in catheter.
nares every 8-12 hours and change the Accumulation of mucus in the catheter can cause
tube daily. upper airway obstruction.
For mask:
19. With the elastic straps very loose, place This position ensures that the mask is not placed
oxygen mask over the head of the child so upside down.
that the oxygen tubing travels downward
and away from the child’s head.
20. Tighten the straps attached to the mask A properly secured mask allows the prescribed

11
 until you can easily fit one finger between amount of oxygen to flow into the respiratory
the strap and the face of the child. system. Irritation may result from tight application.
OXYGEN HOOD
STEPS RATIONALE/POINTS OF EMPHASIS
1. Perform hand hygiene. Gather all necessary Reduces transmission of microorganisms. Promotes
supplies. efficient time management and provides an organized
approach to the procedure.
2. Remove all friction toys or open flames Sparks or static electricity will ignite the oxygen.
from the area and display “no smoking”
signs.
3. Line area that the hood covers on the bed Humidity from the oxygen delivery system will cause
with a waterproof pad. Cover the same area the sheets and mattress to become damp with moisture
with layers of bath or baby blankets. in a very short time. Having a layered area that can be
easily changed will help keep the child from having to
lie on damp sheets.
4. Connect the humidifying unit to the hood. Moistened oxygen is less drying to the respiratory
system. If unheated, O2 from nebulizer may induce
cold stress in neonates. Temperatures within the hood
should be closely monitored to reduce potential for
cold stress or apnea.
5. Following the manufacturer’s instructions, Sterile water is less likely to grow bacteria and clog
fill the reservoir with sterile water. the system with minerals.
6. Connect the unit to the oxygen source. This allows the oxygen to move from the source to the
child.
7. Place the hood on the crib or bed so that Prevents obstruction of the airway. An improperly
the child’s head is inside the unit. The hood sized hood can result in irritation to the infant’s skin.
should not rest on the child’s neck, and the
child should be able to turn his or her head
side to side easily.
8. Turn on the oxygen and humidifying unit Ensures that the ordered oxygen concentration level is
to the prescribed setting. Measure oxygen available.
concentration close to the child’s nose and
mouth. Adjust oxygen to ordered
concentration.
9. Encourage family and other staff to limit Limiting the time that the unit is open will maximize
the amount of time the child is outside of the quality of the oxygen therapy. Each time the unit

12
 the hood. Removable lids and ports should is opened or the infant is removed from the hood, the
be used to access the infant. Encourage oxygen level administered to the infant is decreased.
family to freely touch and stroke the child
and to provide auditory and visual
stimulation. Nasal O2 may need to be
supplied during feeding and nursing care of
the child in a hood.
CHILD AND FAMILY EVALUATION AND DOCUMENTATION
 Evaluate the child/family’s level of understanding of how and why oxygen therapy is being used.
 Discuss safety concerns with the family, giving special attention to avoidance of smoking, open
flames, and electrical or friction toys.
 Evaluate and document the respiratory status of the child.
 Document the following:
 Type of oxygen delivery system that is in use (i.e. cannula, mask, or hood)
 Time that oxygen therapy was initiated.
 Setting of the oxygen flowmeter and the frequency and length of time that the hood is open or the
oxygen device is not in place.
 Skin status for redness or irritation at pressure points of straps or cannula.
COMMUNITY CARE
 If oxygen therapy is to be continued after discharge, verify with the family which home care
companies are covered by their insurance.
 Contact chosen home care company as early as possible to make arrangements for home oxygen
administration equipment.
 Arrange for home care nurse to speak with the family:
 A minimum of 10 feet must separate oxygen apparatus and open flames.
 Restrict use of ignition sources (e.g. sparking toys, cigarettes).
 Secure cigarettes, matches, and lighters in a location away from the area where oxygen therapy is
being used.
 Assess that cylinders of oxygen are secured in an upright position.
 All electrical equipment and oxygen equipment should be intact, in proper working order, and
not emitting sparks. Extension cords should not be used.
 Avoid the use of synthetic materials around oxygen equipment.
 Avoid the use of oils and oil-based or petroleum products in the area of oxygen therapy.
 Instruct the family to contact the healthcare provider:
 Child’s respiratory condition worsens.
 Family remains unclear how to operate home care equipment.
13
 CPAP
(CONTINUOUS POSITIVE AIRWAY PRESSURE)
CPAP, also called continuous distending pressure (CDP), refers to the application of continuous
pressure during both inspiration and expiration in a spontaneously breathing baby. CPAP applied to
premature infants with RDS re-expands collapsed alveoli, splints the airway, reduces work of breathing and
improves the pattern and regularity of respiration. Atelecto-trauma (repeated opening and collapse of the
alveoli), biotrauma (intubation of the airway) and volutrauma (overstretching of the alveoli), the key
determinants of VILI (ventilator induced lung injury) are minimal or absent with this mode of ventilation.

INDICATIONS:-
The common clinical indications of CPAP are –
1. Respiratory distress syndrome (RDS)
2. Apnea of prematurity
3. Post-extubation in preterm VLBW infants
4. Transient tachypnea of newborn (TTNB)/delayed adaptation
Other indications:
1. Pneumonia
2. Meconium aspiration/ other aspiration syndromes
3. Pulmonary edema/pulmonary hemorrhage
4. Laryngomalacia/ tracheomalacia/ bronchomalacia

CONTRAINDICATIONS:-
The important contraindications of CPAP are –
1. Progressive respiratory failure with Pa CO2 levels >60 mm Hg and/or inability to maintain
oxygenation (PaO2 <50 mm Hg).
2. Certain congenital malformations of the airway (choanal atresia, cleft palate, tracheo esophageal
fistula, congenital diaphragmatic hernia, etc).
3. Severe cardiovascular instability (hypotension).
4. Poor respiratory drive (frequent apnea and bradycardia) that is not improved by CPAP.
14
INITIATION OF CPAP
The steps of initiation of CPAP would include
1. Preparing the circuit, the bubble chamber and the machine
2. Fixing the cap
3. Securing the nasal prongs
4. Connecting the circuit
5. Inserting of orogastric tube
6. Setting of PEEP, FiO2 and Flow

1. Preparing the circuit, the bubble chamber and the machine

Connect the machine to the air and oxygen gas inlets. The circuit should have inspiratory and an
expiratory limb. The inspiratory limb of the circuit ensures gas flow from the machine to the humidifier
and then to the patient. It has a heater wire in it for heating the gas till it reaches the patient. The
expiratory limb is connected to the bubble chamber. Fill the bubble chamber with distilled water to the
required level.
2. Fixing the cap
When fixing the cap, ensure to cover the ears. When using ‘Fisher and Paykel’ interface, select the
size after measuring the head circumference. For Hudson prongs the best fitting prongs comes with
appropriate size cap. Indigenously prepared cap should fit snugly on to the head.
3. Securing the nasal prongs
This is the most important and critical step in the initiation and maintenance of CPAP
A. Chose the correct prong size: The correct prong size is one which fits snugly into the nostrils
without distending the ala nasi. When using the Fischer and Paykel or Argyle, choose the correct
prongs and the connectors using the guidelines available with the kit. The selection of the nasal
prongs are based on the following guidelines
i. Size 0 Birth weight < 700 gms
ii. Size 1 Birth weight 700-1000 gms
iii. Size 2 Birth weight 1000-2000 gms
iv. Size 3 Birth weight 2000-3000 gms
v. Size 4 Birth weight 3000-4000 gms
vi. Size 5 Birth weight > 4000 gms
B. Secure the nasal prongs to the nostrils
i. Fischer and Paykel: Choose the correct nasal tubing. Connect the nasal prongs to the nasal
tubing as described in the starter kit. Fix the nasal prongs to the cap using the threads that come
with the connector kit. Secure the nasal tubing to the cap and support them appropriately, to
avoid their weight falling on to the nostrils.

15
 ii. Hudson prongs: Secure them with Tegaderm and Velcro to the nostrils and fix the inspiratory
and expiratory circuits to the cap using safety pins and rubber bands.
iii. Argyle prongs: When securing any nasal prongs ensure a gap from the columella, to prevent
pressure necrosis of this cartilage and long term deformity of the nose.
4. Connecting the circuit
In case of Fisher and Paykel, connect the limbs of circuit to the nasal tubing and for Hudson, connect
the limbs to the nasal prongs. Stabilize the head of the neonate to prevent dislodgement of nasal prongs.
5. Inserting of orogastric tube
As soon as the patient is connected to the bubble CPAP, an orogastric tube should be inserted. It
should be secured either to the lower lip or to the nasal prongs. The open end of orogastric tube should
always be above the level of stomach, to constantly deflate it with the excess gas that enters it during
CPAP.
6. Setting of PEEP, FiO2 and Flow
I. PEEP
a. This is increased or decreased by increasing or decreasing the depth of immersion of expiratory
limb into the bubble chamber (water level being constant) or directly by dialing the knob on
panel.
b. Start with a PEEP of 5 cms in case of RDS or Pneumonia and a PEEP of 4 cms if CPAP is for
Apnea management.
c. PEEP is adjusted to minimize chest retractions and to observe 6 to 8 posterior rib spaces on the
Chest X-ray.
II. Flow
a. The flow should be minimal to produce continuous bubbling in the bubble chamber. It varies
depending on the PEEP set, the lung disease, weight of the baby and the leaks in the circuit or
from patient’s mouth. In the absence of a blender, first set the total flow and then set the air and
oxygen gas flow to get the desired FiO2. In most babies gas flows of 2 to 5 L/min are sufficient.
III. FiO2
a. Start with a FiO2 of 40% to 50% and after adjusting the PEEP, titrate the FiO2 to maintain
SpO2 between 87 to 93%.
b. In the absence of a blender, for adjusting FiO2, mix air and oxygen gas flows to get the
desired FiO2 using a matrix or a chart or the following formula
FiO2 delivered to the patient = (1* oxygen flow + 0.21 * air flow)
Total gas flow reaching the patient

MAINTAINING AND MONITORING OF A NEONATE ON CPAP

This includes
A. Adjustment of PEEP, FiO2 and Flow
16
 B. Maintenance of CPAP interface/circuit and
C. Monitoring for adequacy and complication of CPAP.

A. Adjustment of PEEP, FiO2 and Flow

 Ideal range for PEEP for a baby on CPAP is from 4 cm to 8 cm of water. Increase or decrease PEEP
to minimize chest retractions, maintain 6 to 8 posterior rib spaces and to maintain PaO2 > 50 mm of
Hg. Inadequate PEEP results in alveolar atelectasis and increased chest retractions. Silver scoring is
an objective method to assess the efficacy of CPAP. High PEEP results in hyper-inflated lungs
decreased venous return, poor capillary perfusion and metabolic acidosis.
 Ideal FiO2 for a baby on CPAP is from 21% to 60%. PEEP and FiO2 adjustments are done to improve
oxygenation. FiO2 is adjusted to maintain SpO2 between 87 to 93%. Always increase PEEP before
FiO2 for better oxygenation.
 Flow changes are made only for delivering adequate PEEP. Too high flows results in wastage of
gases, turbulence, and inadvertent high PEEP. The ideal flow is the minimal flow which results in
continuous bubbling in the bubble chamber.

B. Maintenance of CPAP interface/circuit and

Meticulous nursing care is required for the proper maintenance of CPAP interface and the circuit.
Every shift the nurse on duty should
1. Ensure correct position and fixation of the nasal prongs.
2. Clean the nostrils with saline drops, suction the secretions and ensure patency of prongs.
3. Prevent injury to the nasal septum by ensuring a gap between the nasal prongs and columella.
4. Remove condensed water in the inspiratory circuit.
5. Fill the humidification chamber and ensure that the gas reaching baby should be at 37 °C and at
100% relative humidity.
6. Fill the bubble chamber with distilled water.
7. Record the depth of immersion of the expiratory limb in the bubble chamber.
C. Monitoring for adequacy and complication of CPAP.
 The parameters that need to be monitored for assessing adequacy and complications of CPAP
include
 Vitals – heart rate, temperature, respiratory rate, blood pressure and SpO2
 Assessment of circulation – Capillary refill time, blood pressure and urine output.
 Scoring of respiratory distress – It can be done with Silverman Score or with Downe’s score.
 Abdominal distension – bowel sounds and gastric aspirates to prevent CPAP belly.
 Neurological status – Tone, activity and responsiveness.
 CXR – It is done at the starting of CPAP and as when there is a clinical deterioration.

17
  Blood Gas – It is done once or twice per day during the acute stage and later when clinical indicated.
Capillary blood gases are preferred.
CPAP is considered to adequate if a baby on CPAP is
 Comfortable
 Has minimal or no chest retractions
 Has normal CFT, Blood pressure
 SpO2 is between 87 to 93%
 Blood gas: PaO2 is 50 to 80 mm of Hg, PCO2 is 40 to 60 mm of Hg and pH is 7.35 to 7.45
WEANING OF CPAP
Weaning of oxygen and PEEP is considered, when the clinical condition for which CPAP was
indicated is passive. CPAP for apneas may be removed after 24 to 48 hours of apnea free interval. If
a baby is stable on CPAP, first wean off the oxygen to 30% in steps of 5% and then wean the PEEP
to a minimum of 4 cm in steps of 1 cm/change. When a baby is on a PEEP of 4 cms with a FiO 2 <
30% with normal saturations and minimal retractions, CPAP may be removed.
After the removal of CPAP, the baby requires frequent change in posture, oral and nasal suction and
occasionally saline nebulization for effective removal of secretions. For the 12 to 24 hours after
removal of CPAP, careful monitoring is required apneas, tachypnea, worsening retractions and
bradycardia.

FAILURE OF CPAP
CPAP failure is considered when the FiO2 required is greater than 60% and PEEP required is greater
than 7 cm of water. A baby continuing to have retractions, grunting and recurrent apneas on CPAP
should be considered for mechanical ventilation. Inability to maintain SpO2 >85% or PaO2 >50 mm
of Hg on FiO2 >60% and PEEP >7 cm of water and PaCO2 >60 mm of Hg on CPAP are also
indications for mechanical ventilation.
Before considering CPAP failure ensure the following criteria
 Baby is not fighting the CPAP interface
 Nasal prongs are of correct size and are in position.
 Humidification is adequate and there is no condensation in the circuit.
 Adequate PEEP and FiO2 was delivered (neck position, clear nostrils and airway)
 Surfactant was administered in case of RDS.

18
 TRACHEOSTOMY CARE
DESCRIPTION
 Required to ensure airway patency by keeping the tube free of mucus buildup, maintaining mucous
membrane and skin integrity, preventing infection, and providing psychological support.
 Three types of tracheostomy tubes: uncuffed, cuffed, or fenestrated; selection dependant on the child’s
condition and the physician’s preference.
- Uncuffed plastic or metal tube – Allows air to flow freely around the tracheostomy tube and
through the larynx, reducing the risk of tracheal damage.
- Plastic cuffed tube (disposable) – The cuff and tube wont’ separate inside trachea because the
cuff is bonded to the tube; doesn’t require periodic deflating to lower pressure because cuff
pressure is low and evenly distributed against the tracheal wall; reduces the risk of tracheal
damage.
- Plastic fenestrated tube – Permits speech through the upper airway when the external opening is
capped and the cuff is deflated, also allows easy removal of the inner cannula for cleaning, but it
may become occluded.
EQUIPMENT
Aseptic stoma and outer cannula care:
 Water proof trash bag
 Two sterile solution containers
 Sterile normal saline solution
 Hydrogen peroxide
 Sterile cotton – tipped applicators
 Sterile 4"x 4" guaze pads
 Sterile gloves
 Prepackaged sterile tracheostomy dressing (4"x 4" guaze pads)
 Supplies for suctioning and mouth care
 Water soluble lubricant or topical antibiotic cream
 Materials as needed for cuff procedures and for changing tracheostomy ties.

Aseptic inner cannula care

All of the preceding equipment plus a prepackaged commercial tracheostomy care set, or sterile
forceps
 Sterile Nylon brush
 Sterile 6" (15 cm) pipe cleaners
 Clean gloves
19
  A third sterile solution container
 Disposable temporary inner cannula (for a child on a ventilator)
Changing tracheostomy ties
 30" (76.2 cm) length of tracheostomy twill tape
 Bandage scissors
 Sterile gloves
 Hemostat
Emergency tracheostomy tube replacement
 Sterile tracheal dilator or sterile Hemostat
 Sterile obturator that fits the tracheostomy tube
 Extra, appropriate sized sterile tracheostomy tube and obturator.

ESSENTIAL STEPS
 Prepare the equipment properly as follows:
- Wash your hands, and assemble all equipment and supplies in the child’s room.
- Check the expiration date on each sterile package and inspect for tears.
- Place the open waterproof trash bag next to you so that you can avoid reaching across the sterile
field or the child’s stoma when discarding soiled items.
- Establish a sterile field near the child’s bed and place equipment and supplies on it.
- Pour normal saline solution, hydrogen peroxide, or a mixture of equal parts of both solutions into
one of the sterile solution containers: pour normal saline solution into the second sterile container
for rinsing.
- For inner-cannula care, use a third sterile solution container to hold the guaze pads and cotton-
tipped applicators saturated with cleaning solution.
- If replacing the disposable inner cannula, open the package containing the new inner cannula
while maintaining sterile technique.
- Obtain or prepare new tracheostomy ties, if indicated.
- Keep supplies in full view for easy emergency access. Consider taping a wrapped, sterile
tracheostomy tube to the head of the bed for emergencies.
 Assess the child’s condition to determine need for care.
 Explain the procedure to the child and his parents, even if he’s unresponsive. Provide privacy.
 Place the child in semi-Fowler’s position, unless contraindicated, to decrease abdominal pressure on
the diaphragm and promote lung expansion.
 Remove any humidification or ventilation device.
 Using sterile technique, suction the entire length of the tracheostomy tube to clear the airway of any
secretions that may hinder oxygenation.
20
  Reconnect the patient to the humidifier or ventilator, if necessary.

Cleaning a stoma and outer cannula

 Put on sterile gloves if you aren’t already wearing them.
 With your dominant hand, saturate a sterile guaze pad or cotton-tipped applicator with the cleaning
solution.
 Squeeze out the excess liquid to prevent accidental aspiration.
 Wipe the patient’s neck under the tracheostomy tube flanges and twill tapes.
 Saturate a second pad or applicator, and wipe until the skin surrounding the tracheostomy is cleaned.
Use additional pads or cotton-tipped applicators to clean the stoma site and the tube’s flanges.
(Alert -- Wipe only once with each pad or applicator, and then discard it to prevent contamination of
a clean area with a soiled pad or applicator).
 Rinse debris and peroxide (if used) with one or more sterile 4"x 4" guaze pads dampened in normal
saline solution.
 Dry the area thoroughly with additional sterile guaze pads; then apply a new sterile tracheostomy
dressing.
 Remove and discard your gloves.

Cleaning a nondisposable inner cannula

 Put on sterile gloves. Using your nondominant hand, remove and discard the patient’s tracheostomy
dressing.
 With the same hand, disconnect the ventilator or humidification device, and unlock the tracheostomy
tube’s inner cannula by rotating it counterclockwise.
 Place the inner cannula in the container of hydrogen peroxide.
 Working quickly, use your dominant hand to scrub the cannula with the sterile nylon brush.
 If the brush doesn’t slide easily into the cannula, use a sterile pipe cleaner.
 Immerse the cannula in the container of normal saline solution, and agitate it for about 10 seconds to
rinse it.
 Inspect the cannula for cleanliness. Repeat the cleaning process if necessary.
 If it’s clean, tap it gently against the inside edge of the sterile container to remove excess liquid and
prevent aspiration.
(Alert – Don’t dry the outer surface; a thin film of moisture acts as a lubricant during insertion).
 Reinsert the inner cannula into the patient’s tracheostomy tube.
 Lock it in place; make sure it’s positioned securely. Reconnect the mechanical ventilator. Apply a
new sterile tracheostomy dressing.

21
  If the patient can’t tolerate being disconnected from the ventilator for the time it takes to clean the
inner cannula, replace the existing inner cannula with a clean one and reattach the mechanical
ventilator. Then clean the cannula just removed from him, and store it in a sterile container for the
next time.

Caring for a disposable inner cannula

 Put on clean gloves. Using your dominant hand, remove the inner cannula.
 After evaluating the secretions in the cannula, discard it properly.
 Pick up the new inner cannula, touching only the outer locking portion. Insert the cannula into the
tracheostomy and, following the manufacturer’s instructions, lock it securely.

Changing tracheostomy ties

 Get help from another nurse or a respiratory therapist to avoid accidental tube expulsion. Patient
movement or coughing can dislodge the tube.
 Wash your hands and put on sterile gloves if you aren’t already wearing them.
 If commercially packaged tracheostomy ties aren’t used, prepare new ties from a 30" (76.2 cm)
length of twill tape by folding one end back 1" (2.5 cm) on itself; then, with bandage scissors, cutting
a ½ " (1.3 cm) slit down the center of the tape from the folded edge.
 Prepare the other end of the tape the same way.
 Holding both ends together, cut the resulting circle of tape so one piece is approximately 10" (25 cm)
long and the other is about 20" (51 cm) long.
 Assist the child into semi-Fowler’s position, if possible.
 After your assistant puts on gloves, instruct her to hold the tracheostomy tube in place to prevent its
expulsion during replacement of the ties. (If performed without assistance, fasten the clean ties in
place before removing the old ties to prevent tube expulsion).
 With the assistant’s gloved fingers holding the tracheostomy tube in place, cut the soiled
tracheostomy ties with the bandage scissors or untie them and discard.
(Alert – Be careful not to cut the tube of the pilot balloon).
 Thread the slit end of one new tie a short distance through the eye of one tracheostomy tube flange
from the underside: use the hemostat, if needed, to pull the tie through. Thread the other end of the
tie completely through the slit end and pull it taut so it loops firmly through the flange. This avoids
knots that can cause throat discomfort, tissue irritation, pressure and necrosis.
 Fasten the second tie to the opposite flange in the same manner.
 Instruct the child to flex his neck while you bring the ties around to the side, and tie them together
with a square knot. Flexion produces the same neck circumference as coughing and helps prevent an

22
 overly tight tie. Have your assistant place one finger under the tapes as you tie them to ensure they’re
tight enough to avoid slippage but loose enough to prevent choking or jugular vein constriction.
 Placing the closure on the side allows easy access and prevents pressure necrosis at the back of the
neck when the patient is recumbent.
 After securing the ties, cut off the excess tape with the scissors and have your assistant release the
tracheostomy tube.
 Make sure the child is comfortable and can reach the call button easily.
(Alert – Check tracheostomy–tie tension frequently on children with traumatic injury, radial neck
dissection, or cardiac failure because neck diameter can increase from swelling and cause
constriction; also check neonatal or restless children frequently because ties can loosen and cause
tube dislodgement).

Concluding tracheostomy care

 Replace any humidification device.
 Provide oral care as needed because the oral cavity can become dry and malodorous or develop sores
from encrusted secretions.
 Observe soiled dressings and any suctioned secretions for amount, color, consistency, and odor.
 Properly clean of dispose of all equipment, supplies, solutions, and rash, according to the facility’s
policy, then remove and discard your gloves.
 Make sure that the child is comfortable and that he can easily reach the call button.
 Make sure all necessary supplies are readily available at the bedside.
 Repeat the procedure at least once every 8 hours or as needed.
 Change the dressing as often as necessary regardless of whether you also perform the entire cleaning
procedure. A wet dressing with exudate or secretions predisposes the patient to skin excoriation,
breakdown, and infection.

NURSING CONSIDERATIONS
 If the child is being discharged with a tracheostomy, start self-care teaching with the child and his
parents as soon as they are receptive.
 Teach the child, if appropriate, and his parents, how to change and clean the tube.
 If the child is being discharged with suction equipment, make sure that he and his parents feel
knowledgeable and comfortable about using the equipment.
 Keep appropriate equipment at the patient’s bedside for immediate use in an emergency.
 Consult the physician about first-aid measures you can use for your tracheostomy patient should an
emergency occur.

23
  (Alert—Follow your facility’s policy if a tracheostomy tube is expelled or if the outer
cannula becomes blocked. If the patient’s breathing becomes obstructed, call the
appropriate code and provide manual resuscitation with a handheld resuscitation bag
or reconnect the patient to the ventilator. Don’t remove the tracheostomy tube; the
airway may close completely. Use caution when reinserting, to avoid tracheal trauma,
perforation, compression, and asphyxiation).
 Don’t change tracheostomy ties unnecessarily during the immediate postoperative period before the
stoma track is well formed (usually 4 days) to avoid accidental dislodgement and expulsion of the
tube. Unless secretions or drainage is a problem, ties can be changed once a day.
 Don’t change a single-cannula tracheostomy tube or the outer cannula of a double-cannula tube.
Because of the risk of tracheal complications, the physician usually changes the cannula; the
frequency depends on the child’s condition.
 If the child’s neck or stoma is excoriated or infected, apply a water soluble lubricant or topical
antibiotic cream as ordered. Don’t use a powder or an oil-based substance on or around a stoma;
aspiration can cause infection and abscess.
 Replace all equipment regularly (including solutions) to reduce the risk of nosocomial infections.

24
 ENDOTRACHEAL INTUBATION
CLINICAL GUIDELINES
 A physician, nurse anesthetist, or nurse practitioner performs intubaion.
 Intubation is a means to provide a patent airway to facilitate mechanical ventilation and to facilitate
pulmonary toilet.
 Intubation is indicated when an infant or child experiences actual or potential loss of a patent airway,
is in danger from aspiration, has no spontaneos respiration or inadequate ventilation or oxygenation,
is in respiratory distress or failure, or is having surgery requiring anesthesia.
EQUIPMENT
 Intravenous (IV) sites
 Sedatives and paralytics as ordered by a healthcare provider
 Cardiac and apnea monitors
 Pulse oximeter
 Stethoscope
 Gloves, masks, gowns, and goggles for standard precautions
 Length-based resuscitation tape
 Water-soluble or anesthetic jelly (Xylocaine 2%)
 ET tubes of various sizes, cuffed and noncuffed
 Laryngoscope with curved and straight blades
 Extra lightbulbs for laryngoscope
 Self-inflating resuscitation bag with mask connected to oxygen tubing and flow meter and oxygen
source (must be capable of delivering 100% oxygen).
 Stylet
 Water-soluble lubricant
 Soft restraints or safety devices
 Suction with Yankauer or large, rigid suction catheter
 Securement device or tape cut for securing the tube.
 Tincture of benzoin
 Oropharyngeal airway (if needed).
 CO2 detector
 Ventilator
 Nasogastric tube
CHILD AND FAMILY ASSESSMENT AND PREPARATION
 If possible, given the child’s condition, discuss the process of intubation with the child and parent.
Discuss suctioning, the inability to talk, and that the child will be restrained to prevent him or her
25
 from pulling out the tube. If this is nonemergent situation, discuss an alternative means of
communication while the child is intubated. Picture boards or alphabet charts may be used to help
the child communicate.
 If family members are not present during the procedure, communicate with them immediately after
the intubation and reassure them about the status of the child. Allow the family to return to the
child’s bedside as soon as possible.
 If parents stay with their child during the procedure, explain intubation purpose and process. If
possible, assign a staff person to support the family throughout the procedure. Allow family
members to comfort the child even if the child is in a nonresponsive state.
 Before intubation, assess the child’s mouth for loose teeth. Teeth may become dislodged during the
procedure and become a potential risk for aspiration.
 Obtain vascular access before initiating the procedure. If vascular access is not possible to obtain,
intraosseous access should be secured.

AGE LARYNGOSCOPE ENDOTRACHEAL TUBE SUCTION

BLADE I.D (mm) CATHETER (F)
Premature infant 00 2.5, 3.0 uncuffed 5-6
Term to 3 months 0-1 3.0, 3.5 cuffed* or uncuffed 6-8

6 months 0-1 3.5, 4.0 cuffed or uncuffed 8

1 year 1 4.0, 4.5 cuffed or uncuffed 8
2 year 2 4.5, 5.0 cuffed or uncuffed 8
4 year 2 5.0, 5.5 cuffed or uncuffed 10
6 year 2 5.5 cuffed or uncuffed 10
8 year 2 6.0 cuffed or uncuffed 10
10 year 2 6.5 cuffed or uncuffed 12
12 year 3 7.0 cuffed 12
Adolescent 3 7.0, 8.0 cuffed 12
F- French, 1.D- inner diameter. *Cuffed tubes are not recommended for newborns.
PROCEDURE
STEPS RATIONALE/POINTS OF EMPHASIS
1. Notify the appropriate personnel of the Performance of the procedure by qualified personnel
necessity for the procedure. A respiratory increases successful outcomes. The physician, nurse
therapist, an RN, and the healthcare provider anesthetist, or nurse practitioner performs the
intubating the child should be present. procedure; the respiratory therapist assists in managing
the airway; and the nurse monitors the child’s status

26
 and suctions and tapes the endotracheal tube.
2. Verify that the child has a patent IV line for IV access is needed should the child experience
administration of sedatives, paralytics, and cardiac arrest during intubation. Emergency
emergency drugs. medications can also be delivered by the intraosseous
route or by the ET tube once it is verified to be in
place.
3. Perform hand hygiene Reduces transmission of microorganisms.
4. Connect the child to cardiac/apnea monitors Allows ongoing assessment of the child for any
and pulse oximeter. Monitor the child’s heart changes in heart rate, respiratory rate or function,
rate, respiratory status, and oxygenation status oxygen saturation, or level of consciousness.
before, during and after the procedure.
5. Gather and assemble equipment, and check all Promotes efficient time management and provides an
equipment before the intubation procedure to organized approach to the procedure.
ensure proper function. Suction equipment should be readily available to
a. Turn the suction on to between 80 and 100 manage aspiration and to assist in visualization of the
mm Hg, and connect the Yankauer. vocal cords.
b. Connect the self-inflating bag to an oxygen The self-inflating bag should have the ability to deliver
source with the flowmeter at 10 to 15 L/min 100% oxygen to oxygenate the child effectively.
of 100% oxygen. Neonatal-sized (250 mL) resuscitation bags are
discouraged except of use with premature infants. A
bag with a volume of at least 450 L/min is
recommended for term neonates and infants. An
oxygen flow rate of at least 10 L/min is required with
the pediatric resuscitation bag and 15 L/min with the
adult-sized bag.
Bag-valve mask ventilations are necessary before the
c. Select O2 mask to use for bag-valve mask intubation procedure and possibly during the
ventilations. procedure if the intubation attempt is lengthy and the
child requires oxygenation. Maintaining an
appropriately sized mask at the bedside also is needed
in the event of accidental extubation.
A light source is needed to ensure good visualization
of the esophagus and vocal cords.

d. Attach the laryngoscope blade to the handle The McGill forceps is used to advance the ET tube
and check that the light bulb is tightly from the back of the throat during a nasal intubation.

27
 attached and functional.
e. Obtain a McGill forceps for nasopharyngeal
intubation.
6. Select an uncuffed or cuffed age-appropriate If the ETT is too large and an air leak is not present,
ETT per the intubating provider’s orders. damage may occur to the surrounding tissues from
Several methods can be used to select the extensive pressure.
size, including use of a length-based
resuscitation tape or a standard tube size
table.
a. The foll. is a quick formula for determining This is a very rough estimate for selection of an ETT
tube size for children older than 2 years of and should only be used in emergency situations.
age:

ETT = Age (yr) + 4

4
This is an instantaneous guide for determining the
b. A quick visual estimation for tube selection is child’s airway size based on body size and can be used
a tube that is the same diameter as the child’s in emergencies where length-based tapes or other ETT
little finger. size guides are not available.
c. Cuffed ETTs are not generally used for The smallest part of the child’s airway is the cricoids
children younger than 8 years of age. A ring, which functions as a natural cuff, therefore
cuffed tube may be requested for a younger requiring no cuff on the tube. A tube that is too large
child in instances in which an air leak is not (preventing an air leak) may cause damage to the
desirable. child’s fragile airway.
Malfunction of the cuff must be determined before
d. If a cuffed tube is selected, inflate the cuff to tube placement occurs.
make sure it assumes a symmetric shape and Absence of an air leak may indicate that the tube is too
holds the volume without leaking and then large, that the cuff is inflated excessively, or that a
deflate maximally. laryngospasm is occurring around the ETT. These
e. The correct size of an uncuffed ETT should conditions may lead to excessive pressure on
allow for an air leak. surrounding tissue. A tube that is too small in diameter
will allow too much air leakage around the tube and
thus provide ineffective ventilation of the child.
7. Lubricate the distal end of the ETT with A lubricated ETT allows for ease in tube
sterile water, water-soluble lubricant, or advancement. Lidocaine jelly provides an anesthetic
lidocaine jelly (as ordered). effect in the mouth, nose and throat.

28
8. Lightly lubricate the stylet with a water- The stylet supports the tube, making it firmer and
soluble lubricant. Insert the stylet into the easier to insert and direct. Lubricating the stylet
ETT, ensuring the tip does not extend past the facilitates its withdrawal once the tube is positioned.
distal end of the tube. With the stylet in place, Damage to the vocal cords can occur if the stylet
the tube can be shaped into the desired protrudes from the distal end of the tube.
configuration.
9. Cut tapes for securing the ETT after insertion Having the equipment ready in advance prevents
or obtain appropriately sized securement unnecessary delays during the procedure.
device.
10. Administer sedatives or paralytics as ordered The child should be kept quiet and still during the
immediately before the intubation. procedure to prevent additional injuries. If paralytics
Atropine may also be given before treatment are used, an experienced practitioner in intubation
to reduce the incidence of reflex techniques should be present.
bradyarrhythmias. Mechanical stimulation of the airway or hypoxemia
may induce bradyarrhythmias in the infant and young
child.
INTUBATION
STEPS RATIONALE/POINTS OF EMPHASIS
1. Don goggles or face shield, gowns, and Splashing of secretions during intubation frequently
gloves. occurs. Standard precautions should be maintained by
all involved or assisting in the procedure to prevent
contact with child’s secretions.
2. Position the child’s head as close to the edge Ensures good body mechanics.
of the bed as possible. If child’s cervical spine
is not injured, hyperextend the neck using a
small towel roll placed under the shoulder
blades.
a. For the child younger than 2 years of age, Maintains proper alignment of mouth, pharynx, and
place a small pad under the body to keep trachea. The head is large and heavy, causing
the chest on an even level with the head extension of the neck naturally when the head is
and neck. Place the child on a flat surface placed on a flat surface. Infants have large tongues
with the chin in the sniffing position. Keep that may occlude the airway once they are sedated.
the neck midline and in a neutral position.
Open the airway with jaw-thrust or chin- The older child may require some anterior
lift method. displacement of the cervical spine to obtain optimal
b. For the child 2 years of age or older, place airway patency.

29
 the occiput of the head on a small pad and
extend the head and neck. Keep the neck
in a midline position.
3. Maintain good head alignment and manually Proper head alignment opens the airway, providing
ventilate the child with a self-inflating bag optimal oxygenation and perfusion to the brain.
and mask and 100% O2 until the provider Ventilation is needed because preintubation
intubating is ready to intubate. medications cause respiratory suppression or
cessation.
4. Immediately before intubation procedure, Suctioning clears the airway of secretions for better
suction the back of the airway with a rigid visualization of the ETT and prevention of aspiration.
large-bore Yankauer catheter or other large-
bore catheter.
5. Apply gentle cricoids pressure (Selick’s Pressure occludes the esophagus, thereby preventing
maneuver) as required during the procedure. aspiration of gastric contents. May facilitate
visualization of the glottis opening.
6. After insertion, hold the ETT in place while Assessment validates the tube is in the correct
breath sounds are checked bilaterally and over position. Condensation in the tube indicates
the stomach and inspect for symmetric chest pulmonary placement, but lack of condensation does
expansion. Breath sounds should be absent not necessarily indicate incorrect placement. If no
over the abdomen. Do not tape ETT in place breath sounds are heard on the right side but are heard
until proper position of the tube has been on the left, the tube probably was inserted too far. Pull
initially evaluated. the tube back gently (while listening with a
stethoscope) until breath sounds return on the right
Connect CO2 detector as an initial verification side. If the tube is not placed correctly, it must be
of tube placement and deliver 4 to 6 breaths. removed, and the child needs to be reintubated.
Read CO2 detector according to Exhaled CO2 is a particularly reliable indicator of
manufacturer’s instructions. tube placement if the child has a perfusing cardiac
rhythm present. A low end-tidal or exhaled CO2
detector can mislead the provider into mistakenly
suspecting an esophageal intubation in children with
cardiac arrest even though the tube is in the trachea.
7. Continue to manually ventilate and maintain Provides optimal oxygenation and maintains proper
the stability of the tube until it is secure. Use a tube placement. Commercial devices have been
commercial securement device or tape to developed to hold the tube in place. This decreases
secure the tube in place. Measure the distance the need for tape on the face, which can lead to
from the edge of the lip or naris to the end of dermal stripping upon removal. Baseline

30
 the tube. Document the distance on the flow measurement of external length provides comparison
sheet or emergency sheet. If tape is used to to detect tube movement.
secure the ETT
a. Cut two pieces of tape the same length as
the distance from the edge of the mouth or Prepares tape to secure ETT in place; some facilities
nose to the base of the ear. Split the tape use a premanufactured device to secure the ETT.
lengthwise halfway. The tape will adhere to the face more securely.
b. Apply an adhesive under the area where
the tape would be placed. Documentation of the length of the tube is necessary
c. Again, measure the distance from the lip to ensure proper placement in all times.
or naris to the end of the tube just before Provides stabilization of the ETT.
applying the tape. This method stabilizes the tube from the opposite
d. Secure tape to the cheek and wrap one direction, applying traction to maintain the tube more
strand around the tube. The other strand securely.
should lay flat above the lip or across the The ETT may slip in or out while the tape is being
bridge of the nose. applied.
e. Follow the same procedure with the
second piece of tape but wrap it in the
opposite direction.
f. Measure the distance from the lip or naris
again.
8. Suction (if needed) and continue to manually Removes excess secretions and increases
ventilate the child. oxygenation.
9. Verify tube placement with a secondary Most accurate method to verify tube placement.
confirmation technique (chest x-ray).
AFTER INTUBATION
STEPS RATIONALE/POINTS OF EMPHASIS
1. Connect the ETT to the ventilator and Establishes baseline lung sounds and air leak once on the
assess the child’s respiratory status on ventilator. Ensures tube has not become dislodged when
the ventilator. transferring from bag-valve ventilation to a ventilator.
2. Remove gloves, mask, gown and Reduces transmission of microorganisms.
goggles and perform hand hygiene
3. Apply restraints or safety devices to Keeps the child safe from attempting to pull out the ETT.
the extremities if the child is not
sedated.
4. Dispose of intubation equipment and Reduces transfer of microorganisms.

31
 waste in appropriate receptacle. Place
laryngoscope and blades in area for
cleaning and sterilization.
5. Insert an oral airway into the mouth (if The oral airway prevents the child from biting on the ETT.
ordered) and secure with tape. The An airway that is too long causes increased gagging and
airway should fit into the mouth but may cause aspiration with vomiting.
not reach the back of the throat.
6. Place a nasogastric tube in the child. For gastric decompression, this can assist ventilation.
7. Continue to assess cardiac and It may be necessary to remedicate the child to prevent him
respiratory status and to evaluate the or her from fighting the ventilator.
child’s comfort level.
8. Evaluate for complications. Complications may include swelling of the airway,
increased airway resistance, mucus plugging,
pneumothorax, and dislodgement of the tube.
9. Ensure that the ETT cuff, if present, Deflation may lead to dislodgement of the tube. The cuff
continues to be inflated. should only be deflated during intubation, extubation, and
tube repositioning.

CHILD AND FAMILY EVALUATION AND DOCUMENTATION

 Document the following:
 Tube size and centimeter level of insertion at the nares or teeth and gums.
 Whether the tube is cuffed or uncuffed. If it is a cuffed tube, record the amount of air used to
inflate the cuff.
 Any medications administered during the procedure and any side effects from them.
 Child’s response to the intubation, noting if there was an improvement in respiratory status or
comfort with breathing.
 Amount and type of secretions that were suctioned from the ETT.
 Response to sedation.

COMMUNITY CARE
 After extubation, the child’s throat may be sore. Ice packs may be applied to the throat to provide
comfort.
 Instruct the family to contact the healthcare provider if
 Child experiences difficulty swallowing that does not resolve within a few days.
 Child experiences difficulty breathing
 Child complains of sore throat that does not resolve within 1 week after intubation.

32
 NEONATAL RESUSCITATION
INRODUCTION
Spontaneous breathing after birth is not a problem for most babies. However, one in twenty babies
might require help with breathing at birth. It is not always possible to know in advance which babies will
need this help since half of them (who require resuscitation) have no identifiable risk factors before birth.
Hence resuscitation must be anticipated at each birth.
KEY TO SUCCESSFUL RESUSCITATION
All health professionals who attend the mother at birth must be skilled at resuscitation and know how
to recognize babies at risk. They must:
 Anticipate
 Be prepared
 Know what to do
 In what order
 Be able to work quickly in coordination
PREPARATION IN THE DELIVERY ROOM
When a baby has asphyxia, resuscitation must be started right away. If things are not prepared, much
time can be lost before starting resuscitation. With this lost time a baby can become worse.
Preparation should include having warmth, place to do the resuscitation, equipment and supplies.
These are summarized as:
1. A draught free, warm room with temperature >25°C.
2. A clean, dry and warm delivery surface.
3. A radiant heater.
4. Two clean, warm towels/clothes.
5. A folded piece of cloth (1/2 to 1 inch thick).
6. A newborn size self inflating bag
7. Infant masks in two sizes: size ‘1’ for normal weight baby and ‘0’ for small baby.
8. A suction device.
9. Oxygen (if available).
10. A clock (with seconds hand).
Important points about the equipment used for resuscitation
 Equipment must be cleaned and checked after each delivery and checked again before the next
delivery to ensure it is ready to use.
 Broken equipment is dangerous and should be replaced.

33
  Equipment must be of the appropriate size. Pediatric and adult bag and masks cannot be used on
newborn babies who have small and fragile lungs.
 The volume of the bag should not be more than 240-250 mL; it should be able to generate a pressure
of atleast 35 cm of water.
 If a mucus extractor is used the trap should be big enough (20 mL) to prevent aspirated fluid going
into the resuscitator’s mouth.
 A mucus extractor with a bulb is NOT recommended because they are difficult to clean and might
act as a source of cross infection.
 Suction should not exceed a negative pressure of 100 mm Hg or 130 cm water.
 Resuscitation can be done without having piped oxygen available.
 If oxygen is available, it should be used; but avoid using 100% oxygen in premature infants.
GOALS OF RESUSCITATION
1. Minimizing immediate heat loss.
2. Establishing normal respiration and lung expansion.
3. Increasing arterial pO2
4. Supporting adequate cardiac output.
NEED FOR RESUSCITATION

Assess baby’s risk for requiring resuscitation

Provide warmth
Position, Clear airway, Dry, stimulate to breathe

Give supplemental oxygen, as necessary

Assist ventilation with positive pressure
Intubate the trachea

Provide chest
Compressions
Administer
medications

34
STEPS OF RESUSCITATION
TABC’s of resuscitation
T- Maintenance of temperature
 Provision of radiant heat source
 Drying the baby
 Removing wet linen.
A- Establishment of an open airway
 Suction the mouth, nose and in some instances the trachea (in meconium stained liquor)
 If necessary insert the ET tube to ensure open airway.
B- Initiation of breathing
 Tactile stimulation to initiate respirations.
 Positive pressure ventilation, using either bag and mask or bag and ET tube
C- Maintenance of circulation
Stimulate and maintain the blood circulation by chest compression and/or medication.

35
RESUSCITATION ALGORITHM

36
Apgar score and resuscitation
 Resuscitation initiated before score assigned
 Not used to determine
- Need for resuscitation
- Steps to be taken and when to resuscitate
 Three signs for evaluation (Evaluated simultaneously)
- Respiration
- Heart rate
- Color
- Muscle tone
- Reflex
Apgar Scoring is a means of scoring the severity of the asphyxia. A score of 0, 1, or 2 is given to five
parameters; heart rate, respiratory effort, muscle tone, response to stimulation and colour. It is usually
determined at one and five minutes and at eight minutes if the scores are low. It should be repeated at 5
minute intervals until a score of 7 is reached. Particular emphasis should be placed on the heart rate and
respiratory effort.
 Resuscitation should never be postponed to calculate the Apgar score.

Characteristics Apgar Scoring

0 1 2
Heart Rate Absent <100 >100
Respiratory Effort Absent Weak, cry or shallow Good strong cry
Muscle Tone Limp Some flexion Active well flexed
Reflex/irritability None Grimace Cry
Color Pale/blue Body pink Pink
Extremities blue
 Taking an Apgar score is not a prerequisite for resuscitation.
 The need for resuscitation must be recognized before the end of the first minute of life which is
when the first Apgar score is taken.

INITIAL STEPS
Provide warmth:
Placed under radiant warmer, Leave the baby uncovered under warmer, to allow full visualization, to
permit radiant heat to reach the baby
37
Position; clear airway as necessary:
 Secretions removed from airway with a towel/ bulb syringe/ suction catheter
 Copious secretions- turn face to side
 Gentle suction- Pressure < 100 mm Hg
 Mouth before Nose (M before N)
 Stimulation of posterior pharynx causes Vagal stimulation and bradycardia- stop

Dry, stimulate and reposition

 Dry :Use pre-warmed absorbent towels or blankets
 Keep head in ‘sniffing’ position to maintain good airway
 Stimulation :Suction and drying sufficient stimulation
 If inadequate respiration then additional tactile stimulation given briefly by
 Slapping or flicking the soles of the feet
 Gently rubbing the back, trunk or extremities
 Overly vigorous stimulation harmful
 Reposition the baby.

USE OF BAG AND MASK

After 30 seconds of Initial steps if
 Baby is not breathing or is gasping
 Heart rate is less than 100 bpm and /or
 Is cyanotic despite supplemental oxygen.
Different Types of Resuscitation Devices
1. Flow inflating bags: Fills only when oxygen from a compressed source flows in to it
2. Self inflating bags: Fills spontaneously after it is squeezed, pulling oxygen or air in to the bag.
3. T-piece resuscitator: Also works when gas from compressed source flows into it. The gas is
directed into the baby by occluding the opening on T-piece.

General Characteristics
 Size of bag – 240 to 750 ml
 Oxygen capacity -- capable of delivering 90-100% oxygen
 Safety features – capable of avoiding excessive pressures
 of Size mask – appropriate sized mask

38
Inserting Orogastric Tube
 Needing PPV longer than several minutes
 Measure the length to be inserted
 Insert the tube through the mouth
 Gently aspirate stomach contents
 Leave the end of the tube open
 Tape the tube to the cheek of the baby
 Equipment Required:8 F feeding tube,20 - syringe

If the Baby Is Not Improving

 Is the chest movement adequate
- Is the face-mask seal tight
- Is the airway blocked: Improper position or Secretions
- Is he equipment working
- Is air in stomach interfering with chest expansion
 Is adequate oxygen being used
- Is oxygen tube attached to ventilation device and to oxygen source
- Is gas flowing through the flow meter
- Self-inflating bag, is the oxygen reservoir attached
- If using cylinder (rather than wall oxygen), is there oxygen in the cylinder

NEXT STEP: CHEST COMPRESSION

39
  When to begin chest compressions during resuscitation
 How to administer chest compressions
 How to coordinate chest compressions with PPV
 When to stop chest compressions
 Indication: Heart rate less than 60 bpm despite 30 sec of effective positive-pressure ventilation
 Endotracheal intubation at this time may help to ensure adequate ventilation and facilitate the
coordination of ventilation and chest compressions

Why perform Chest Compressions

 Myocardium is depressed because of poor oxygen levels - Low cardiac output
 Mechanical pumping of heart required to improve perfusion to the lungs
 Also referred to as External Cardiac Massage
 Rhythmic compressions of sternum that
 Compress the heart against the spine
 Increase the intrathoracic pressure
 Circulate blood to the vital organs.

How many people required:

How many people required:

 Chest compressions and PPV should be simultaneous
 Two people required

Thumb Technique
40
  Can’t be used effectively if infant is big and hands of operator small
 Less tiresome than two finger technique
 Better control over depth of compression
 Press only sternum
 Pressure on ribs can cause fractures

Two Finger Technique

 More convenient if baby is large or hands of operator are small
 Better control over depth of compression
 Can’t be used by people with long finger nails

Common Things in Two Techniques

 Position of Baby
- Firm support for the back
- Neck slightly extended
 Compressions
- Same location, depth and rate

Location of Compression
 Heart lies between sternum and spine
 Pressure is applied on lower third of sternum
 Avoid Xyphoid

Position of Thumbs or Fingers

 Essential to
- Locate the position of Xyphoid
- Intermammary Line
 Go along the costal margin identify the Xyphoid and just above this point
 Place your thumbs for fingers immediately above Xyphoid
 Avoid putting direct pressure on Xyphoid

Positioning during Two Finger Technique

 Two fingers (tips of index & middle fingers)
 Position perpendicular to the chest
41
  Support the back from hand
 Be cautious of putting pressure of whole of your hand on chest

How much pressure needed?

 Approximately 1/3rd of anteroposterior diameter of the chest
 One Compression
- Downward Stroke plus the Release

Dangers associated with Chest Compressions: Trauma

- Liver - Laceration
- Ribs - Fracture

Frequency
 Coordinate with IPPR
 One ventilation interposed after every third compression
 Total of 120 events
- 30 breaths
- 90 compressions

When to Stop Chest Compressions:

 After approx. 30 sec of CC & PPV

42
 - Count Heart Rate
- If > 60 - Stop Chest compressions
 Continue PPV at 40 - 60 bpm Till
- Baby breathing spontaneously
- Heart rate >100 and
- Baby pink

NEXT STEP: ENOTRACHEAL INTUBATION

 If after 30 seconds of effective PPV with supplemental oxygen the baby is not improving: Evaluate
 Not breathing: Perform ET intubation and continue PPV
 Breathing but HR < 100 continue PPV
 Breathing, HR > 100, central cyanosis + continue PPV
 Heart rate < 60 Initiate Chest compressions

Indication of ET tube insertion

 Prolonged PPV required
 Bag & mask ineffective: Inadequate chest expansion
 If chest compressions required: Intubation may facilitate coordination and efficiency of ventilation
 Tracheal suction required : e.g. MSAF
 Diaphragmatic Hernia
 Use of Drugs through ET tube
Prerequisites for Intubation
 Pre oxygenate before intubation PPV with 100% oxygen
 Deliver Free Flow oxygen during intubation
 Not more than 20 sec per attempt : Not more than 3 attempts
 Ventilate with Bag and mask with 100% oxygen in between attempts
Size of ET tube
Tube size Weight Gestational
(ID -mm) (gms) Age (in weeks)
2.5 <1000 < 28
3.0 1000-2000 28-34
3.5 2000-3000 34-38
4.0 > 3000 >3

43
Insertion of ET tube
 Insert ET tube holding in the right hand
 Introduce through the right angle of the mouth
 Keep glottis in view
 Insert when vocal cords are apart
 Do not push through vocal cords
 If cords are together wait, if do not open within 20 sec stop and ventilate with Bag & mask

Signs of ET Tube in Esophagus

 Poor response to intubation (cyanosis, bradycardia etc
 CO2 detector fails to show presence of Expired CO2
 No audible breath sounds
 Air heard entering stomach
 Gastric distension may be seen
 No Mist in tube
 Poor chest movements

NEXT STEP: MEDICATIONS

When to use medications
 Despite Administration of effective chest compressions and effective positive-pressure ventilation
with 100% oxygen:
 Heart Rate is below 60 bpm

HR < 60/min
 Recheck effectiveness of
- Ventilation
- Chest compression
- Endotracheal intubation
 Consider possibility of
- Hypovolemia
- Severe metabolic acidosis
-
Epinephrine hydrochloride

44
  Cardiac stimulant
- Increases strength & rate of cardiac contractions
- Causes peripheral vasoconstriction
 It is indicated when HR remains < 60 after 30 sec of effective PPV and another 30 sec of coordinated
chest compressions and ventilation
How to prepare and give Epinephrine
 Available concentration 1:1000
 Dilute it 10 times to make it 1:10,000
- 1ml of 1:1000 with 9 ml of water for injection
 Dose: 0.1 – 0.3 ml/kg of 1:10,000
 Preferred Route: Intravenously
- Followed by flush of Normal saline: 0.5 – 1.0 ml
 While IV access is being obtained may give endotracheally

Rate of administration
 Rapidly – As quickly as possible

How to give Epinephrine Endotracheally

 Dose: 0.3 – 1.0 ml/kg of 1:10,000 solution
 Safety of these higher tracheal doses not established
 Do not give high doses intravenously
 After giving endotracheal dose give several positive-pressure breaths

Umbilical route
 Prefill 3.5F - 5F umbilical catheter with NS
 Cut the cord about 1.5-2.0 cm from skin
- Position of Vein & Arteries
 Insert catheter until free flow (2 – 4 cm in FT)
 Inject drug followed by 0.5 to 1.0 ml NS
- Once the baby is fully resuscitated remove catheter

What is expected response?

 After 30 seconds of administration and continued PPV and CC
- HR should increase to > 60 bpm
45
  If no response repeat the dose every 3-5 minutes
 Repeat doses should preferably be give IV

epinephrine hydrochloride
If No Response
 Recheck effectiveness of
- Ventilation, Chest compression
- Endotracheal intubation, Epinephrine delivery
 Consider possibility of
- Hypovolemia
- Severe metabolic acidosis

Volume Expander
 Poor response to resuscitation
 Evidence of blood loss
 Pale
 Poor pulses
 CFT

Recommended solutions
 Isotonic crystalloid
- Normal Saline
- Ringer Lactate
- O-negative blood cross-matched with mother’s blood
 Dose – 10ml/kg
 Route – Umbilical vein
 Preparation – large syringe
 Rate of administration – 5-10 minutes (In premature babies: Rapid boluses may induce ICH )

46
 MONITORING OF NEONATES- CLINICALLY AND
WITH MONITORS
INTRODUCTION
Monitoring of a sick neonate helps in the early recognition of existing or potential problems as it is
important to initiate appropriate treatment as soon as possible. Monitoring helps in the identification of
neonates who are risk for various problems. Information collected can be reassuring to the family or can
identify problems that must be treated. So it is important for nurses as central care providers, to monitor a
sick neonate.

WHO IS A SICK NEONATE

A sick neonate is one who has any one of the following features:
 Weight less than 1800 gm
 Temperature less than 36C despite warming of 1 hour.
 Cried after 5 min of birth.
 Absent sucking
 Not arousable
 Respiratory rate more than 60/min with chest retraction
 Apnea or gasping respiration
 Central cyanosis
 Jaundice staining palm/soles
 Convulsions
 Major malformation

NORMAL, AT RISK AND SICK NEONATE

Clinical Normal neonate ‘At risk’ neonate Sick neonate

Weight > 21.5 kg 1.5 – 2 kg < 1.5 kg

Temperature 36.5 – 37.5C 36.0 – 36.4C < 36C

Cry after birth < 1 min 1-5 min > 5 min

Sucking Good Poor Absent

Sensorium Active Depressed Non arousal

47
 Respiration Rate < 60 min Rate > 60 min Retractions/ apnea/
no retractions gasping
Jaundice Absent Present without staining of Staining of palms/
palms/soles soles

Diarrhea, vomiting None Presence of any one Presence of two

Abdominal distension
Umbilical discharge (pus)
Skin pustules
Fever

CLINICAL MONITORING OF NEONATE

SIGNS TO BE MONITORED IN A SICK NEONATE

 Temperature  Weight
 Respiration  Sensorium
 Heart rate  Convulsion
 CFT  Bleeding
 Color  Sucking
 SpO2  Diarrhea
 Urine output  Vomiting
 Abdominal distention

RESPIRATORY MONITORING
a) Respiratory rate (40-60)
b) Chest movements
c) Retraction
48
 d) Grunting
e) Cyanosis

f) Air entry

Feature observed Score 0 Score 1 Score 2

Chest movement Synchronized Lag on Seesaw
respiration respirations respiration
Intercostals retraction None Just visible Marked
Xiphoid retraction None Just visible Marked
Nares dilation None Minimal Marked
Expiratory grunt None audible with Audible with
stethoscope unaided ear

EVALUATION OF NEWBORN ACCORDING TO SILVERMAN RESPIRATORY

SCALE
0 score - Indicates respiratory distress
4-6 score – Indicates moderated distress

49
7-10 score – Indicates severe distress
HEART RATE
Normal HR – 120-160/min
If Bradycardia - < 60/min – resuscitation
If Tachycardia – look for cause

Causes of Bradycardia Causes of Tachycardia

Asphyxia Hyperthermia
Hypothermia Hypotension
Hypothyroidism Anemia
Increased ICP Hypovolemia
Hypertension Maternal drug (caffeine, nicotine)
Drug induced- IV calcium Hyperthyroidism
PDA
Drug induced – theophylline

CAPILLARY REFILL TIME

 Assesses the state of peripheral circulation

 < 3 secs – Normal
 CRT > 3 secs- Compromised
 If CRT is < 3 secs
- Check temperature and blood pressure
50
 - Maintain temperature
- IV NS bolus – 10 ml/kg/hour

COLOUR
 Pink - Warm baby
 Blue - Hypoxic baby
 Yellow - Jaundice baby
 Pale - Hypothermic baby
 Red - Polycythemic

CYANOSIS
Peripheral cyanosis
 Normal at birth
 Seen in extremities due to cold
Central cyanosis
 Always needs appropriate referral
 Seen in lips and mucosa
 Indicates cardiac or pulmonary disease

URINE OUTPUT
 Normal urine output 1-3 ml/kg/hr
 Oliguria < 0.5 ml/kg/hr for 24 hours
 Anuria – absence of urine output
 Babies on morphic – urinary retention
 Failure to pass urine – may pass within 48 hrs, may be due to obstructive uropathy or renal agenesis.

FAILURE TO PASS MECONIUM

May be passed in utero or suspect obstruction

WEIGHT MONITORING
Abnormal weight loss pattern
 10% of birth weight in term
 15% of birth weight in preterm
51
  5% acute weight loss

SEIZURES VERSUS JITTERINESS

Jitteriness is –
 Provocated by stimulation
 Terminated by holding
 Absence of EEG changed
 Absence of abnormal eye movement
 Absence of autonomic changes

MONITORING OF GI SYSTEM IN SICK NEONTE

 Developmental handicaps in sick infants
 Immaturity of bowel function
 Inability to suck and swallow
 High risk of NEC
 Illnesses interfere with adequate enteral feeds
 Medical intervention preclude feeds
 Sucking reflex
 Feed intolerance

Symptoms
 Vomiting – Blood, bite
 Systemic – Apnea, Bradycardia, Cyanosis
 Stool output – Increased/decreased
Signs
 Abdominal distension with/without visible bowel loops
 Increase in abdominal circumference by ≥ 2 cm
 Pre-feed gastric aspirate > 2ml/kg/> 25-50% of feed volume
 Any change from previous pattern
 Gastric residual characteristics – green (bilious), red (blood-tinged)
 Abdominal tenderness
 Sluggish bowel sounds

52
MONITORING FOR SEPSIS
 Lethargy  Diarrhea/vomiting
 Refusal to suck  Hypothermia
 Poor cry  Poor perfusion
 Not arousable, comatose  Sclerema
 Abdominal distension  Poor weight gain
 Fever

ELECTRONIC MONITORING OF A SICK NEONATE

Different types of monitoring to be covered are

A) Temperature monitoring
B) Weight monitoring
C) Saturation monitoring
D) Blood pressure monitoring
TEMPERATURE MONITORING
Temperature Monitoring is indicated in following cases
 A very sick neonate
 A neonate with hypothermia
 Baby being nursed under servo controlled heating device

Different types of probes available are

 Thermistor probe

53
  Thermocouple probe

Method of applying probe

 Ensure that the probe and the skin surface are clean
 Apply on anterior abdomen or on the flank
 Fix with micropore
 Cover the probe with reflective pad
 Check proper position of the probe periodically

ELECTRONIC WEIGHING SCALE

Electronic weighing scale is an essential part of all special care neonatal units, essential to monitor
the adequacy of nutrition as well as fluid balance.

Indication of weighing a baby are

 All babies at birth
 At weeks
 Sick neonate once or twice in a baby
 To plan fluid therapy
 Measuring urine output

54
 PULSE OXIMETRY

 Pulse oximeter became widely use since 1980’s

 Concept of pulse oximetry is based on Beer-Lambert law
L (out) = L (in) – (D.C.A.)
L= Intensity of light, C= concentration of solution,
D= Distance the light travels through solution, A= absorption coefficient of solute
A pulse oximeter displays the percentage of arterial hemoglobin using a non-invasive instrument.
Typically, it shines a small pair of light-emitting diodes, across from a photodiode, through a translucent
part of the body, like an earlobe or fingertip. One diode is red, and the other is infrared, and they are able to
show difference between oxyhemoglobin and its deoxygenated form through a measurement of the
hemoglobin ratio of light absorption. The signal bounces in time with the patient heart beat, as this is the
same pace at which the arterial blood vessels expand and contract, and also measures oxygen absorption in
accordance with the patient pulse.
Pulse oximeters are very useful in any setting where a patient oxygenation may become unstable.
This includes intensive care units, operating rooms, recovery, and ERs. Pilots also use them in unpressurized
aircraft to determine whether they will need supplemental oxygen. With oxygen being such an essential
element of life, a pulse oximeter is a crucial part of many healthcare environments.

INDICATION
 Measuring oxygenation in sick neonates
 Monitoring side effects of therapy
 Monitoring response to therapy in extremely low birth weight babies.
55
  During neonatal anesthesia.
Usefulness of pulse oximetry
 Fifth vital parameter
 An adjunct in assessment during or following resuscitation
 Aid in titration of oxygen therapy
 Acts as apnea monitor
 Valuable companion during transport
 Can detect ulnar artery patency
STEPS INVOLVED IN CHECKING SATURATION
 Clean with alcohol
 Turn on the monitor
 Apply probe to the site well perfused
 Ensure both sides are directly opposite each other
 Secure probe in place
 Set the alarm limits, volume
 Observe and change site at least once per shift
BLOOD PRESSURE
Blood pressure is the force exerted by the blood against any unit of the vessel wall, at the moment
when it is measured B.P. can be non-invasive and invasive.
Range of normal mean B.P.
Birth weight (kg) MBP (mm of Hg)
<1 30-35
1–2 35-40
2–3 40-45
>3 45-50
NON –INVASIVE METHOD
 All direct measurements rely on the use of inflatable cuff for
arterial occlusion and digital or aural assessment of the return
of arterial flow.
 Oscillometric sensor, piezo electric microphons or
Doppler probe to detect return of flow signals.
INDICATION OF INVASIVE B.P.
 Routine monitoring of sick babies

56
  During illnesses
 During treatment on drugs causing hypotension
 Babies on inotropes

AVAILABLE NEONATAL BP CUFF

Cuff number Cuff size (cm)
1 3-6
2 4-8
3 6-11

TECHNIQUE OF MEASURING B.P.

 Place the baby supine with limb extended
 Measure the circumference and select the appropriate size cuff
 Apply the cuff to bare limb
 Measure the pressure

ROLE OF NURSE IN ELECTRONIC MONITORING OF SICK

NEONATE
Neonatal nurse is one of the important members of the NICU team, monitoring the baby
continuously using clinical and electronic monitoring. Neonatal nursing is considered to be a highly
specialized area of knowledge and practice that requires lengthy supervised experience to reach to a level of
competence that permits independent functioning.

57
 ASSESSMENT OF JAUNDICE
The yellowness comes from a blood byproduct, bilirubin, and a child that develops high levels of
bilirubin has a potentially serious condition called hyperbilirubinemia. Now pediatric researchers say that
this longstanding practice of visual inspection is an unreliable method of predicting the baby's risk of
hyperbilirubinemia. Only infants with a total absence of visible jaundice can confidently be expected to have
a very low risk of hyperbilirubinemia.
Neonatal jaundice is very common, occurring
in as many as 60 percent of newborns annually,
according to the American Academy of Pediatrics.
It appears as a yellow skin color, a sign of excess
bilirubin, a byproduct of the normal breakdown of red
blood cells. In the vast majority of cases, jaundice
disappears in one to two weeks as the baby's liver
reduces bilirubin to normal levels, permitting the excess to be excreted.
But extremely high levels of bilirubin can cause kernicterus, a potentially life-threatening condition
that can result in long-term brain damage, hearing loss and other neurological problems. Although extremely
rare, kernicterus has been increasing in the U.S. over the past two decades, leading some professional
organizations to advocate universal bilirubin screening before newborns leave the hospital. The standard
treatment for significant hyperbilirubinemia is phototherapy—exposing the baby to ultraviolet lights that
chemically change bilirubin under the skin to a harmless form.
CORRELATION OF DERMAL ZONES AND LEVELS OF JAUNDICE

58
Dermal Zone Bilirubin (mg/dL)
1 5
2 10
3 12
4 15
5 >15

59
 ECHO–CARDIOGRAM (ECG)
INTRODUCTION:-
An echocardiogram (also called an echo) is a type of ultrasound test that uses high-pitched sound waves that are
sent through a device called a transducer. The device picks up echoes of the sound waves as they bounce off the
different parts of your heart. These echoes are turned into moving pictures of your heart that can be seen on a
video screen. Echo can be used as part of a stress test and with an electrocardiogram (EKG or ECG) to help your
doctor learn more about your heart.

DEFINITION:-
“An echocardiogram (echo) is a test that uses high frequency sound waves (ultrasound) to make pictures of
heart. The test is also called echocardiography or diagnostic cardiac ultrasound”.

“An echocardiogram (echo=sound + card=heart + gram=drawing) is an ultrasound test that can evaluate the
structures of the heart, as well as the direction of blood flow within it”.

TYPES:-
The different types of echocardiograms are:

1) Transthoracic echocardiogram (TTE). This is the most common type. Views of the heart are obtained
by moving the transducer to different locations on your chest or abdominal wall.
2) Stress echocardiogram. During this test, an echocardiogram is done both before and after your heart is
stressed either by having you exercise or by injecting a medicine that makes your heart beat harder and
faster. A stress echocardiogram is usually done to find out if you might have decreased blood flow to
your heart (coronary artery disease).
3) Doppler echocardiogram. This test is used to look at how blood flows through the heart chambers, heart
valves, and blood vessels. The movement of the blood reflects sound waves to a transducer.
The ultrasound computer then measures the direction and speed of the blood flowing through your heart
and blood vessels. Doppler measurements may be displayed in black and white or in color.

60
 4) Transesophageal echocardiogram (TEE). For this test, the probe is passed down the esophagus instead
of being moved over the outside of the chest wall. TEE shows clearer pictures of your heart, because the
probe is located closer to the heart and because the lungs and bones of the chest wall do not block the
sound waves produced by the probe. A sedative and an anesthetic applied to the throat are used to make
you comfortable during this test.

Why It Is Done:-

a) Transthoracic echocardiogram (TTE):-

This test is done to:

 Look for the cause of abnormal heart sounds (murmurs or clicks), an enlarged heart, unexplained chest
pain or pressure, shortness of breath, or irregular heartbeats.
 Check the thickness and movement of the heart wall.
 Look at the heart valves and check how well they work.
 See how well an artificial heart valve is working.
 Measure the size and shape of the heart's chambers.
 Check the ability of your heart chambers to pump blood (cardiac performance). During an
echocardiogram, your doctor can calculate how much blood your heart is pumping during each heartbeat
(ejection fraction). You might have a low ejection fraction if you have heart failure.
 Detect a disease that affects the heart muscle and the way it pumps, such as cardiomyopathy.
 Look for blood clots and tumors inside the heart.

A transthoracic echocardiogram may also be used to:-

 Look for congenital heart defects or to check the effectiveness of previous surgery to repair a congenital
heart defect.
 Check how well your heart works after a heart attack.
 Identify the specific cause of heart failure.
 Look for a collection of fluid around the heart (pericardial effusion).
 Look for a thickening of the lining (pericardium) around the heart.

b) Stress echocardiogram:-
A stress echo may be done to:-Identify and monitor reduced blood flow to heart muscle (ischemia). This
is usually more apparent after some form of stress, such as exercise or medicine.
c) Doppler echocardiogram:-A Doppler echocardiogram can be done during a transthoracic
echocardiogram (TTE), a transesophageal echocardiogram (TEE), or a stress echocardiogram to:
 Measure the speed at which blood travels through the heart.
 Measure the blood pressure and speed of blood flow through the heart valves.
d) Transesophageal echocardiogram (TEE)

Transesophageal echocardiogram (TEE) may be done to:

 Monitor heart function during surgery.

 Check how well an artificial heart valve works.
 Look for masses or blood clots in the upper left chamber (left atrium) of the heart.

61
  Identify abnormal blood flow between the chambers of the heart (cardiac shunt).
 Help find out if you have endocarditis, which is an infection of the heart's valves or its inner lining
(endocardium).
 Guide procedures done during cardiac catheterization.
 Help find out if you have a tear in the aorta (aortic dissection).

 How To Prepare;-
a) Transthoracic echocardiogram (TTE) and Doppler echocardiogram:-You do not need any special
preparation for a transthoracic or Doppler echocardiogram.

b) Stress echocardiogram:-Do not eat heavily for a few hours before a stress echo to help prevent nausea.
You may feel nauseated if you exercise with a full stomach or from the injection of dobutamine.
 Wear flat, comfortable shoes (no bedroom slippers or sandals) and loose, lightweight shorts or
sweatpants for an exercise stress echo.
 Ask your doctor whether you should take your regular medicines as usual.
c) Transesophageal echocardiogram (TEE):-
 Do not eat or drink for at least 6 hours before the TEE.
 If you have dentures or dental prostheses, you may need to remove them before the test.
 If you have medical problems involving the throat, esophagus, or stomach, tell your doctor before getting
this test.
 Before a TEE, you will be given a sedative. You will not be able to drive for at least 12 hours after the
procedure. Be sure to make arrangements in advance for someone to pick you up after the test.
 Before an echocardiogram, you may be asked to sign a consent form that says you understand the risks of
the test and agree to have it done.

How It Is Done:-

 An echocardiogram may be done in a hospital, clinic, or doctor's office. It can also be done at your
bedside in the hospital.
 it will need to remove any jewelry and clothes above your waist (you may be allowed to keep on your
underwear if it does not interfere with the test). Patient may be given a cloth or paper covering to use
during the test.
 A transthoracic echocardiogram (TTE), Doppler echocardiogram, and stress echocardiogram are
performed by a specially trained ultrasound technician. A transesophageal echocardiogram (TEE) is
performed by a cardiologist with the help of assistants.
 Patient may receive an IV so you can get medicine during the test. The IV can be used to give you
a contrast material, which helps your doctor check your heart function. A contrast material may be used if
it is difficult to get good views of your heart. A good view might be hard to get because of certain
conditions such as obesity or chronic lung disease.

a) Transthoracic echocardiogram (TTE) and Doppler echocardiogram:-

 Patient will lie on your back or on your left side on a bed or table. Small pads or patches (electrodes) will
be taped to your arms and legs to record your heart rate during the test. A small amount of gel will be
rubbed on the left side of your chest to help pick up the sound waves. A small instrument (transducer)
that looks like a microphone is pressed firmly against your chest and moved slowly back and forth. This
instrument sends sound waves into the chest and picks up the echoes as they reflect off different parts of
62
 the heart. The echoes are sent to a video monitor that records pictures of your heart for later viewing and
evaluation. The room is usually darkened to help the technician see the pictures on the monitor.
 At times you will be asked to hold very still, breathe in and out very slowly, hold your breath, or lie on
your left side. The transducer is usually moved to different areas on your chest that provide specific
views of your heart.
 The test usually takes from 30 to 60 minutes. When the test is over, the gel is wiped off and the electrodes
are removed.

b) Exercise stress echocardiogram

 An echo without activity or stress will be done before you start exercising. This is called the baseline, and
after it is established patient will exercise for a specific amount of time. Patient will either walk on a
treadmill or pedal a stationary bicycle while being monitored by an EKG machine.
 Patient will then lie on a bed or table, and another echocardiogram will be done. At times you will be
asked to hold very still, breathe in and out very slowly, hold your breath, or lie on your left side. The
transducer is usually moved to different areas on your chest that provide specific views of your heart.
 An exercise stress echo takes about 30 to 60 minutes.

c) Dobutamine stress echocardiogram

 Sometimes medicine called dobutamine is used instead of exercise to stress your heart. For this test,
patient will lie on back or left side on a bed or exam table, and a baseline echocardiogram will be done.
EKG electrodes will be taped to your arms and legs to record your heart rate during the test.
 Next, the technician cleans the site on your arm where the medicine will be injected, and an intravenous
(IV) line will be placed in a vein in your arm.
 After the IV is started, you will be given dobutamine, which increases your heart rate and causes your
heart to work harder. Echocardiogram images will be taken while you receive the dobutamine. Patient
peak heart rate is reached in about 15 minutes. At times patient will be asked to hold very still, breathe in
and out very slowly, hold your breath, or lie on your left side. After peak heart rate is reached, the
medicine will be stopped and your heart rate will return to normal (in about 1 to 3 minutes). More
echocardiogram images will be taken when your heart rate returns to normal.
 A dobutamine stress echo takes about an hour.

d) Transesophageal echocardiogram (TEE)

 Before a TEE, your throat may be numbed with an anesthetic spray, gargle, or lozenge to relax your gag
reflex and to ease insertion of the probe. Shortly before the procedure begins, an IV line will be placed in
a vein in your arm. Medicine to decrease saliva and stomach secretions may be given through the IV. A
pain medicine and sedative will be given to you through the IV in your arm during the procedure. Patient
should feel relaxed and drowsy but still alert enough to cooperate.
 Patient heart rate, breathing rate, and blood pressure will be monitored throughout the procedure. Also, a
small device used to measure the amount of oxygen in your blood (pulse oximeter) may be attached to
your finger or earlobe.
 Patient will be asked to lie on your left side with your head tilted slightly forward. A mouth guard may
be inserted to protect your teeth from the probe. Then the lubricated tip of the probe will be guided into
mouth while your doctor gently presses your tongue out of the way. Patient may be asked to swallow to
help move the tube along. It may be helpful to remember that the instrument is no thicker than many
foods you swallow. When the probe is in your esophagus, it will be moved down gently to the level of
63
 your upper right heart chamber (atrium), and ultrasound images will be taken. Patient will not feel or
hear the sound waves during the test.
 During the procedure, try not to swallow unless requested. An assistant may remove the saliva from
your mouth with a suction device, or you can just let the saliva drain from the side of your mouth. A
transesophageal echo is generally painless, though you may feel nauseated and uncomfortable while the
probe is in your throat.
 The test takes about 2 hours. The probe will be in place in your esophagus for about 10 to 20 minutes.

How It Feels:-

a) Transthoracic echocardiogram (TTE) and Doppler echocardiogram

 Patient will not have pain from the echocardiogram. Gel is put on your chest for the ultrasound. It may
feel cool. The handheld ultrasound device is pressed firmly against your chest, but it does not cause pain.
You will not hear or feel the sound waves.
 Patient may feel uncomfortable from lying still or from the transducer pressing on your chest. If patient
need to take a break, tell the technician.
 Most people do not experience any discomfort from ultrasound tests. But if you have severe difficulty
breathing or cannot lie flat for a long exam, you may not be able to have an entire echo study. Talk to
your doctor or the technician performing your echo about any concerns you have.
b) Dobutamine stress echocardiogram
 Patient may have a brief, sharp pain when the intravenous (IV) needle is placed in a vein in arm.
 If medicine to stress your heart is used, you may have symptoms of mild nausea, headache, dizziness,
flushing, or angina (such as chest pain or pressure). These symptoms only last a few minutes.

c) Transesophageal echocardiogram (TEE)

 During the test

 Patient may notice a brief, sharp pain when the intravenous (IV) needle is placed in a vein in arm.
 The anesthetic sprayed into your throat may taste bitter and will make patient tongue and throat feel
numb and swollen. Some people report that they feel as if they cannot breathe at times because of the
probe in their throat, but this is a false sensation caused by the anesthetic. There is always plenty of
breathing space around the probe in your mouth and throat. Remember to relax and take slow, deep
breaths.
 Patient may gag and feel nauseous, bloated, or have mild belly cramps when the probe is moved. If the
discomfort is severe, alert your doctor with an agreed-upon signal or a tap on the arm. Even though you
won't be able to talk during the procedure, patent can still communicate.
 The IV medicines will make you feel sleepy. Other side effects-such as heavy eyelids, trouble speaking,
a dry mouth, or blurred vision-may last for several hours after the test.

 After the test

 Patient may have a tickling, dry throat; slight hoarseness; or a mild sore throat. These symptoms may last
for 2 to 3 days. Throat lozenges and warm saltwater gargles can help relieve these symptoms. Throat
lozenges can be used by people age 4 or older. And most people can gargle at age 8 and older.
 Do not drink alcohol for 24 hours.
 Contact your doctor immediately if you have:
64
  Difficulty swallowing or talking.
 Shortness of breath or a fast heartbeat.
 Chest pain.

RISK:-
An echocardiogram is safe, because the test uses only sound waves to evaluate your heart. These high-frequency
sound waves have not been shown to have any harmful effects. If contrast material is used, there is a slight risk of
having an allergic reaction. Most reactions can be controlled using medicine.

1) Transthoracic echocardiogram (TTE) and Doppler echocardiogram

There are no known risks from a transthoracic or Doppler echocardiogram. During a transthoracic echo, the
technician may have to press hard on your chest with the transducer. Tell the technician if feel any pain or
discomfort.

2) Stress echocardiogram

A stress echocardiogram can cause dizziness, low blood pressure, shortness of breath , nausea, irregular
heartbeats, and heart attack.

3) Transesophageal echocardiogram (TEE)

A transesophageal echocardiogram (TEE) can sometimes cause:

 Nausea.
 Mouth and throat discomfort.
 Minor bleeding.
 Trouble breathing.
 Slow or abnormal heartbeats.

Insertion of the probe may tear or puncture your esophagus. This is rare.

This test is not recommended if patient have:

 Recently had radiation treatment to your neck or chest.

 Serious problems with your esophagus, such as a very narrow esophagus, dilated (engorged) veins in the
esophagus that could rupture and bleed (esophageal varices), or severe arthritis of your neck.
 Trouble swallowing.
 A bleeding disorder, such as hemophilia.

RESULTS:-
An echocardiogram is a type of ultrasound test that uses high-pitched sound waves that are sent through a device
called a transducer. The device picks up echoes of the sound waves as they bounce off the different parts of your
heart. These echoes are turned into moving pictures of your heart that can be seen on a video screen.

Results are usually available within one day. If the test is done by a cardiologist, the results may be available
immediately after the test.

65
 Echocardiogram -

Normal Abnormal

The heart chambers and walls of the heart are Heart chambers are too big. The walls of the
of normal size and thickness, and they move heart are thicker or thinner than normal. A thin
normally. heart wall may mean poor blood flow to the heart
muscle or an old heart attack. A thin, bulging
Heart valves are working normally, with no
area of the heart wall may indicate a bulge in the
leaks or narrowing. There is no sign of
ventricle (ventricular aneurysm). The heart
infection.
muscle walls do not move normally because of a
The amount of blood pumped from the left decreased blood supply from narrowed coronary
ventricle with each heartbeat (ejection arteries.
fraction) is normal.
One or more heart valves do not open or close
There is no excess fluid in the sac properly (are leaking) or do not look normal.
surrounding the heart, and the lining around Signs of infection are present.
the heart is not thickened.
The amount of blood pumped from the left
There is no excess fluid in the sac ventricle with each heartbeat (ejection fraction)
surrounding the heart, and the lining around is lower than normal.
the heart is not thickened.
There is fluid around the heart (pericardial
There are no tumors and blood clots in the effusion). The lining around the heart is too
heart chambers. thick.

A tumor or blood clot may be found in the heart.

AFFECT THE TEST:-

Overweight, have a thick chest or large breasts, or have lung disease, such as chronic obstructive pulmonary
disease (COPD). In these situations, other heart tests may be done.

o Cardiac Blood Pool Scan

o Electrocardiogram
o Exercise Electrocardiogram
o Cardiac Catheterization
 Not able to lie still during the test.
 Not able to stand having a probe in your throat during a transesophageal echo (TEE).

NURSING CARE:-

 Assess cardiac rhytmn, vital signs level of consciousness; oxygen saturation at east every 15 min.
until the patient is awake and his or her condition is stable.
 Discontinue IV once patient is stable unless needed for other purpose.
 Once patient is awake, progress diet as tolerated.

66
  Assess patient for discomfort and any complications ( respiratory, cardiac and esophageal) and report
findings to physician.
 Charting. your observations.

 Report the rate, rhythm, conduction, p waves, frontal plane axis, QRS complex.
 Comment on T waves over R chest. Look at QT interval
Rate = 1500 / number of little squares or
= 300 / number of big squares

67
 GASTRIC LAVAGE
INTRODUCTION
Although the use of “stomach pumps” in animals dates to the mid 18th century, its first use (in human
poisoning) is attributed to physic of Pennsylvania, who in 1812, lavaged twins poisoned with
laudanum, prescribed for whooping cough. The lavage fluid was brandy and water.
Gastric lavage, also commonly called stomach pumping or gastric irrigation, is the process of
cleaning out the contents of the stomach. It has been used for over 200 years as a means of
eliminating poisons from the stomach. Such devices are normally used on a person who has ingested
a poison or overdosed on a drug. They may also be used before surgery, to clear the contents of the
digestive tract before it is opened.

DEFINITION
“Gastric lavage is the aspiration of the stomach contents and washing out of the stomach by means of a
gastric tube.”

“Gastric lavage involves the passage of a tube via the mouth or nose down into the stomach, followed
by sequential administration and removal of small volumes of liquid.”
PURPOSES
1. To remove unabsorbed poison after poison ingestion.
2. To diagnose and treat gastric hemorrhage and for the arrest of hemorrhage.
3. To cleanse the stomach before endoscopic procedure.
4. To remove liquid or small particles of material from the stomach.
INDICATION
 Oral poisons
 Gastrointestinal bleeding
 Meconium aspiration syndrome and meconium induced gastritis.
 Suspected congenital tuberculosis
 Before endoscopic procedure.
CONTRAINDICATION
 Ingestion of corrosive poisons.
 Ingestion of most hydrocarbons.
 Presence of neurologic symptoms likely to impair normal airway protective mechanism.
68
  Tetanus.
EQUIPMENT
1. Stomach tube (orogastric/ryles tube) of appropriate size.
2. Suction machine, syringe or aspiration bulb.
3. Liquid paraffin or Vaseline.
4. Mouth gag
5. Normal saline

PROCEDURE

S STEPS RATIONALE
1. Measure the distance on the tube from the mouth or tip To determine the approximate length of the
of nose to ear lobule to epigastrium and mark the tube tube to be inserted.
with an indecible marking pencil or with a piece of
adhesive tape.
2. Keep the child in supine position with head slightly To clear the passage and easy insertion
hyperextended and supported from beneath with hand.
3. Smear the tube with liquid paraffin or Vaseline as a It help to minimize the friction between
lubricant. It should not be used in neonates so as to tube and mucosa.
prevent aspiration.
4. Open the patient mouth using a gag, if necessary. If patient is unconscious or disoriented, then
he can bite the tube so to prevent it mouth gag
can be used to open the mouth.
5. Pass the tube over the tongue and toward the back of
the throat (orogastric) or through one of the nostrils.
6. Pass gently the tube until the mark on the tube reaches To avoid trauma to the mucosa.
up to lips or anterior nostrils. If the tube meets an
obstruction when introduced about half way to the
mark, it has probably entered the trachea. Sudden
aphonic also indicates tracheal introduction. In such
cases, do not use force but simply remove the tube and
gently repeat the procedure until the tube passes
readily to the mark indicated.
7. Confirm the presence of tube in stomach by pushing Because wrong placement of tube can cause
69
 the air through syringe and auscultating over stomach, chocking or aspiration.
or by placing the other end of tube in glass in glass of
water. Building on expiration indicates placement in
trachea.
8. After confirmation, secure the tube with adhesive tape To prevent displacement or pulling of the tube
applied over face of forehead.
9. Position child in the left lateral decubitus position or in Gastrointestinal reflux is more common in the
a supine position with the head elevated, depending on right than in the left lateral position. Elevation
age and clinical condition of the child. of head discourages aspiration of gastric
contents by using gravity to keep fluid down
when lavaging.
10. Remove the gastric contents by use of gentle suction Because forceful aspiration may cause injury.
or syringe or aspiration bulb.
11. After the stomach contents have been removed, Because normal saline minimizes the risk of
perform gastric lavage by normal saline. The use of tap electrolyte imbalance.
water or hypertonic saline should be avoided.
12. Instill 10mL/kg of warmed lavage solution for children Warmed fluids helps to minimize the risk of
younger than 5 years, and 150-200 mL in children hypothermia in young children. To avoid
older than 5 years. Water should not be used in electrolyte imbalance, the volume of lavage
children return should equal the amount of fluids
given. Water if used in children increases the
risk of developing hyponatremia and water
intoxication.
13. Instill fluid at consecutive intervals until the fluid Clear aspirate indicates that particulate matter
aspirate is clear. has been removed.
14. Always ensure to close the tube by pinching while To prevent the spillage of tube contents into
withdrawing it from the stomach. respiratory tract.

COMPLICATIONS
 Aspiration pneumonia, secondary to vomiting during the procedure
 Laryngospasm with cyanosis
 Esophageal perforation, again, speaks against the use of force.
 Trauma and false passage formation

70
  Hypoxia, bradycardia, epistaxis, hyponatremia, hypochloremia, water intoxication, mechanical
injury to stomach.

SPECIAL NOTES
 The tube may also be inserted through the nostril.

 Do not use excessive force while passing the tube.

 Watch out for laryngospasm and bradycardia during the procedures.

71
 MECHANICAL VENTILATOR
INTRODUCTION:-

The advent of modern ventilator therapy in the 1980s has been a prominent milestone in the history
of advanced pediatric care. Ventilation should be undertaken in centers with adequate manpower, skill and
technology. Available ventilators for pediatric use have a wide range of capabilities, versatility and clinical
application. Some are more suitable for use with infants, others with older children. Nurses must be well
acquainted with the characteristics of the particular machine being used and the meaning of the setting and
alarms on the machine.

DEFINITION:-

Mechanical ventilation refers to the use of life-support technology to perform the work of breathing for
patients who are unable to do so, on their own.

OBJECTIVES:-
The fundamental objectives for ventilatory support in acutely ill patients may be viewed
physiologically and clinically:

PHYSIOLOGICAL OBJECTIVES:-
 To support or manipulate pulmonary gas exchange
 To normalize alveolar ventilation (PaO2, PaCO2 and pH)
 To achieve and maintain PaO2 >60 mm Hg and peripheral Sat O2 > 90%.
 To increase lung volume and maintain adequate functional residual capacity (FRC)
 To obtain lung expansion and to prevent or treat atelectasis.
 To improve oxygenation and lung compliance.
 To reduce the work of breathing in presence of high airway resistance and/or reduced
compliance, when spontaneous breathing becomes ineffective.
72
  CLINICAL OBJECTIVES:-
 In presence of pathologic lung- Lung pathology may be connected with difficult gas diffusion,
particularly concerning alveolar oxygen levels (principally paO2), or with ineffective inhaling and/or
exhaling condition, which affect the elimination of CO2 particularly, as well as the acquisition of O2.

Objectives:
 Improve lung pathology
 Reverse hypoxemia, hypercarbia and acute respiratory acidosis
 Decrease systemic or myocardial oxygen consumption
 Relieve respiratory distress and reverse ventilatory muscle fatigue
 Stabilize chest wall in case of rib instability and/or loss of integrity

 In healthy lung
Objectives:
 Provide adequate gas exchange
 Permit sedation and/or neuromuscular blockage (e.g. to control seizures or provide general
anesthesia)
 Prevent complications connected with ventilatory support
 Avoid appearance of atelectasis and ventilation/perfusion (V/Q) mismatch.

ADVANTAGES:-
 Correct ventilation of both lungs and progressive improvement of lung pathology
 Improvement of oxygenation and reduction of hypercapnia.
 Reduction of respiratory fatigue and oxygen consumption.
 Protection of airways and efficacious broncho-suctioning if tracheal intubation is performed.

ABSOLUTE INDICATION FOR INTUBATION AND MECHANICAL VENTILATION ARE:-

 emergency
 apnea and severe irregularity of spontaneous breathing
 severe respiratory failure
 ineffectiveness of oxygen therapy by mask, CPAP or non- invasive ventilation

BASIC PRINCLIPLE OF A VENTILATOR:-

To understand the basic principle of a ventilator, we have to conceptualize the AYRES- T-piece
principle. If you completely occlude one end, you produce inspiration by diverting gas flow to the baby. If
the occlusion is released completely, gas flows through a path of least resistance and produce expiration. If
the occlusion is released partially, pressure builds up at the end of expiration due to incomplete gas
emptying. This is called positive end expiratory pressure (PEEP).
Mechanical ventilators incorporate a time cycling mechanism to occlude the expiratory limb of the
patient circuit (inspiratory time), which may be pneumatic electronic such as Bear Cub, Sechrist or
microprocessor controlled such as Infant Star.

73
TYPES OF VENTILATION STRATEGIES:-

Mechanical ventilation can be applied both invasively and non-invasively in the following
ways:
1. Assisted spontaneous breathing: Continuous Positive Airway Pressure (CPAP)
2. Supported spontaneous breathing: Pressure or volume support in spontaneous breathing: Pressure
Support Ventilation and Volume Support Ventilation
3. Mixed respiratory support: Intermittent Mandatory Ventilation and Synchronized Intermittent
Mandatory Ventilation
4. Controlled mechanical ventilation: Pressure controlled Ventilation, Volume Controlled Ventilation,
Pressure Regulated Volume Controlled Ventilation, High Frequency Ventilation

1. ASSISTED SPONTANEOUS BREATHING-

1.1 Continuous Positive Airway Pressure (CPAP):
CPAP is a mode of ventilation, which enables the elevation of end-expiratory pressure to levels
above atmospheric pressure to increase total lung volume, and functional residual capacity, thus favoring
improved oxygenation
This method presents several advantages because of:
 increased lung volume and FRC and improve in ventilation/perfusion ratio
 Preventing and resolving atelectasis.
 reduced work of breathing and prevention of muscle fatigue
 Reduced sternum and chest deformities and normalization of respiratory frequency
CPAP is indicated in:
 recurrent apnea, not from CNS origin, connected with exhaustion and muscle fatigue
 Moderate Idiopathic Respiratory Distress Syndrome of premature baby (RDS), transient tachypnea,
pulmonary edema and not severe pneumonia and bronchopneumonia
 Weaning from the ventilator and when reduction of intubation is desired.
CPAP is not advisable in:
 high risk patients
 apnea prolonged over 20 sec or recurrent, complicated by bradycardia
 insufficient spontaneous breathing from different origins
 severe respiratory effort to maintain ventilation
 hypercapnia (PaCO2 > 50 mm Hg).

2. SUPPORTED SPONTANEOUS BREATHING-

Assisted modes of ventilation are those in which part of the breathing pattern is contributed
or initiated by the child. The work of breathing performed by the child is never abolished.
2.1 Pressure Support Ventilation (PSV):
Pressure support ventilation (PSV) is designed to support spontaneous breaths during inspiratory
phase. It is primarily designed to assist spontaneous breathing and therefore the patient should have an intact
respiratory drive.
The patient triggers each breath by opening the demand valve of the ventilator. A supplementary gas
flow is delivered to the inspiratory circuit to produce positive inspiratory pressure at a pre-set value. Cycles

74
are pressure limited and there is no pre-set tidal volume. The patient triggers assisted breathing and regulates
respiratory rate, inspiratory and expiratory time and tidal volume.

Advantages:
 minimizes work of breathing
 reduces respiratory muscle fatigue and oxygen consumption
 hemodynamic stability favored as breathing is triggered spontaneously
 Can be used to compensate for extra work produced by endotracheal tube and demand valve.
Disadvantages:
Tidal volume is uncontrolled and variable and depends on respiratory mechanics, cycling frequency and
synchrony between patient and ventilator.
 If pressure support is high, the patient tends to reduce his respiratory rate and tidal volume. The risk of
baro and volutrauma is increased and ventilated gases may not be adequately warmed and humidified.
 If pressure support is low, patient tends to increase respiratory frequency and reduce tidal volume.
In such case oxygen consumption and work of breathing are increased.
 In cases of inhomogeneous lung pathology, PSV tends to favor ventilation of better-aerated
areas without affecting collapsed or atelectatic areas.
PSV needs continuous and careful adaptation of respiratory support to avoid the aforementioned
undesirable effects (increased support from health workers).
Indications:
Intensive care
 Weaning from ventilation after improvement in lung pathology
 Weaning from long term ventilation
 Weaning of patients with chronic obstructive pulmonary disease e.g. infants with severe BPD
 To promote respiratory muscle training
 To compensate for high resistance of endotracheal tubes during CPAP.
Postoperative care
1. To preserve or reactivate spontaneous breathing
2. 2. To resolve atelectasis after surgery.
Contraindications:
1. Deep sedation and muscle paralysis
2. Severe neurological disorders
3. Hypoventilation syndromes
4. Patients who may be unable to activate trigger demand valve.

2.2 VOLUME SUPPORT VENTILATION (VSV):

VSV is a new means of assisting spontaneous breathing which avoids the disadvantages deriving
from pressure support ventilation which needs frequent adaptation by medical staff. The ventilator, breath by
breath, adapts inspiratory pressure support to changes in the mechanical properties of the lung and the thorax
in order to ensure that the lowest possible pressure is used to deliver pre-set tidal and minute volume that
remain constant. Inspiratory pressure is constant and flow is decelerated.
When the patient is able to ventilate pre-set tidal volume, the ventilator does not support the breath.
At this stage, extubation may be performed with safety. In cases of apnea the ventilator automatically
switches to PRVC. The initial values for expected tidal and minute volume should be set as should all
parameters to be used in PRVC in the presence of apnea ventilation. Indications and contraindications are
75
similar to PSV. The main advantages of VSV vs. PSV is the possibility of maintaining stable tidal volume,
being protected should apnea occur and being able to recognize when the patient no longer requires pressure
support to ventilate pre-set tidal volumes (extubation can safely be performed).

3. SYNCHRONIZED INTERMITTENT MANDATORY VENTILATION – SIMV

SIMV combines a pre-set number of ventilator-delivered mandatory breaths of predetermined tidal
volume with the facility for intermittent patient-generated spontaneous breaths. The ventilators on the
market offer the possibility of delivering pressure-or volume-targeted breaths during mandatory cycles.
Child with SIMV can activate mandatory breaths but if child trigger is not efficacious, ventilator can deliver
a mandatory breath. Pressure or Volume Support can be applied during non-mandatory support.
Advantages:
 possibility to maintain spontaneous breathing and avoid muscle atrophy, especially in
neuromuscular patients who rapidly lose ability to breath spontaneously
 Progressive reduction of controlled breaths can favor return to complete spontaneous breathing.
The method is difficult to apply in cases of acute and severe lung pathology, in compromised clinical
status and in cases of neurological disorders than can interfere with ventilation drive. In these cases children
could adapt completely to control breathing furnished from ventilator that could be insufficient to maintain
adequate gas exchange.

4. CONTROLLED MECHANICAL VENTILATION – CMV

This mode of ventilation controls the patient's respiratory activity completely. Introduction of gases
into the lung, inspiration, is obtained using positive pressure, which pushes gases into the lung (30). This
method is completely different from spontaneous breathing in which introduction of gases into the lung
occurs as a result of negative pressure inside the lung. As a consequence, venous return and cardiac output
can be reduced.
The expiratory phase is passive and is regulated by the opening of expiratory valve at end of
inspiration. This valve is opened when a prefixed pressure or tidal volume is achieved in the lung.

1.1. Constant Pressure Generators (Pressure Controlled Ventilators):

The pressure ventilator delivers a volume of gas at constant pressure to the lung during set inspiratory time.
Volume received by patient is determined by set inspiratory pressure, respiratory rate and inspiratory time.
Pressure remains constant during inspiration, while flow decelerates.

Advantages:
 flow rate is geared to reach Peak Inspiratory Pressure (PIP) as quickly as possible and flow will exceed
patient's demand, improving patient ventilator synchrony and decreasing work of breathing;
 Using decelerating flow pattern and square-wave pressure pattern; distribution of gas within the lung can
be improved.
Disadvantages:-
 pressure remains constant while tidal volume will vary, according to changes in compliance and airway
resistance
 Any thorax and diaphragmatic compression reduces tidal volume, which can be insufficient to maintain
adequate gas exchange.

76
 This mode of ventilation has been proposed to protect the lung from barotraumas but instability of tidal
volume and PEEP can create in homogeneity of lung. Hypoventilation or hyperventilation may occur:
e.g. in infants with RDS, with low compliance and normal airway resistance, pressure ventilation may
lead to insufficient tidal volume and hypoventilation.

4.2. Constant Flow Generators (Preset Volume Controlled Ventilators ): The generator
delivers the same preset tidal volume with each breath. During inspiratory time pressure will be slowly
increased while flow pattern produces a square wave.
Advantages of volume controlled ventilation:
 supply of constant minute volume
 Maintenance of preset tidal volume with variation of compliance and/or pulmonary resistance.
Disadvantages:
 Atelectatic areas are not re-ventilated, as they require higher pressure in order to be reopened
 Less damaged areas tend to be hyperventilated
 Using uncuffed tubes, a large part of preset tidal volume can be lost leading to inadequate ventilation.
This ventilatory mode, using small tidal volume and high respiratory frequency to maintain stable
minute volume, has been demonstrated to be effective in reducing Ventilation Associated Lung Injury
(VALI), morbidity and mortality in ARDS. The best results have been obtained when PEEP levels have
been maintained over inferior flex point and lung expansion under superior inflection point of
volume/pressure curve.

4.3 Pressure Regulated Volume Controlled Ventilation -PRVC: PRVC ventilation delivers
controlled tidal and minute volume in a pressure-limited manner using lowest possible pressure, kept
constant during inspiratory phase. Gas flow is decelerated and pressure and flow constantly vary, breath by
breath, in order to achieve pre-set tidal volume at minimum peak inspiratory pressure. The ventilator tests
the first breath at 5 cm H2O above PEEP and calculates pressure-volume ratio. Inspiratory pressure changes
breath by breath until preset tidal volume is reached at a maximum of 5 cmH2O below set upper pressure
limit. At this stage measured tidal volume corresponds to preset value and pressure remains constant. If
measured tidal volume increases above preset level, inspiratory pressure is reduced until set tidal volume is
reached.
Advantages of PRVC ventilation
 improvement of respiratory mechanics and gas exchange
 reduction of barotrauma connected with Peak Inspiratory Pressure (PIP)
 reduction of oxygen toxicity due to possibility of using reduced FiO2 to maintain adequate gas
exchange as compared with conventional mechanical ventilation
 opening of closed areas of lung connected with use of decelerated and laminar flow
 Immediate reduction of PIP in presence of a rapid change of compliance and resistance
as surfactant, bronchodilators, nitric oxide, etc. are used.
Indications:
 when lung compliance and resistance vary rapidly
 If there is an initial requirement of high flow in order to re-open closed pulmonary areas
(e.g. atelectasis, etc.)
 To reduce high ventilatory peak pressure (e.g. in premature infants, interstitial emphysema, etc.)

77
  To control ventilatory pressures from the moment non-ventilated alveoli and bronchioles are re-
opened (e.g. surfactant, theophylline or nitric oxide administration, etc.)
 In presence of broncho- and bronchiole-spasms (e.g. asthma, bronchiolitis, etc.)
 In all patients in whom PEEP levels must be reduced in order to avoid hemodynamic complications.
Clinical controlled trials are required to evaluate real benefits of PRVC ventilation in acute phase of
lung pathology (need of peak pressure to reopen non ventilating areas), in ventilation of healthy lungs (i.e.,
neurosurgical patients) and during weaning from ventilator.

5. NON-INVASIVE POSITIVE PRESSURE VENTILATION – NIPPV-

The feasibility of applying a ventilatory mode capable of avoiding airway invasion has been
evaluated and tested over time. Two modes using different methodologies to attain respiration have had
large consensus: 1) Negative Pressure Ventilation by means of either iron lung or chest cuirass (42-44), and
2) Positive Pressure Ventilation in spontaneous breathing, with CPAP, or Non-invasive Positive Pressure
Ventilation with mask (45-47).

COMPLICATIONS:-
 Reduction of venous return and cardiac output as a consequence of politicization of inhalatory phase.
This can be seen mainly in cases of hypovolemia
 Lung volume and FRC reduction
 Lung in homogeneity due to over-expansion of better ventilated areas
 Small airway closure connected with impossibility to expel secretions and their migration to more
declivous and dependent areas
 Secretion stiffening, loss of ciliary activity and mucus alteration if not well-warmed and humidified
gases are used
 Lung trauma connected with high peak pressure (barotrauma), large volumes (volutrauma) and
biological factors (biotrauma) e.g. inflammation
 Development of infection due to incorrect nursing, insufficient secretion clearance, atelectasis
development, etc.
 Vocal chords and tracheal lesions which can evolve into stenosis if traumatic tracheal intubation is
applied - hypoventilation and hypoxia due to technical problems

EQUIPMENT:-
1. Gloves
2. Manual resuscitation bag and face mask
3. Suction equipment and catheters
4. Positive end-expiratory valve (PEEP) valve
5. Two sources of oxygen delivery
6. Air source
7. Constant electrical source
8. Sterile water
9. Mechanical ventilator with heated, filtered humidifier, and in-line thermometer
10. Oxygen analyzer
11. Stethoscope
12. Intubation equipment
78
 13. Cardiopulmonary monitor and equipment
14. Pulse oximetry equipment
15. Intravascular therapy equipment
16. Sedation, pain medication

CHILD AND FAMILY ASSESSEMNT AND PREPARATION:-

a) Inform the child and the parents of the need for mechanical ventilation or positive-pressure
ventilation.
b) Prepare the family to provide interaction with the child, including touch, talking with, and
providing other comfort measures, even while the child may be sedated.
c) Determine the child’s baseline weight. This will help in determining how much tidal volume or
pressure is required for mechanical ventilation.

MANAGING THE CHILD DURING SYSTEM SETUP

STEPS RATIONAL/POINTS OF EMPHASIS

1) Notify respiratory care therapist of In most institution, the respiratory care
need for mechanical ventilator. If the therapist conducts the initiation and setup
child is not intubated, the respiratory of ventilator management.
therapist should be prepared to assist in
intubation procedures.
2) Place appropriately sized manual For the child on a ventilator, emergency
resuscitation bag, oxygen reservoir, respiratory equipment must be maintained
tubing, flowmeter and appropriately at the bedside at all time in case the child
sized face mask at the bed side. Place becomes extubated and requires manual
suction catheters and suction equipment ventilation.
at the bedside.
3) Verify that the child has a patent IV IV access is needed if the child
line for administration of sedatives, experiences cardiac arrest during
paralytics, and emergency drugs. intubation. Emergency medication can
Initiate IV access if none is in place and also be delivered.
if IV access will be needed.
4) Perform hand hygiene and wear gloves. Reduces transmission of microorganism.
5) Initiate bag and mask ventilation or Manual ventilation may be needed if the
manual ventilation though endotracheal child’s respiratory status is declining
or tracheostomy tube until mechanical rapidly.
79
 ventilator is ready to be connected to
the child.
6) If not already completed, connect the Provide for ongoing assessment of the
child to cardiopulmonary monitor and infant/child for any changes in heart rate,
pulse oximeter monitor for the child’s respiratory rate or function, oxygen
heart rate, respiratory status, and saturation, and level of consciousness.
oxygenation status throughout the
procedure.
7) Assess the child for signs of inadequate These signs indicate respiratory distress
ventilation. Observe the child for and a need for mechanical ventilation.
increased work of breathing.
8) Obtain and assess child’s blood gases Determine presence of acute respiratory
(as indicated) acidosis, hypoxemia, or hypercapnia,
which would confirm the need for
mechanical ventilation.
9) Suction the child’s airway as needed. Removes secretions and any potential
airway blockage that may impede
successful ventilation and intubation of
child.
10) Administer pain medications, sedatives, The infant/child should be kept quiet and
or paralytics as ordered immediately still during the procedure to prevent
before the intubation, additional inquiries
11) Atropine may also be given Mechanical stimulation of the airway or
pretreatment to reduce the incidence of hypoxemia may induce brady-arrhythmias
reflex bradyarrhythmias. in the infant and young child
12) Assist in intubation procedure. A properly placed and secure tracheal tube
is the most effective and reliable method
of assisted ventilation.
13) Once the child is intubated and the Provides for mechanical ventilation to be
respiratory therapist has set up the instituted to the child.
ventilator, attach airway circuitry
adapter from ventilator to artificial
airway alarms are on and functioning.
14) Confirm that the ventilator setting and Ensures that ventilator setting have been
parameters are as prescribed and that established in the manner prescribed by
alarms are on and functioning. the physician.
15) Ensure that the circuitry tubing is free Provides child-ready ventilation with
of water and is not kinked, all assurance that it is working in the
connections are secure. prescribed manner with emergency
equipment at the bedside.
16) Visually assess child’s chest for Monitors efficacy of ventilator and alerts
symmetry of movements auscultate parents to potential problems.
child’s breath sounds with stethoscope
to ensure that there is equal inflation in

80
 all lung fields, without adventitious
sounds.
17) Dispose of equipment and waste in Standard precautions.
appropriate receptacles.
18) Ensure that child is placed in Ensures child’s safety and comfort.
comfortable safe position and is free
from pain
19) Perform hand hygiene. Reduces transmission of microorganisms

MAINTENANCE PROCEDURES:-
Protective maintenance
A program of cleaning, operational preventive maintenance is important for the proper function and
life of the ventilator. Using the quick checkout procedure on a routine basis will help identify potential
problems.
Routine cleaning and checkout between patients should include:
1. Check out procedure as prescribed for the particular ventilator.
2. Water trap filter check.
3. Cleaning the exhalation block, diaphragm and patient circuit (if reusable), wiping the exterior of the
ventilator.
4. Check air temperature of humidifier (37°C) and adjust control dials accordingly.
Monthly operational checks
1. Battery condition, LED display
2. Air and oxygen pressure gauge accuracy test
3. FiO2 check
4. Proximal airway pressure gauge accuracy test
5. Driving pressure check
Yearly preventive maintenance
The machine’s maintenance should be done every two yearly or after every 10,000 hours of use.

CLEANING AND STERILIZATION:-

a) Follow instructor’s manual for the equipment.
b) Clean the exterior with mild detergent or a damp cloth. Do not let water enter the ventilator.
c) Do not use strong solvents to clean the panels.
d) The ventilator may be covered with cloth or plastic cover in case it is not in use.
e) It is ideal to use disposable patient circuits compatible with the ventilator. Reusable circuits should be
immersed in gluteraldehyde solution for at least 6 hours and then rinsed in running water. Some
tubing’s which are autoclavable can be autoclaved.
f) Gas sterilization for 4 hrs 140°F with ethylene oxide and CO2 or Freon is ideal for a ventilator.
g) The filters of compressors should be cleaned with water daily. Bacterial filters should only be
autoclaved. However, to extend its use, a culture of the bacterial filter can be taken after running on a
test set up for half an hour. If the results are good, the filter is put to use. It is advisable to repeat the
procedure monthly after 25 autoclaves.

81
 PHOTOTHERAPY
INTRODUCTION
Phototherapy has been in use since 1958 and has stood the test of time. Phototherapy was introduced
by Cremer in the year 1958. It is now widely used modality for treatment of neonatal indirect
Hyperbilirubinemia as it is effective and relatively safe. Despite the use of phototherapy for over 40 years
now, there are still many simple issues, which the treating physician should know.

DEFINITION
Phototherapy is a non-invasive, inexpensive and easy method used for treatment of unconjugated
Hyperbilirubinemia and has considerably the need for exchange transfusion.

PRINCIPLES
It has been shown that bilirubin absorbs light maximally at 420-490 nm (peak at 460 nm) and light
sources whose peak emission are of this range cause photo-isomerization of bilirubin to more polar
water soluble products which are readily excreted in feces and urine.
Phototherapy also enhances hepatic excretion of unconjugated bilirubin into the intestinal lumen.
Phototherapy acts upon bilirubin in the skin and subcutaneous tissues up to a depth of around 2 mm.
it takes about 1-3 hours for fresh bilirubin from the blood to re-equilibrate into the tissues.
For phototherapy to effective, bilirubin needs to be present in the skin; hence there is no role for
prophylactic phototherapy.

MECHANISM
Phototherapy reduces the serum bilirubin by the following 3 mechanism:
1) Configurational isomerization:
Here the Z-isomers of bilirubin are converted into E-isomers. The reaction is instantaneous upon
exposure to light but reversible as bilirubin reaches to bile duct. After exposure to 8-12 hours of
phototherapy, these isomers constitute about 25% of total bilirubin (TSB), which is nontoxic. Since this
is excreted slowly from the body, this is not a major mechanism for decrease TBS.
2) Structural isomerization:
This is an irreversible reaction where the bilirubin is converted into lumirubin. This conversation is
directly proportional to the dose of phototherapy. This product forms 2-6% of TBS and is rapidly
excreted from the body. Thus this fraction is mainly responsible for phototherapy induced decline in
TBS.
82
3) Photo-oxidation:-
This is a minor reaction where photo-products are excreted in urine.
INDICATION

 Indicated in babies with indirect Hyperbilirubinemia which is more than accepted for its maturity,
postnatal age and weight, still less than the level at which an exchange transfusion would be
performed.
 It is recommended when serum bilirubin due to any cause approaches 10-12 mg/dl in preterm babies
and 12-15 mg/dl in term babies.
 Prophylactic phototherapy is recommended in very low birth weight babies with perinatal risk.
 In case of hemolysis, start phototherapy at lower level.
 Acidosis, asphyxia, hypoglycemia or sepsis makes the blood brain barrier less efficient and more
susceptible to BIND. So, consider early phototherapy.
 In case of prolonged jaundice (>3 wk), one should always check fractional bilirubin estimation.
Phototherapy is contraindicated in the presence of conjugated hyperbilirubinemia (≥ 2 mg/dL)
because it may result in bronze baby syndrome.
 Phototherapy should not be undertaken at centers where round the clock facilities for serum bilirubin
estimation and exchange blood transfusion are not available.

CONTRAINDICATION
 Direct hyperbilirubinemia
 Porphyria
 Conjugated hyperbilirubinemia (≥ 2 mg/dL)

PHOTOTHERAPY UNIT
A light source designed to give an irradiance of 6 to 8 µw/cm2/nm in the 400-500 nm range at the
surface of baby’s skin is desirable. It should preferably be a mobile unit which can be used for babies
nursed in cots, incubators or radiant warmer.
The height should be adjustable, while a few units may be tilted on axis. Phototherapy lights may be
mounted on the radiant warmers themselves. A standard phototherapy unit consists of 6 to 8
fluorescent tubes (20 watts). To increase the effectiveness, double surface phototherapy is preferred.

83
(a) Halogen spotlight
In recent years, halogen bulb spotlight phototherapy units have been available in the market. This
can emit a relatively high level of irradiance compared with the conventional fluorescent tubes.
A light of relatively narrow spectrum is emitted when a high voltage excites a mixture of
halogens. They have a 150 watt, 21V halogen bulb with a specially coated reflector which
absorbs infrared waves.
A fan continuously cools the heated bulb. Positioning of the light on baby is critically important
in determining the spotlight’s effectiveness. They are most effective when delivered from
directly above the infant at a distance of 45-50 cm.

(b) Combination of special blue and white fluorescent lights (2 special blue + 4-6 white fluorescent
tubes)
The blue tubes must have the serial number F20T12/BB to be special phototherapy lights. This
combination would deliver 12-16 µw/cm2/nm.
They degenerate with time, so units delivering less than 6 µw/cm2/nm should have tubes replaced
even though they still appear to be working. Again, directing the light from the side of the infant
significantly reduces the dose delivered.

(c) 6-8 white fluorescent lights (20/40 watt each)

These should be positioned above the infant and deliver 6 – 8 µw/cm2/nm. They also continue to
appear effective despite giving minimal irradiance.
If the irradiance delivered falls below 6 µw/cm2/nm the tubes need replacement.

(d) Compact fluorescent lights (CFL)

84
 They consist of compact high intensity bulbs (usually 4 blue and 2 white bulbs) enclosed in unit
with reflecting grills. The units have adjustable distance but can lead to overheating, if brought
too near to the baby. Head tilting of the unit is possible.

(e) Bili-blanket
The latest phototherapy units are based on the principle of fibreoptics in which an illuminated
blanket is wrapped around or placed under the baby, which delivers lights in the 425 to 475 nm
waveband.
The pad is cool and can be placed in direct contact with the baby. The unit consist of an
illuminator with halogen bulbs which is connected by a fibreoptic cord to an illuminator pad
(blanket) on which baby lies. It ensures greater surface area of exposure.
It minimizes infant/mother separation, has less risk for hypothermia or hyperthermia and does not
increase insensible water loss.
There is no for occlusive eye patches. The blanket needs cleaning if soiled and must be
disinfected if used for another baby.
The three settings on the unit deliver the following irradiance: low= 7 µw/cm2/nm; medium = 12
µw/cm2/nm; high = 15 µw/cm2/nm. It can be used as a sole source of phototherapy ar as an
adjunct to conventional treatment by laying the infant on the blanket to give “double surface
phototherapy” i.e. increasing the surface area exposed.
EQUIPMENTS
 Overhead phototherapy light
 Isolette
 Eye shield
 Disposable diapers/ surgical mask (for smaller baby)
 Towel or disposable water proof pad
 Bilirubin leght meter
 Isolette temperature monitor
 Thermometer
 Documentation sheet for Intake and output.
PROCEDURE
STEPS RATIONALE
1) Gather the necessary supplies Promotes efficient time management and provides
an organized approach to the procedure.

85
2) Perform hand hygiene. Reduces transmission of micro-organisms.
3) Set up the fluorescent over lights following Bilirubin absorbs light in the range of 400-500 nm.
manufacturer recommend- -dation as The distance of the light source from the infant
close to the infants as possible in an open affects how well the lights penetrates skin and is
bassinet about 44-45 cm from the infant. absorbed by bilirubin (this effect is most significant
when special blue tubes are used).
4) Turn the light unit on. Using the light Intensity of lights may decrease over time. Lights of
mater, verify that the level of irradiance is intensity may be ineffective or may require longer
appropriate. Approximately 12-15 7 length of exposure to the infants to achieve the
µw/cm2/nm fro low intensity (single) or desired therapeutic effect.
30-35 7 µw/cm2/nm for high intensity
(double).
5) Perform hand hygiene. Reduces transmission of micro-organism.
6) Undress the infant, leaving a diaper in Undressing the infant increases the amount of skin
place to cover the genitals. Use a surgical surface area exposed. The diaper protects the
mask for a diaper if diaper covers too much gonads against chromatic radiant damage from the
skin area of a small infant. phototherapy light exposure.
7) Ensuring that the infant’s eye lids are Eyes are closed to prevent corneal excoriation eyes
closed, carefully cover the eyes completely are covered by protective eye shields to protect
with protective shield. Remove eye patches them against retinal damage.
every 4 hours.
8) Place the infant in bassinet or isolette. For the overhead lights to be safe and effective, an
Ensure that the position of the lights are exact distance from the lights must be maintained
maintained about 45-46 cm. throughout the treatment.
9) Turn the infant every 2 hours assessing Ongoing skin surveillance can detect problems early
skin integrity, hydration, temperature and and prevent dehydration or damage to the infant’s
neurologic status. skin integrity.
10) Monitor the infant’s temperature in an Verifies that the naked infant in an open bassinet
open bassinet every 30 min for the first can maintain his or her temperature in a safe range
hour and then every 2 hours as needed. and to detect alteration promptly.
11) Remain vigilant in keeping the diaper area Excretion of bilirubin and exposure to phototherapy
as clear as possible. cause the infant’s skin to be at greater risk for
compromise.
12) Provide exclusive breastfeeding every 2-3 Provides the caloric support for hepatic processing

86
 hours. Water supplements are not of bilirubin and stimulates peristalsis which allows
recommended. the bilirubin rich meconium stool to be excreted.
13) Insure that bilirubin blood monitoring is Evaluation of bilirubin levels provides data needed
completed as ordered by the physician. to determine when phototherapy can be
discontinued.
14) Discontinue therapy when ordered by the Therapy can be discontinued when bilirubin levels
physician. fall into normal range for the infant.

CLINICAL GUIDELINES
a) Phototherapy is recommended for term neonate if total bilirubin level rise above 5 mg/dL in the 1 st day
of life. TSB greater than 8 mg/dL in the 1st 24 hours of life is considered “pathologic” and should be
evaluated for hemolytic disease or other disorder.
b) Phototherapy is generally initiated sooner and at lower levels in premature neonates and infants with
risk factors.
c) Intensity of phototherapy lights is checked daily.
d) Serum bilirubin levels are checked as ordered.
e) Infants receiving phototherapy treatment must be weighed daily.
f) Place an eye pad over eyes and diaper over genitals.
g) Encourage frequent exclusive breastfeeding.
h) Monitor for and ensure urinary frequency 6-8times/day.
i) Monitor temperature every 4 hour.
j) Estimate serum bilirubin frequently every 24 hours.
k) Change tube lights every 6 months (or usage time > 1000 hours) whichever is earlier.
l) Monitor irradiance of the phototherapy machine once every week. Use a flux meter to monitor
irradiance.
m) Do not place anything on the phototherapy unit (this blocks air vents).

CAUTION
1) Do not use phototherapy unit under a warmer.
2) Ensure that the eye patches used do not obstruct the nostrils.
3) For babies below 2 kg preferably use phototherapy over incubator.
4) After switching on the unit checks if all tubes/ bulbs are on.

COMPLICATIONS
87
  Increase in environment and body temperature, irritability and dehydration due to increased
insensible water loss.
 Skin changes like increased pigmentation, erythema, rash, burns.
 Passage of loose green stools because of transient lactose intolerance and irritant effects of
photocatabolites.
 Bronze baby syndrome:- in a baby with direct Hyperbilirubinemia.
 Flea bite rash on trunk and extremities.
 Platelets turn over may increase resulting in low platelet count, but bleeding does not occur.
 There is theoretical increased risk of developing malignancies of skin later in life.
 Phototherapy induced hypocalcaemia.
 Retinal damage.
 It has been reported that phototherapy affects function of immune system via alteration in cytokines
production.

MAINTENANCE TIPS FOR PHOTOTHERAPY UNIT

1) With flux-meter, measure the blue-green content of light output from the phototherapy equipment
and replace the tubes or halogen light sources with new ones if the useful phototherapy output has
fallen to two third of its original value.
2) If a flux-meter is not available, it is better to keep a record of the hours each tube/bulb is used. In a
few phototherapy units this facility is in built at an additional cost. Change halogen bulb or tubes
every 1000 hours of use or every 3 months whichever is earlier.

88
 IDENTIFICATION & ASSESSMENT OF
RISK FACTORS
INTRODUCTION
- Early identification of high risk fetuses and optimal care of high- risk fetuses and neonates are matters of
utmost importance if the levels of perinatal morbidity and mortality are to be reduced.
- Threats to wellness and, indeed, life can occur at any time prenatally, perinataly and postnataly, between
the time of viability of the fetus to 28 days after birth.
- A variety of factors identifies a pregnancy as high- risk and frequently results in a high risk fetus.
DEFINITION
Many high- risk neonates are those in whom the levels of growth and development are less than or
exceed those of the normal neonates.
1) Low Birth Weight (LBW):- Infants are those who weigh 2500grams or less at birth regardless of
gestational age.
2) Small for Gestational Age (SGA) Small for Date (SFD):- Many newborns of low birth weight can
be characterized as small for gestational age or small for date infants, whose birth weights fall below
the 10th percentile on intrauterine growth charts.
- These terms are used regardless of whether birth is at or near term. SDF or SGA infants have
intrauterine growth retardation (IUGR).
3) Appropriate for Gestational Age (AGA):- Newborn can be classified also as being AGA.
4) Large for Gestational Age (LGA):- Newborn is those whose weights are above the 90th percentile on
intrauterine growth charts.
5) Premature (preterm) Infants: - Regardless of birth weight are those delivered before 37 weeks from
the first day of the last menstrual period.
6) Full- Term Infants: - Are those born between 37 to 42 weeks’ gestation.
7) Post- Mature Infants (Post- Term): - Those had born after a prolonged gestation (after the forty-
second weeks).
ASSESSMENT OF GESTATIONAL AGE
- The accurate assessment of gestational age is important after birth because the plan for care, the
problems that will probably encounter, and the possible outcomes are directly related to it.
- An accurate assessment of gestational age can be made through the use of three techniques developed
by Dubowitz, and Goldberg (1970); Farr, Mitchell, Neilgan, et al. (1966); and Amiel- Tison (1968).

89
- The Dubowitz method developed using these techniques are accurate to within plus or minus 2 weeks
of gestational age.
A) Assessment of certain external physical characteristic:-
- The changes in physical characteristic of the fetus are weighted according to when they appeared
during gestation.
- This assessment can be done immediately after birth.
B) Assessment by neurologic examination:-
- The neurologic assessment of the newborn must be done while the neonate is rested and in a quite
state, this examination may be carried out at any time from birth when the anaesthetized neonate is
alert and awake to the second or third day of life.
- During the first hour after birth, the neonate should not be handled too much because of the need for
rest and because the parents should have these precious minute to continue bonding with their
neonate.
- Neurologic development can be assessed by evaluating active and passive muscle tone.
- The infant who is neurologically damaged or ill may be particularly difficult to assess at any time;
therefore, the initial assessment should be repeated within 24 hours.
- According to Dr. Ballard, a simplified version of assessment, it is performed most reliably between
30 and 42 hours of age. In this neonatal maturity rating from, some external physical characteristic
have been deleted and those neurologic criteria have been retained that can be used if the neonate is
not quiet and rested. This simplified score consists of six neurologic criteria. This scoring system
provides an accurate assessment of gestational age whether the newborn is well or ill.
- It is of vital importance that the assessment of gestational age be done as soon after birth as possible.
- Since nurses are assuming increasing responsibility for assessing the gestational age of neonates, an
understanding of the techniques used is of vital importance.

90
Neuromuscular Maturity

91
ASSESSMENT AND MONITORING OF HIGH-RISK NEONATE:
- All members of the medical team caring for the high- risk neonate must be able to assess changes in
condition promptly and to provide appropriate care.
- They need to have specialized knowledge concerning the physiology, characteristics and
pathophysiology of these infant.
- In the NICU and acutely and seriously ill neonate may be cared for by a nurse who is responsible for the
care of no other infants.
- As the infants recovers, however, he or she may be moved to an intermediate care unit where a nurse
may be responsible for from three to five infants, depending on their level of need, until they are ready to
be taken home.
- The equipment and procedures that can be used in monitoring the physiologic status of the high risk
neonate including the following-
1) Maintenance of controlled thermal environment:-
- The maintaining of normal body temperature within a normal range: 36.5 to 37.5*C (97.7 to
99.5*F), rectally for normal or large infants and 35 to 36.5*C (95 to 97.7*F) for those who
weigh 3.3lb (1500gm) or less at birth.
- The use of radiant heaters or incubators can meet this nursing objective on a short- or long-term
basis.
- If the temperature of the surrounding air or skin of the neonates deviates from normal, a visual
display and an alarm can alert the nurse can action must be taken to correct the situation.
2) Monitoring of Heart, Respiratory and Blood Pressure:-
- In heart rate monitoring, a pulse rate indicator is used that signals ventricular contractions
through a flashing light and an audible beep. If the pulse rate goes above a predetermined limit
(usually 160 beats per minute) or below a predetermined limit (usually 80 beats per minute,
depending on the condition of the neonate) an alarm sound that alerts the nurse to the problem.
- The nurse must quickly assess the neonate and decide whether there is a change in status that
must be corrected or whether the problem is being caused by malfunctioning equipment. The
nurse is responsible for correcting these difficulties.
3) Collection of Specimens:-
- Laboratory examinations of blood and urine specimens from high-risk neonates are important in
the continuing assessment of these infants.
- The test most frequently done on the blood of high-risk infants include blood glucose,
hematocrit, calcium, bilirubin and blood gases. The nurse must record the amount of blood taken

92
 from small infants since frequent removal of even minute amount may seriously diminish the
total blood volume.
- Blood specimens may be obtained from a heel or figure, from a peripheral vein or from a catheter
in an umbilical artery or vein.
- Umbilical artery catheterization is widely used to obtain blood samples for blood gas
determinations and other studies. It may also be used for infusing fluids, nutrients or medications;
for measuring systemic blood pressure; for inserting dye for x-ray studies and for exchange
transfusion.
- Complications that may result from the use of umbilical catheters include infection, thrombosis,
embolization, hemorrhage, vasospasm and necrotizing enterocolitis.
- An accurate recording of intake and output and laboratory examination of urine are important in
the care of high-risk infants. A plastic pediatric urine collector may be used or the diaper may be
weighed in order to collect a specimen. Urine also can be collected by using a disposable diaper
or a cotton ball on a piece of plastic wrap.
- A radiant warmer may influence the specific gravity and the volume of urine obtained. The
specific gravity of urine provides some indication of the adequacy of hydration of an infant.
- A refractometer found in the NICU is used instead of the usual standard urometer.

NORMAL LABORATORY VALUES OF INFANTS

Hb Hct WBC Na K Cl Ca Glu

(mEq/L (mEq/L) (mEq/L) (mg %) (mg%)
)
Term 18.0 54 9000 145 6.3 103 7.8 63
(±3000) (132- (5.3-8.9) (87-114) (6.9-9.4) (30-90)
159)
Preterm 16.4 49 12200 (± 135 5.4 105 7.0 50
7000) (132- (5.3-8.9) (87-114) (6.5-9.4) (30-90)
159)

NEONATAL ACID- BASE BALANCE

Ph PO2 PCO2 HCO3 (Bicarbonate)

Cord Blood 7.2 16-32 60-70 23
Arterial blood at 1 hr 7.32 90-100 35- 40 20
93
GENERAL NURSING MANAGEMENT:
 Maintenance of body temperature
- Normal temperature is maintained only if there is a balance between the production of heat and its
dissipation from the body.
- The high-risk infant whose weight is less than normal has difficulty in maintaining normal body
temperature because the body surface area is disproportionately large for body weight; the amount of
insulated or subcutaneous adipose tissue is less than that necessary to conserve body heat; the surface
vasculature, visible through the skin because of the lack of subcutaneous fat and the thin epidermis,
loses heat readily to the environment; and the lack of flexion of the extremities increases the
exposure of the total body surface to the environment.
- Excessive heat loss is a continuing problem in the maintenance of normal body temperature.
Although peripheral vasoconstriction occurs in the high-risk neonate who loses more body heat than
is produced, the infant cannot physiologically respond to cold stress by shivering, as does the child or
adult.
- Heat is produce through increased metabolic activity, primarily by non shivering thermogenesis.
- The difference between the environmental temperature and the infant’s skin temperature is called the
external thermal gradient. The extent of this difference depends on the movement and temperature of
air, the temperature of surfaces around the body and the relative humidity of the surrounding air.
- Heat is transferred between the infant’s body and the environment by evaporation, radiation,
conduction and convection.
- Thermal stability, the maintenance of a normal core temperature within narrow limit, results when a
balance exists between the production and conversion of heat and the dissipation.
- The provision of a neutral thermal environment, which permit the maintenance of a normal core
temperature in an infant whose oxygen consumption and metabolic rate at rest are minimal, is the
goal in the care of the high-risk infant.
- Since optimal medical and nursing care of the high-risk neonate necessitates that the infant be
unclothed, a neutral thermal environment is imperative. The neonate is therefore placed in a heated
environment at birth and remains there until able to maintain thermal stability.
- The abdominal skin temperature over the epigastrium is maintained at 36.5*C (97.7*F). At this
temperature, oxygen consumption and metabolic rate are normal.
- Oxygen consumption is increased by 6% when the skin temperature rises to 37.2*C (98.9*F). When
the skin temperature falls to the 35.0*C (96.6*F), oxygen consumption increases by 10 percent.
- One problem to which insufficient attention has been paid is the noise level to which infants are
exposed in intensive care nurseries owing to equipment noise, crying and personnel conversations.

94
 - The high noise level may be a perinatal risk factor that may result later in emotional problems or
hearing and speech impairment. Such noise may also block out the “mothering sound” that parents
and nurses make to infants.
- Another problem is the distortion of visual images when infants attempt to look through the walls of
incubators at their caregivers. This inability to see normal human faces may have a lasting effect on
development.

 Prevention from infection and injury:

- In general, nosocomial infections that could spread to the nursery can be prevented by minimizing
the numbers and kinds of organisms transmitted to susceptible neonates.
- Thorough hand washing and complete sterilization or disinfection of equipment and supplies are two
important points that require further elaboration.
- Nurses are in a primary position to enforce the rules that can prevent nosocomial infections.
- Meticulous and thorough hand washing by all persons entering the nursery is absolutely essential.
Failure to wash the hands thoroughly between handling of different infants is the major method of
spread of infection by any organism.
- The hands should be washed for at least 2 minutes to above the elbows when first entering the
nursery. Washing for at least 15 seconds should also be done between caring for different infants.
- The use of soap or iodinated preparation is recommended. Iodinated preparation is active against
gram- negative rods and gram-positive cocci.
- All equipments and linens that come in contact with the infants must be sterile or scrupulously clean.
Equipment that are used and become wet, such as respirator tubing or oxygen hoods, must be
changed every 24 hours. Incubators and cribs must be washed with an antiseptic solution at least
every week and after an infant is removed.
- If the infant is in a incubator, humidity may be provided by using a reservoir water. This is a danger
that it will also provide a good medium for the growth of Pseudomonas aeruginosa.
- High humidity must be provided in order to reduce evaporative heat loss, that the water reservoir be
emptied, cleaned and refilled with distilled water to which iodophor or silver nitrate solution has
been added at least every 8 to 12 hours.
- Neonates who are transported from other nurseries to the intensive care nursery must be isolated in
an incubator with gown isolation until the results of throat, urine and skin cultures become available.
- Infants who have toxigenic or invasive E. coli gastrointestinal infection, draining lesions or viral
infections or who are were delivered of mothers who have infectious diseases are isolated in
separated rooms away from the intensive care nursery.

95
 - Before giving any therapeutic agent to a high-risk neonate, the nurse should be certain of its action
and the possibility of its having toxic effect on very small infants.
- The consumption, preparation and administration of medications given by any route and the giving
of parenteral fluids and nutrients to high-risk neonates are vitally important and serious
responsibilities of the nurse in the neonatal intensive care nursery. Since such small amounts of these
therapeutic agents are required, the nurse must use extreme caution in their administration.
- The administration of parenteral fluids, medication and nutrients to high-risk infants may pose two
problems for the nurse because of the small size and fragility of the peripheral blood vessels and
because of the delicate skin to which adhesive tape must be applied to hold the needle in place.
- Rupture of the peripheral blood vessels and infiltration of fluid into the tissue are common problems
in neonatal intensive care unit. The use of pump-type infusion apparatus is necessary in order that
fluids be given regularly in minute amounts, but it may also lead to increase infiltration of fluids.
- The nurse must be constantly aware of this danger and identify its early infiltration as soon as it
occurs. Intravenous infusion must be checked by observing the actual site of insertion and then the
surrounding area. Infiltration of fluid may cause puffiness at the injection site and an enlargement of
the entire area as well.
- The nurse must also observe for signs of overhydration when intravenous infusions are being given.
- The removal of paper or hypoallergic tape from the infants’ sensitive skin when an intravenous
infusion is changed or discontinued is difficult.
- The least traumatic method of removal is to lift an end of the tape and slowly and carefully remove it
while pressure is exerted on the skin directly beneath it. The use of scissors to remove tape is
dangerous and may result in injury to the infant.
 Use of equipment
- The nurse is responsible for having the knowledge and skill to determine whether the monitoring
devices are set at the require limits and that the tracing are within normal expectation; whether the
equipment for assisted ventilation and oxygen therapy is at the correct pressure and/or volume setting
and is tightly connected; whether infusion pumps and other equipment for giving parenteral or
enteral feeding are functioning properly and are delivering the correct type and amount of fluid;
whether the amount of suction is adequate when pumps are in use; and whether the equipment for
phototherapy is functioning as expected.
- If a problem of malfunctioning or an electrical hazard cannot be resolved by the nurse, immediately
reporting and recording of the observation is mandatory so that proper action can be taken.

 Premature and Low Birth Weight Infants

96
 - Premature neonates and those having low birth weights account for the highest mortality rate among
infants during the first year of life.
- The new born infant’s behavior is evidence of immaturity in that the normal reflexes and the ability
to carry on the vital functions are lacking.

 Assessment
- When the nurse does a physical assessment of the premature infant on admission to the intensive care
unit, the finding will show that the infant is at the same stage of anatomic and physiologic
development as a fetus of a similar gestational age.
- The anatomic and physiologic maturity of the immature premature infant is adapted to life in utero.
- The infant is small and limp. The skin is thin and small blood vessels can be easily seen beneath the
epidermis. The skin is wrinkled and red with an excess of lanugo and little or no vernix caseosa
covering it.
- The subcutaneous fat deposits are not yet present, so the neonate appears wizened.
- Very small premature infants may see plump because of edema, which is soon lost.
- The head is relatively large in proportion to the body, reflecting evidence of cephalocaudal growth.
- The eyes are prominent but close, the ears are soft and the chin receds.
- The thorax is fewer firms, owing to soft bones, than that of the full term infant.
- Engorgement of the breast, normal in the full-term infant, is absent in the premature one, since it is
due to hormones that are passed form the mother to the fetus in the late months of gestation.
- The abdomen appears to protrude.
- The genitalia of the male premature infant have few scrotal rugae and the testes are not descended. In
the female, the libia and clitoris are prominent.
- The extremities are thin, the muscles small. The fingernails and toenails are soft and short. Since the
palms and soles have minimal creases, they appear smooth.
- The premature infant generally lies inactive, with the arm and legs extended. Reflex activity is not
fully developed. Although the fetus sucked and swallowed in utero, the sucking reflex may be
absent, minimal or ineffectual and the swallowing, gag, and cough reflexes weak at birth.
Coordination of the sucking and swallowing reflexes occurs between 32 and 34 weeks of gestation;
therefore, they are not well developed well developed at birth. Because of these factors, aspiration
may easily occur.
- Other neurologic signs are diminished or absent.

 Nursing Management
97
 - Nursing management in the care of the premature infants is based on the physiologic handicaps of
immaturity that creates problems in the care of the infants, as follows-
1) Poor Control of Body Temperature is due to the large amount of skin surface in proportion to the
body weight, the lack of insulation of subcutaneous fat, immature nervous system and poor muscular
development.
2) Respiratory Difficulty is caused by an immature regulatory center, incomplete development of the
alveoli, weakness of the thoracic cage and respiratory muscles. Gaseous exchange is hindered
because of the immature alveolar membrane. The gag and cough reflexes are too weak to clear the
airway of foreign material. Abdominal distention may interfere with action of the diaphragm.
Hypoventilation and episodes of periodic breathing may result.
3) Increased Susceptibility to infection is due to immature globulin synthesis, antibody formation and
cellular defense. There is a lack of immune substances normally transmitted from the mother to the
fetus during the last months of gestation. The premature infants have more avenues for access of
infection because the skin and mucous membranes are not as protective as those of the full-term
neonate. The immature infant does not react to infection with an elevated temperature or WBC
count.
4) Difficulties with Nutrition are due to absent or weak sucking and swallowing reflexes, small
stomach capacity and diminished motility, and inability to adequately absorb fat and other nutrients
owing to an immature digestive enzyme system.
5) Immaturity of Renal Function results in an inability to excrete solutes in the urine.

Nutritional Considerations
- In a mature infant, sucking usually precedes swallowing, which in turn inhibits respiration. When the
infant swallows, the nasal passages are open but the epiglottis is closed allowing air to enter the
stomach. As the epiglottis opens, air enters the trachea. Because respiration is inhibited during
swallowing, aspiration does not occur.
- In the immature infants, there are short sucking attempts that may be preceded or followed by
swallowing. Since the infant cannot coordinate this activity, aspiration may occur.
- In the immature infant, periodic breathing may occur soon after a feeding is completed. Large
amount of air may be found in the esophagus and stomach.
- The immature infant also has poor muscle tone of the cardiac sphincter and feeding is regurgitated
easily into esophagus.

98
- After the feeding is swallowed, the emptying time of the stomach depend on the condition of the
neonate, the type of feeding given, the amount of the feeding and the position in which the infant is
held during and after the feeding.
- The right lateral position or the prone position is recommended after feeding neonates, especially
those who may show intolerance to the volume of fluid given.
- The emptying time of the stomach is more rapid after tube feeding than after bottle feeding. Infants
must be bubbled, after any type of feeding.
- The immature infant’s intake of nutrients must satisfy individual requirements for growth as well as
replacing losses in feces, urine and those due to tissue breakdown.
- The goal is to meet the metabolic requirements of the various developing organ systems in the body.
- The nutritional requirements of the immature infant depend on the individual rate of metabolism,
body weight and gestational age.

A) Water and Calories

- The water content of the infant is approximately 85% of body weight at 28 weeks’ gestation, but it
decreases to 70% at term.
- The low birth weight infant who has increased water contents in the skin, increased skin permeability
and a thin epidermis is in great danger of extracellular water loss. This loss is increased if the infant
is in a single-walled incubator or a radiant warmer or if additional losses occur from the
gastrointestinal tract.
- A loss greater than 10% of birth weight in the first 3 to 4 days after birth may be excessive. When
this amount of fluid is lost, the hematocrit or serum sodium may increase and apneic periods may
occur.
- It is important to monitor fluid requirements through atleast daily weight, measurement of intake and
output, testing to determine levels of electrolytes, blood urea nitrogen, urine osmolarity, urinary
specific gravity and recording of body and environmental temperatures.
- The amount of fluid needed to give the required 100 to 140 calories per kg each day depends on the
number of calories per millimeter given in the feeding.
- Some small for gestational age infants who have a higher metabolic rate may require even more
calories.

B) Protein
- The amount of protein required by the low birth weight infant depends on the quality of protein
given.

99
- Although the optimal protein intake has not been established, it is thought that an intake of between 3
to 4 gram/ kg/day is necessary, representing 10 to 15% of caloric intake.
- The type of protein and amino acid given is most important in maintaining optimal nutrition.
- The feeding of breast milk or humanized commercial formulas with whey-predominant protein is
recommended.
- Fat is high in fuel value and also transport fat-soluble vitamins. The type of fat ingested, the surface
from which it can be absorbed and the functioning of the pancreas and liver determine how well it
can be utilized in low birth weight infants.
- In general human milk fat and certain vegetable fats are tolerated better than butter fat.
- If gastrointestinal surgery is done in neonates, fat may be malabsorbed because of the lack of an
absorptive surface.
- The immaturity of the pancreas and liver may result in fat malabsorption, which can reduce the rate
of growth in low birth infants.
C) Vitamins and Sodium
- Low birth infants grow rapidly and therefore need extra vitamins to maintain their rate of growth.
They need supplementation especially of vitamin D, in order to prevent rickets and vitamin E, to
prevent vitamin E-dependent hemolytic anemia.
- Very small premature infants are prone to hyponatremia early in life because of a low sodium intake
and renal immaturity.
- Infants born at term need 1 to 1½ mEq of sodium per kg per day. However, small infants of less than
32 weeks’ gestation require 2 to 4mEq per kg per day in order to prevent hyponatremia.
- Monitoring of serum sodium and electrolyte level is necessary atleast once a week.
- Preterm infants may lack some trace minerals because most are provided during the last two months
of gestation and also because prolonged parenteral therapy, if not supplemented with these
substances, may increase the deficiency.

D) Feeding Techniques
- Low birth weight infants are usually gavage-fed or fed parenterally until they have an adequate gag
reflex. They may also be fed through a nasojejunal tube passed through the nostril and through the
pylorus into the duodenum.
- Premature infants indicate readiness to suck from the breast or bottle when the suck is vigorous and
can be stimulated by a gavage tube or other object placed near the mouth, when they can coordinate
sucking and swallowing and when they awaken before and sleep after feedings.

100
 - The protein in breast milk is best for the immature infant. Breast milk is also the least allergic and
most digestible food for infants, whose immature gastrointestinal enzymes are unable to break down
complex substance for absorption and assimilation. Breast milk has a lower solute load; fewer
burdens are placed on the immature kidneys. Breast milk may provide some protection against the
premature infant’s developing acute necrotizing enterocolitis. This protection is due to the presence
in unfrozen milk of macrophages, which control the growth of potentially pathogenic bacteria.

NEED FOR STIMULATION

- Research during the last 15 years has shown that high-risk infants who are born before term and are
placed in a nursery environment where they have stimulation develop better and have fewer physical
problems than those to whom such stimulation is not given.
- Specifically, being placed in water mattresses, being gently rocked in an incubator hammock and
being exposed to auditory stimulation such as a recording of maternal heartbeats and of their
mother’s voices minimize the change from the environment of the uterus to that of the nursery.
- These forms of sensory stimulation and environmental enrichment enhance the development of the
premature infant and have a positive influence on weight gain and activity levels. Because such
sensory stimulation is beneficial to preterm newborns, parents are permitted – indeed, in many
nurseries they are encouraged- to visit their infants frequently.
- In some hospitals, high-risk infants who weigh between 4 and 5 pounds and seem to be doing well
may even be taken to their mother’s beds in order to encourage their interaction.
- Parents are encourage their to caress, tough, rock in rocking chairs and talk or sing to their infants
when they are physically able to be handled in this ways.
- Nurses who helped parents to provide their high-risk infants with sensory stimulation are teaching
them much more than the techniques of basic physical care.

SUPPORTING AND EDUCATING PARENTS

- The birth of a low birth weight infant presents a crisis for the family. Usually, unless the parents have
expected a multiple birth and know that the infants may be premature, they have no warning and are
therefore not prepared for the event.
- After a first trip to the hospital following the onset of labor, the mother is usually treated with some
degree of apprehension and the rushed to the delivery room.
- The parents may or may not see their infant before placement in an incubator. They may be startled
by the unattractive appearance of the low birth weight newborn.

101
- Although the parents may have many questions after the birth, physician and nurses often avoid
answering them directly because they do not want to arouse either false hope or despair.
- The parents may sense the air of concern surrounding the infant’s condition and respond with anxiety
and fear.
- When the mother is ready to discharge, she must leave her frail child in the nursery until the infant
weights 5 or 5 ½ pounds. This may mean separation from the parents for weeks or months.
- Parents have a need to know if their infant will develop normally, both mentally and physically.
Since it may be difficult to give a definite answer, parents should be instructed regarding the need for
frequent follow up. If these parents are not aware of what is considered “Normal,” they should be
taught what to expect of their infant.
- They should be encouraged to report any concerns they have to the primary nurse or health team
member who is familiar with the infant. Because premature infants have a higher risk of
developmental disabilities, special attention is focused on achievement of developmental norms.
- Parents should be informed of the availability of resources in their community. Early infant
stimulation programs are available in many areas, and both parents and their infants benefit by the
support and activities provided.
- Parents have the opportunity to learn about their infant’s development and about method of physical
and psychological stimulation, as well as interacting with other parents with similar concerns.
- If it is determined that their infant is affected by a hereditary condition, parents should be referred for
genetic counseling.

102
 APGAR SCORE
 At 1 minute or 5 minutes, after the neonates body is completely born.
 The five objective criteria should be evaluated to determine the need for lifesaving, support: heart rate,
respiratory effort, muscle tone, reflexes irritability and color.
 The new born baby is in the best possible condition if the score is 10. Scores of 7 to 10 indicate no
difficulty in adjustment to life.
 Score of 4 to 6 signify moderate difficulty. If the score is 3 or below, the neonate is in severe distress and
must be immediately diagnose and treated.

To obtain a correct APGAR score, the following assessment criteria are used:
1. Heart rate
- The heart rate is taken for at least for 30 second, preferably for a full minute.
- The heart rate and the level of the infant’s activity should correlate.
- Immediately after the birth the rate ranges from 150 to 180 beats per minute, later it ranges from 120
to 150 beats per minutes.

2. Respiratory Effort:
- The extent of respiratory effort provides an indication of pulmonary ventilation.
- A mature neonate cries spontaneously about 30 seconds of after birth and maintains rapid, regular
respiration by one minute of age.
- Respiratory distress is evident if the neonate’s respirations are gasping, slow or irregular.

3. Muscle tone:
- The extremities of the normal new born baby are flexed and held against the body.
- When straighten the arms or legs, some resistances should be felt.

4. Reflex irritability:
- This can be tested either by passing a catheter through the nose after suctioning or by slapping the
baby’s sole with the palm.
- The healthy new born infant should respond by crying loudly.
- A neonate, whose mother was heavily sedated, may respond only minimally to such stimulation.

103
5. Color:
- At the movement of birth, all neonates are cyanotic. After respiration began, the skin becomes pink
or more normal in coloring, depending on the race of the parents.
- The nurse should assess the level of oxygenation of peripheral tissue by inspecting the color of the
mucous membranes the mouth as well as the coloring of the lips, palms and soles
- The temperature, pulse and respiration of the new born baby may vary in an unpredictable way,
because of the physiology; resilience nature has provided the new baby.
- The normal neonate is relatively indifferent to a range of body temperature from as low as 36.1 °C
(97 °F) to as a high as 37.7 °C (100 °F), in premature infants, the body temperature may even drop to
34.4 ° C. (94 ° F).
- The infant has an unstable heat regulating system, the body temperature being influenced by the
environmental temperature.

104
 GESTATION AGE CALCULATION
The importance of determining gestational age as accurately as possible to structure perinatal care
(including decisions about timing and route of delivery or terminology issues like allocating diagnosis of
abortion versus Intra Uterine Fetal Death) has no debate.
It is noteworthy to name some ways of determining gestational age based on Last Menstrual Period
(LMP).
1. Nagele’s Rule: This was developed in the 1850’s by Dr. Nagele, who determined that the average
human pregnancy was 266 days from conception, or 280 days (40 weeks) from the first day of the of the
last menstrual period. To calculate this, one should add 7 days, and then subtract 3 months from LMP.
(LMP + 7 days) - 3 months) = Expected Date of Delivery.
E.g.: (the LMP on 1st April + 7 days) - 3 months) = January 8. This “rule” doesn’t take into account the
fact that many women are uncertain of the date of their last menstrual period, not all women have 28 day
cycles, and not all women ovulate on day 14 of their cycle.(4)

2. Mittendorf Rule: In an article in 1990, Mittendorf showed that an average pregnancy is 269 days for
mothers who’ve given birth before. Non-Caucasian women have shorter pregnancies than Caucasian; for
example, African-American women average 266 days. To calculate “Mittendorf’s Rule”, one should add
15 days for first time Caucasian women, or add 10 days if non-white or this is not the first baby. Then
subtract 3 months. (3) (LMP + 15 days) - 3 months) = Expected Date of Delivery for first time pregnant
Caucasian women Example: (( LMP on 1st April + 15 days) - 3 months) = January 16. The Nagele rule
is based on 280 day-from-LMP gestational age while Mittendorf believe multiparas and non-white
women deliver 5 days in advance.

3. Miscellaneous: There have been pregnancy wheels (1) and gestational age calendars (2) and calculation
software’s like Microsoft Excel program which are related to English months, thus not of use to Persian
audience (which are made up of vast arrays of population ranging from Persian to Arabic pregnant
women) who use different terms in their calendars. The available date calculation programs give the age
between two dates in months or days.

4. Calculations by fingers: As days of a year are composed of a heterogeneous combinations of numbers

(like six months of 31 days, one month of 29 days which is 30 days every 4 years), introducing a simple,
straight forward formula is practically impossible. The Obstetrics rule that gestational age should be
presented in weeks +days adds to the complexity. The only resort is to go through the lengthy procedure

105
of our ancestors to use fingers or add /divide mathematics. The following algorithm is what we go
through unconsciously when we calculate the gestational age; from LMP to the time of visit.
A) First we have two dates: LMP: like 85/12/3(which is 2007/Feb/22), and the date the woman comes
to clinic like 86/ 4/2. We consider the beginning and the end months, with three months in between.
The difference of days is calculated based on table 1. If the number falls in the highlighted zone
(yellow numbers), one month is added to the LMP; in this example 85/12/3 would change to 85/1/3.
The difference of the days is 29 days. If the number falls in the non-highlighted zones, the month of
LMP wouldn’t be changed.
B) The difference of months between LMP and visit is calculated according to table 2. According to
the LMP of 85/12/3 (here it changed to 86/1/3) and visit on 86/4/2, the table shows there are 3
months (12 weeks) / plus 3 months of 31 days in between.
C) Now we have 32 days (29+3) and 12 weeks. Going to the column of three (12 weeks), we reach the
number 32. Then we read the number on the red-lighted column that is 5w+3d.
D) So the final number of gestational age would be 17w+3d.
E) If the month of 12 is 29 days, the gestational age is 17w+2 d, and if it is 30 days, GA is 17w+3d. It
should also be stated that for the sake of convenience, table 2 can be used alone if the first
calculation is done by rote. If a traditional calculation of one GA takes about 5 minutes, using the
table (after mastery of working with it) will take 2 minutes. If this has to be done 50 times a shift, in
a crowded clinic like Shariaty Hospital in Bandar Abbas a district near Persian Gulf, then 2 and a
half hour is left for concentration on more important issues if not to talk about error of measurement
so common in finger calculation.

106
 ANTHROPOMETRIC ASSESSMENT
BACKGROUND
The term anthropometric refers to comparative measurements of the human body. The
anthropometric measurements commonly used as indices of growth and development for infants
include length, weight, and head circumference.
Typically, growth is evaluated by comparing individual measurements to reference standards,
represented by percentile curves on a growth chart. In assessing and monitoring the nutritional status
of a low birth weight infant it is most helpful to evaluate a pattern of measurements obtained on a
regular basis over time.
For anthropometric measurements to be valid indices of growth status, they must be highly accurate,
requiring precision in measuring technique. Accurately measuring children with physical
abnormalities is often a challenge.

LENGTH MEASUREMENT

EQUIPMENT:
Use a length-measuring device with a fixed headboard and a moveable footboard that are
perpendicular to the surface on which the child is lying. A fixed measuring tape, marked in millimeters or in
1/16 in. segments, should be attached to the surface with the zero end at the edge of the headboard. Several
commercial versions of length boards are available.
Technique:
Two people are required to measure length accurately:
1. Person A
 Hold the head with crown against the headboard so that the child is looking straight upward.
 Make sure the trunk and pelvis are properly aligned with the measuring device.
2. Person B
 Straighten the child's legs and hold the ankles together with the toes pointed directly upward.
 Move the footboard firmly against the soles of the feet.
107
 Read the measurement to the nearest 0.1 cm (1/8 in).
 Repeat the measurement until two measurements agree within 0.2 cm (1/4 in).
 Record the numerical value and plot length for age on the appropriate growth chart.
 If the child is uncooperative and you cannot get an accurate measurement, record your best estimate on
the growth chart and note the circumstances of the measurement.

WEIGHT MEASUREMENT

EQUIPMENT:
Use a beam scale with non-detachable weights or an equally accurate electronic scale. For infants
and young children who are weighed lying down use a pan-type pediatric scale that is accurate to within 10
gram or ½ oz. Do not use spring-type bathroom scales; with repeated use, they may not maintain the
necessary ° of accuracy.
Frequently check and adjust the zero weight on the beam scale by placing the main and fractional
sliding weights at their respective zeros and moving the zeroing weight until the beam is in balance at zero.
If a pad or diaper is used to make the pan more comfortable, place it in the pan when the zero adjustment is
made; otherwise the weight of the pad or the diaper must be subtracted from the weight of the child each
time a measurement is made. Whichever method is used to account for the weight of the diaper or pad, note
it on the growth chart. At least two or three times per year, have the accuracy of the scale checked with a set
of standard weights by a local dealer or inspector of weights and measures.
TECHNIQUE:
 Remove all clothing including the diaper and place the infant in the center of the weighing surface.
 Read the measurement to the nearest 10 gram or 1/2 oz.
 Repeat the measurement two to three times and, after excluding those that are obviously wrong,
average the values.

108
  Record the numerical value on the growth chart and plot weight for age and weight for length on the
appropriate growth chart(s) Note: It's not always possible to plot weight for length on small infants
with lengths below 55 cm.
 If the infant moves excessively, an accurate measurement is unlikely; postpone the measurement for a
few minutes.
 If the infant still does not keep still, skip the measurement unless you can make a reasonable estimate.
If the weight you record on the growth chart is an estimate, note the circumstances on the growth chart.

HEAD CIRCUMFERENCE MEASUREMENT

The measurement of head circumference is an important screening procedure for detecting
abnormalities of head growth. Although usually caused by non-nutritional factors, slow head growth
can be a result of severe under nutrition.
Children with poor head growth frequently have poor linear growth as well. Thus knowledge of head
size is very important in assessing possible nutritional factors contributing to short length or stature.
Head circumference should be measured routinely until at least 36 months of age.
EQUIPMENT:
Use a flexible, non-stretchable measuring tape.
TECHNIQUE:
 Position the child standing or in a sitting position in the lap of the caregiver.
 Place the lower edge of the measuring tape just above the child's eyebrows, above the ears and around
the occipital prominence at the back of the head.
 Pull the tape snugly to compress the hair. The objective is to measure the maximal head circumference.
 Repeat the measurement twice or until two measurements agree to 0.1 cm (1/8 in).
 Record the numerical value immediately and plot on the growth chart.
 If the measurement appears abnormal when plotted, check the accuracy of plotting and recheck the
measurement.

109
 NEWBORN EXAMINATION
INTRODUCTION
This introduction is not intended to be comprehensive, but is instead designed to cover the main
components of the newborn examination. During nurse’s time in the nursery, they trust that they will
become comfortable with the essential elements of the exam and be able to identify many of the common
physical findings.

 Although assessment is done as soon after birth as possible.

 The mother should be allowed to spend some time with the baby immediately after birth to initiate the
bonding process.
 Early assessment can assist the nurse in ascertaining if the newborn infant is within the range of
“normal”.
 As part of assessment, the nurse must review the mother’s history, including age, history of previous
pregnancies, health during this pregnancy, the complications of the pregnancy, a history of any drug she
has taken and her Rh typing.
 The nurse must also review the birth history of this neonate, including the gestational age, the kind and
duration of labor, the color of the amniotic fluid, the type of delivery, whether sedation or anesthesia was
given to the mother, the resuscitation required, the APGAR score, the weight and length and the infant’s
color and cry at birth.
 The infant’s physiologic status, including temperature, pulse and respiratory rates, ° of consciousness
and general level of activities is ascertained.
 Immediately after birth, the newborn infant is inspected for any gross anomalies, as well as for evidence
of shock or birth trauma.

110
 Many anomalies are not immediately evident on inspection and these are the concern of the physician
and the nurse caring for the neonates during the postnatal period.
PHYSICAL ASSESSMENT OF NEW BORN
1. GENERAL APPEARANCE

Before even touching the infant, notice the following:

Color, Posture/Tone, Activity, Size, Maturity, and Quality of Cry
This infant has a normal pink color, normal flexed posture and strength, good activity and
responsiveness to the exam, relatively large size (over 9 pounds), physical findings consistent with term
gestational age (skin, ears, etc), and a nice strong cry.

2. MEASUREMENTS:
- The length of the average newborn boy is 20 inches (50 cm) of the girl. 19.6 (44 cm)
- About two thirds of all fall term infants weigh between 2700 and 3850 gm, or between 6 and 8.5
pounds. The average girl weights approximately 7 pounds. The average boy approximately 7.5
pounds.
- During the first few days after birth, the infant tends to lose about 6 to 10 ounces or 5 to 10% of birth
weight.
- Factors contributing to this initial loss are the withdrawal of hormones originally obtained from the
mother, the low intake of fluid, and the loss of fluid in faces and urine.

3. VITAL SIGN:
- Although the infant’s temperature at birth is slightly higher than the mother’s, the temperature drops
immediately after birth. The temperature rises to normal within about 8 hours.
- The pulse is normally irregular, due to immaturity of the cardiac regulatory center in the medulla.
The rate is rapid, about 120 to 150 per minute.

111
 - Respirations in the neonate are irregular in depth, rate, and rhythm and vary from 35 to 50 per
minute. Normally they are quite and shallow.
- The normal cry is dusty, frequent and many time apparently without cause. If the newborn infant
does not cry adequately, stimulation should be given to encourage expansion of the lungs.
- The blood pressure is not routinely recorded on new born infants, the expected approximate systolic/
diastolic range is from 46/20 for an 800 gm neonate to 70/30 for 300 gm infant.

4. INTEGUMENT:
- At birth, the skin of the Caucasian neonate is red or dark pink, in the black infant a reddish black,
and in the oriental, the color of a tea rose.
- It is soft, covered with lanugo, and overlaid with vernix caseosa. Good elasticity or turgor is
evidence that an infant is in good condition.
- Lanugo: is a light, downy distribution of fine hair over the body most evident on the shoulder, back
extremities, fore head and temples. It begins to appear on the fetus by about the 16 th week of
gestation and to disappear after the 32 week.
- Vernix caseosa: is a cheese like, greasy, yellowish white substance, some time likened to cream
cheese or cold cream which covers the new born skin.
- Tissue turgor: Refers to the sensation of fullness derived from the presence of hydrated
subcutaneous tissue.
- Desquamation: or peeling of the skin, occurs during the first 2 to 4 week of life.
- Milia: Are tinny white papillae, occurring particularly on the nose and chin, which are caused by
obstruction of the sebaceous gland. This blemishes disappear in a week or two.
- Physiologic Jaundice: (Icterus neonatrum): become definite between the third and seventh day.
- Telangitectatile nevi (stroke bites)- These are flat, red, localized area of capillary dilatation on the
upper eyelids, between the eyebrows and on the nose, upper lip or back of the neck.
- Temporary forceps marks: may be left upon the part of the body or head where the blades exerted
pressure.
- Mongolian spot: these are slate colored spots usually occur on the buttocks or lower portion of the
back of the infants whose parents are black. They fade during the preschool year without treatment.
- Acrocyanosis: symmetric cyanosis of the extremities.
- Cutis mamorata: A transitory mottling of the skin, sometimes due to the exposure of the skin to
cold.

112
 - Harlequin color change: a rare discrepancy in color between the two longitudinal halves of the
body when the neonate is placed on the side for several minutes. The dependent portion of the body
becomes pink while the upper half remains pale.
- Erythema toxicum: a pink popular rash on which vesicles may be superimposed. This is a self
limiting condition, appearing one to two days after birth and disappearing several days later.

5. HEAD:

- The head, covered with fine, silky hair is proportionately large, over ranging 34 to 35 cm (13.6 to 14
inches) in circumferences.
- The normal limits of head size are 33 to 37 cm (13.2 to 14.8 inches) the head is ¼ of the total length.
- The cranium is large and the face relatively small when compared with the adult cranium and face.
- The skull is formed of 8 bony plates, each one connected to others by suture lines.
- Caput Succedaneum: is welling or edema of the presenting portion of the skull and may be
localized or fairly extensive. It is usually disappears by the third day.
- Cephalhematoma: is an accumulation of blood between the periosteum and flat skull bone.
- The collection of blood does not cross a suture lien.
- The mass is soft, irreducible, and fluctuating. It does not increase when the baby cries.
6. EYES:

113
 - The eyes are blue or gray at birth, changing to the permanent color in 3 to 6 month.
- In a non causation infant the iris may be grayish- brown or brown.
- Eye movements are not coordinated and both eyes momentarily may inward or outward.
- The eyelids may be edematous for about 2 days after birth, until the excess fluid is eliminated by the
kidneys.
- Chemical conjunctivitis may follows instillation of silver nitrate drops into the eyes soon after birth
to prevent opthalmia neonatorum (gonococcal conjunctivitis)
- Subconjuctival hemorrhage: which provoke anxiety in parents. They should be assured that this
condition has no pathologic significance and that the red areas disappear in 2 to 3 weeks.
- Retinal hemorrhages: if the pressure on the head is sufficiently severe, this may occur. Although
this are usually considered being unimportant, extensive hemorrhages may indicate that the baby also
may have a subdural hematoma.

7. NOSE:
- The narrow nostrils of the new born may be slightly obstructed from an accumulation of mucous. An
unusual amount of nasal discharge should be removing since neonates can breathe only through the
nose.

8. MOUTH AND THROAT:

- The neonatal mouth and throat are best examined when the tongue is gently depressed as the infant
cries.
- This examination is important in determining the pressure of minor variations as well as the more
serious problem of cleft palate.
- Precocious dentition or supernumerary teeth: may be observed in the lower incisor area or elsewhere
on the gums. They may be pink instead of white if they are covered with the membrane. They are
found loose they should be removed to prevent aspiration.
- Epstein Pearls: are temporary accumulations of epithelial cells, one small cystic structure on each
side of the hard palate. It will disappear spontaneously about a week or so after birth.
- No salivation is obvious in the mouth.
- The tongue appears relatively large for the size of oral cavity.
- The sucking pads are deposit of fatty tissue in the cheeks that persists even when the infant is
extremely malnourished. They disappear when sucking is no longer the only way of taking food.

114
9. NECK:

- The neck appears short in comparison with the size of the baby and is creased. The creases,
particularly in a fat infant, are deep and likely to become excoriated unless carefully cleaned and
dried.
- In the normal neonate, it should be possible to turn the head freely from side to side.

10.CHEST:

- The chest is bell- shaped and at birth is approximately the same circumference as the abdomen and
about one inch less than the head circumference.
- Palpation of the clavicle should revel smooth, straight bones. A bulge felt on either bone may
indicate that a fracture occurred during delivery.
- The thorax of the new born is almost circular. The infant does not use the thoracic case in breathing
but uses the diaphragm and abdominal muscles.
- The breast may be swollen because of hormonal activity originating from the mother and a pale
milky fluid (“Witch milk”) can be expressed. The condition disappear in 2 to 4 weeks.
- The thymus, located in the upper chest is usually proportionately large. It place a dominant role in
the development of immunologic competence by the fetus and young child. It has been disproved
that a large thymus is the cause of respiratory difficulty or sudden death by asphyxia.

115
11.LUNGS AND HEART

LISTEN FOR AND ASSESS:

Breath Sounds, Heart Murmurs, and Femoral Pulses
Lung sounds should be clear and equal. Normal respiratory rate is 40 - 60 bpm. Normal heart rate is
120 - 160 bpm. Quality and location of murmurs should be noted. Femoral pulses are best obtained when the
infant is quiet. They should feel strong and equal.

12.HEMATOLOGIC SYSTEM:
- The vascular system and heart are large in the neonate in comparison with their size in adult life.
- The blood volume of the new born infant is about 10 to 12% of body weight.
- The blood contains a relatively high no. of RBCs approximately 4.0 to 6.6 millions of cells/ mm3,
and a high hemoglobin level approximately 48 and 69 volume percent.
- The hematocrit is between 48 and 69 volume percent. These characteristics are essential to provide
adequate oxygenation in utero and during the few postnatal days before the lungs expend fully.
- Oxygenation improves during the first week of life to the extent that a high red cell count and
hemoglobin level is no longer necessary and hemolysis occurs.
- During the first 2 to 3 months of life, the red cell counts and hemoglobin level continue to fall,
resulting in a physiologic anemia.
- At the birth the leukocyte or white blood cells count is approximately 10,000 per mm, increasing to
25,000 to 35,000 with a relative neutrophilia during the 24 hours of life. Normally WBC count falls
during the first week after birth, but a relative lymphocytosis persists.
- Most new born babies have reduced level of vitamin K in their blood, resulting in prolonged
prothrombin clotting times. This is because of their intestinal tracks are sterile at birth. Since vitamin
K is essential for the formation of factor VII, IX and X, this vitamin is given to neonates after

116
 delivery. Intestinal flora begin to accumulate after their first feeding therefore, normal synthesis of
vitamin K is possible.
- Physiologic jaundice may be seen in approximately 55 to 70% of all neonates on the second to fourth
day of life when the level of billirubin increases from the normal level of 1 to 3 mg per dl in
umbilical cord blood 5 to 6 mg/dl. It decreases to below 2 mg/ dl by the 5th to 7th day of extra uterine
existence.

13. ESOPHAGUS, STOMACH AND INTESTINE:

- The cardiac sphincter is not as well developing as the pyloric sphincter. For this reason, the infant
should be “bubbled” several times while being fed so that air that has been swallowed may be
eructed.
- It is difficult to measure the size of the infant stomach. The contents are emptied almost immediately
into the duodenum, as evidenced by the fluid leaving the stomach before a feeding is complete. It is
likely that at birth the stomach holds from one to two ounces at 2 weeks, 3 ounces at 5 months, 7
ounces and at 10 months 10 ounces.
- The intestinal tract functions as an outlet for amniotic fluid as early as 5th month of intrauterine life.
- The normal gastrointestinal tract assumes its function readily after birth. Because of the rapidity of
peristalsis in the intestinal tract of the neonate in comparison with that of the adult the loss of fluid
and nutrients is rapid and if increased because of illness, may easily result in dehydration and
malnutrition.
- Meconium: The first fecal material is sticky odorless material, greenish black to brownish green,
which is passed from 8 to 24 hours after birth. The nature of the stools changes daily in the first
week. These are called transitional stools. From the 3rd to 5th day they are loose, contain mucous and
are greenish yellow. After the 5th day, the nature and frequency of the stool depend on the feeding.
The stools of the breast feed infant are yellow and pasty, between two and four are passed a day. The
stools of an infant fed on a formula of modified cow’s milk are light yellow and hard and are passed
once or twice daily. The composition of some commercially prepared formulas is so similar to that of
breast milk.

117
14.ABDOMEN:

- On inspection the normal neonate’s abdomen appears rounded and slightly protuberant.
- Peristaltic waves may be observed on the abdominal surface of thin neonates but cannot be seen in
well nourished child.
- Bowel sounds may be heard soon after birth.
- The umbilical cord is a bluish white, gelatinous structure at birth; it normally contains two umbilical
arteries and one umbilical vein encased in Wharton’s Jelly. If only one umbilical artery is evident,
the baby should be assessed for the presence of congenital anomalies.
- During the first day of life, the cord begins to dry and shrink. It changes in color from a dull yellow-
brown to black. It sloughs off by 6 to 10 days after birth, living an granulating area that heals in
another week.
- If the base of the cord is moist, urachus, which is fetal life connect the bladder with the umbilicus,
may still be patent and draining urine.
- If the base of the cord is moist, reddened or worm, or has a foul discharge, infection may be present.
This condition must be treated immediately because of the danger of infection entering in blood
stream through the abdominal vessels and causing septicemia. It also inspect for an umbilical hernia.
- After inspecting the abdominal surface, the nurse palpates the abdominal organs.
- The liver usually can be felt about 1 inch (2 to 3 cm) below the right costal margin.
- The tip of the spleen may be palpable by about 1 week after birth in the left upper quadrant.
- Before the intestines fill with air, the experienced nurse may be able to palpate the kidneys.
- The femoral pulses are also palpated. They should be equal on both sides and strong.

15.ANOGENITAL AREA:

118
 - The infant’s buttocks are plump and firm. In the anal region there should be no redness or fissures.
- The size of the male newborn genitalia, penis and scrotum varies. The prepuce or foreskin of the
penis may adhere to the glans. It should not be forcefully retracted because of the possibility of
tearing the thin membrane that connects the foreskin to the soft of the penis and causing adhesions.
The urethral opening should be at the tip of penis.
- The scrotum in many male neonates is edematous. The skin of the scrotum of the full term infant is
deeply rugated and darker in color than the surrounding skin. The testes have usually descended in to
the scrotum by the eight month of intrauterine life.
- The female genitalia may be slightly swollen from the action of maternal hormones. The labia
minora and clitoris appear large. The vagina exudes a mucous discharge that occasionally may be
blood tinged. This is caused by hormones transmitted from mother to new born daughter. The
discharge disappears when the hormones are no longer present in the baby’s body.

16.SKELETAL STRUCTURE:

119
 - The bones of the new born are soft because they are composed chiefly of cartilage. The skeleton is
flexible and the joins are elastic to ensure a safe passage through the birth canal.
- The back is normally straight and flat when the baby is lying prone. The lumbar and sacral curves
develop later, when the infant sits up and begins to stand.
- The skin over the vertebrae is examined for cystic masses, tufts of hair, discoloration or other
anomaly.
- Inspection should be made of the base of the spine to determine whether a tinny opening or dermal
sinus is present.
- While the new born infant is still lying prone the gluteal folds should be examined for the presence
of symmetry. If there is asymmetric, further investigation should be done to rule out the possibility of
dislocation hip.
- The extremities are inspected for symmetry and range of motion. The legs are small, short and
bowed or curved outward with the turned inward, similar to a fetal position. If the feet can be
manipulated into straight alignment, there is little cause for concerned. If the feet do not both align
normally with manipulation, a talipes deformity should be suspected.
- The arms, like the legs, are relatively short and the position of the neonates when placed on the back
is often that of the tonic neck reflex. In the mature neonate, the hands are plump, the fingers are
relatively short and the nails are smooth and soft and extend over the finger tips. The hands are
clenched. The fingers should be separated and inspected.
- The arms and legs should moves symmetrically and equally well. If an arm does not move normally,
the baby may have sustained a birth injury.
- Some of the common anomalies of the neonates can be noted in the extremities. E.g. Clubfoot,
syndactyly and polydactyly.

17.MUSCULAR DEVELOPMENT:
- Muscular contour in the healthy, plump infant is smooth and the muscles, in spite of their lack of
purposeful strength, feel hard and slightly resistant to pressure.
- If the neonate does not offer normal muscular resistance bilaterally to passive movement, cerebral
injury, necrosis or shock may be present.
- If the infant feels limp in the nurse’s hands. The condition should never be mistaken for a mare
characteristic of immaturity but should be investigated.
- The movements of the neonates are random and uncoordinated. When the nurse holds the infant, the
back and head must be supported.

120
18.NERVOUS SYSTEM AND REFLEXES:

- The nervous system is strikingly immature when compared with that of the child or adult. The bodily
functions and responses to external stimuli are carried on chiefly by the midbrain and reflexes of the
spinal cord. The movements are general and diffuse prior to myelination of the nerve fibers.
- As soon as myelination of the nerve fibers occurs and the necessary connections are made between
nerves, control from the higher cerebral centers begins and increasingly by complex and purposeful
behavior is possible.
- Certain reflexes are absolutely essential to the life of the neonate and many are protective.
- Successful use of the reflex mechanism is evidence of normal functioning of the nervous system.
- If a reflex is impaired or absent, possibly the central nervous system has sustained injury. Although it
may not be possible to correct this condition, the care of the infant must be adopted to the disability.
- With maturity, certain neonatal reflexes disappear as the cerebrum exercises greater control over the
nervous system. This brings about changes in behavior to which the care given by the parent or nurse
must be adopted.

19.BACK AND SPINE

121
 Assess back and spine for:
Symmetry, Skin Lesions, and Masses
Back should appear symmetric and spine should be palpable all along its length. Unusual skin lesions,
tags, or masses should be noted as these may indicate underlying spinal dysraphism.

20.SPECIAL SENSES:
- A neonate responds to various sensations with evidence of pleasure or general discomfort. The sense
of touch is the most highly developed of the special senses and is most acute on the lips, tongue, ears,
and fore head.
- Failure to grasp the nipple, therefore, is one indication of brain damage.
- The normal infant responds to the gentle touch of the hands of those providing care from the
movement of birth and withdraws from painful stimuli such as extreme pressure.
- When assessing vision, it is difficult to know exactly what a neonate sees. The eyes are only half
open and the lids are swollen. The pupils react to light and bright lights appear to be unpleasant to
the infant.
- Hearing occurs after the first cry, owing to the presence of fluid in the external auditory canal and the
unequal pressure within and outside the auditory apparatus at birth. The infant normally makes some
response to sound from birth and there is evidence that ordinary sounds are heard well before the
tenth day. The newborn infant responds to sound with eye movements, cessation of activity startle
reaction or crying. By the forth week the infant is likely to react to the mother’s voice more
frequently than to a loud
- The sense of taste is fairly well developed. Sweet fluids are accepted, whereas acid or bitter ones are
resisted.
- The only evidence of smell is that many newborn infants appear to smell breast milk and search for
the nipple. Individual variation is found among infants in their apparent ability to smell.
- The newborn infant appears to be highly sensitive to organic stimulation. Since hunger and thirst are
the most common cause of crying. The neonate is not likely to have pain from gas in the intestine,
but the infant a few weeks old.

States
- The reduction of the neonate to internal and external stimuli is manifested in state related behavior.
(prechtt. And associates 1973)
- A state is a complex phenomenon and not just a general level of arousal or consciousness.
- The newborn infant can exhibit at least five different statuses.
122
 a. Quite or regular sleep: no muscular movements, regular respiration, eyelids closed
b. REM (Rapid Eye Movement)- Or active sleep- minimal muscular movement, irregular
respirations, eye lids closed, rapid eye movement.
c. Quit Alert: (no muscular movement, eyelid open)
d. Crying- Fussing, eyelid closed or pen.
- Transitional states occurring between these are called indeterminate a sixth state
- A neonate in REM sleep has slow, continuous, rolling eye movements with occasional rapid eye
movements. The infant may at the same time show some muscular twitching and an increase in the
rate and irregularity of respiration. REM sleep occupies more of the neonate’s time than the adult’s
time.
- During the first day of life, the newborn infant’s state is unstable and not likely to be changed by
adult intervention as in later days.
- During the first weeks of life, state durations increase and the length and number of indeterminate
periods decrease.
- Newborn infants who are not normally because of metabolic difference, congenital anomalies, or
infections do not have the usual state cycles. The nurse who assesses newborn infants and young
infants must be alert to the importance of the meaning of such deviations report them so that they can
be investigated further.
- The Nurse who recognizes the various states of infants, especially that of crying, can use this
knowledge to change them by providing tactile stimulation (holding, stroking or patting) visual
stimulation (Changing the infant’s visual fields) or auditory stimulation (singing, humming, or
playing the radio or television for the baby)
- Nurses can also teach parents the use of these various techniques before they assume complete
responsibility for the case of their infant in the home.
- The parents will learn to recognize that the various behaviors of the infant are not only the result of
their care but also the result their baby’s state cycles, thus increasing their level of self confidence.

123
 DETECTION OF LIFE THREATENING CONGENITAL
ABNORMALITIES

CLINICAL GUIDELINES
 A register nurse or licensed practical nurse may perform new born screening.
 All new born are screened for phenylketoneuria and hypothyroidism and undergo other state-specific
mandated studies, preferably between 24 and 72 hours of age, before hospital discharge and in no case
later than 7 days of life.
 Screening of premature or sick infants is completed as close as possible to the time discharge from the
nursery or at or near the 7th day of age regardless of feeding status.
 If the initial specimen for newborn screening is collected before 12 hrs of age, a 2nd specimen should be
collected at1 to 2 weeks of age.
 It is best to complete screening prior to transfusion or dialysis if the child’s condition permits. If the
infant requires a blood transfusion or dialysis before the specimen is collected, complete new born
screening 24 hours after completion of the blood transfusion/ dialysis.
 If the new born is transferred to another facility for continuing care on or before the 7 th day of age, the
receiving hospital will obtain the specimen, a “Hospital Report of Newborn Specimen Not Obtained”
form must be completed and sent immediately to the Department of Health Services, Genetic Disease
Branch.
 New born screening is repeated as soon as possible if the initial sample was inadequate.
 Parents/ legal guardian may refuse the test on the basis of religious beliefs or practices. A “New Born
Screening Test Refusal” for must be signed and copies sent as directed on the form.
 New born screening results are forwarded to the infant primary health care provider.
 The parent is provided with result of new born screening.
 Abnormalities found through new born screening are referred to the appropriate provider for follow-up
and treatment.

EQUIPMENT
 Non sterile
 Supplies needed for heel-stick blood draw
 Newborn screening blood collection form per state regulation

124
 Parental information materials about newborn screening tests
CHILD AND FAMILY ASSESSMENT AND PREPARATION:
Instruct parent about procedure and reason for screening. Provide family printed information about
the screening tests that will be complicated.

STEPS RATIONAL
1. Identify infant and write infant and maternal Ensure correct patient for procedure and correct
biographic data on new born screening blood results will be documented for the correct patient.
collection form.
2. Write hospital data and infant’s primary Ensure that new born screening results are
health care provider information, including forwarded to appropriate primary health care
physician license number on new born provider.
screening blood collection form.
3. Perform hand hygiene and Don gloves. Reduces transmission of microorganisms.
4. Perform heel stick. Obtain blood sample for screening.
5. Wipe away first drop of blood from heel stick Ensure that sample will not be contaminated with
area with sterile gauze alcohol used to clean heel-stick site or serous
drainage from heel stick.
6. Allow second large drop of blood to form at Collects adequate blood samples.
site for heel stick and gently apply filter paper
to drop of blood, allowing blood to soak in to
paper, completely filling preprinted circle on
new born screening blood collection form.
7. Repeat procedure, filling each circle Collect adequate blood sample.
completely with an individual drop of blood.
8. Dispose of heel lancet in needle receptacle. Promotes needle safety. Reduces transmission of
Remove glove and dispose of gloves in microorganism.
appropriate receptacle. Perform hand hygiene.
9. Allow blood- soaked circle to air- dry Dying of blood sample collected on filter paper
thoroughly for at least 4 hours. preserve sample to allow for proper processing.

10. Forward copies of new born screening blood Provide appropriate notification and documentation
collection form to appropriate location, per that sample has been obtained.
state protocol. One copy will go to infant’s
125
 parents, one copy will go in to the infant’s
medical record, and the remaining copies will
be retained with the blood sample.
11. Place collected sample on completed new Prevent health care personnel exposure to blood
born screening blood collection form in bio and body fluids and roots sample to appropriate
hazard bag and forward to testing laboratory. location for processing.

CHILD AND FAMILY EVALUATION AND DOCUMENTATION:

- Document the following:
a. Completion of newborn screening in infant’s medical record. Attach chart copy of newborn
screening blood collection form to medical record.
b. Infant’s response to procedure in medical record.

COMMUNITY CARE
- Schedule 2 week follow up well child appointment with infant’s primary health care provider before
infants discharge to whom after delivery.
- At infant well child appointments, assess for signs and symptoms of possible abnormalities on new born
screen.
- Almost all new born screened have residual blood samples up to 21 years. With parental permission,
these samples may be used for population based epidemiology data on disease prevalence, for research
purposes or for future clinical or forensic testing.

126
 ADMISSION OF THE CHILD

CLINICAL GUIDELINES
 The registered nurse (RN) or licensed practical nurse (LPN) admits all the children to the unit.
 Unlicensed assistive personnel (UAPs) may complete admission tasks that are consistent with their job
descriptions as delegated by the registered personnel.
 The RN is accountable for the nursing assessment and must validate data obtained by the UAP.
 All assessment data gathered become a permanent part of the child’s medical record.
 Children are assign a bed, crib, isolate, warmer, or a bassinet appropriate for their chronologic age,
developmental age, and/ or clinical condition.
 Children should be assigned to room based on gender, developmental age, diagnosis and seriousness of
condition, communicability of illness, and projected length of stay.
 Each child must wear an identification band throughout the length of hospitalization. In the event that it
is not possible to place an identification band on the child’s extremity, other arrangements must be made
to identify the child all time.
 Principles of family-centered care should be used by all healthcare providers during the admission
process and throughout the course of the child’s hospitalization.

EQUIPMENTS
For assigned room and personal care:
 Bed, crib, isolate, warmer, or bassinet
 Blankets, linens, bath towels, washcloths
 Washbasin
 Toiletry items (e.g., comb, soap, lotion, toothbrush, toothpaste, as applicable)
 Water pitcher and drinking glass
 Diapers and wipes (if needed)
 Diaper scale (if needed)
 Bedpan, urinal, or specimen hat (if needed)

To admit the child;

 Identification band for child (and parents, if appropriate)
 Scissors

127
 Measuring tape (for head circumference in patient younger than 2 years of age, recumbent length, and
abdominal girth measurement)
 Scale:
- Infant scale for child 2 years of age and younger
- Standing scale for child 3 years of age and older
- Bed scale is indicated by the child’s condition
 Thermometer
 Sphygmomanometer and blood pressure cuff (appropriate size for child)
 Stethoscope
 Pulse oximeter (as needed)
 Child and family welcome and orientation brochures
 Patient admission documentation forms
 Patient property envelope (if needed)

CHILD AND FAMILY ASSESSMENT AND PREPARATION

 Beyond infancy, children should be assigned to rooms with other children of the same gender and
developmental age.
 Very sick children who may require quite and rest should not be roomed with more active and loud
children.
 Immunocompromised children should be placed in rooms with a positive airflow ventilation system and
should not be placed in rooms with children who have infections.
 A child with communicable disease should be placed in a room with a negative airflow ventilation
system and should not have a roommate.
 Children with cystic fibrosis should not be cohorted in the same room unless their sputum is negative for
Burk-bolderia cepacia to avoid cross-colonization of this potentially devastating organism.
 Children requiring respiratory or contact isolation should be placed in a room with a negative airflow
ventilation system.

PROCEDURE
A. PREPARING THE ENVIRONMENT
STEPS RATIONAL/ POINTS OF EMPHASIS
1. Perform hand hygiene. Reduces transmission of microorganisms.
2. Obtain all necessary equipment and Promote child and family comfort by ensuring that items

128
 furniture for the room. Be sure to obtain needed for the child’s personal care are reality available.
any special equipment indicated by needs Prevent delays when immediate treatment must be
of the child. initiated because of child’s conditions.
3. If applicable, prepare roommates for Roommate may be occupying some of the space needed
arrival of new patient in the room. for the new patient, or nurse may need to take measures
to help roommate secure his or her privacy in the room.
4. Check room equipment (e.g. call light, Ensuring that all equipment is ready at bedside and in
bed controls) for proper functioning. good working order prevents delays in admission and
treatment process.
5. Prepared bed by adjusting to lowest Proper positioning of bed decreases likelihood of patient
horizontal position with top sheet and falls or back injury to staff assisting the child.
blanket turned down and brakes locked. Crib side rails must lock in place to ensure the child is
Prepare bassinet or crib by ensuring that not able to get out of the crib.
rails latch in all position and/ or brakes Brakes should be in a locked position to prevent
are locked. hazardous movement of the bed or crib.

6. Arrange for a translator if necessary. Children and family members may need the aid of a
translator to communicate their concerns and understand
the explanations of the healthcare providers.

B. ASSESSING THE CHILD

STEPS RATIONAL/ POINTS OF EMPHASIS

1. Greet child and family:
 Determine whether child is addressed by a Child will feel more comfortable and will be more
specific or nickname. likely to respond when addressed in a fashion
common to him or her.
 Introduce yourself by name and title. Explain Clarifies unique roles of healthcare providers.
your role and responsibilities in the care of the
child. Promote friendly welcoming attitude.
 Try to dispel fears and to anticipate family’s
questions.
2. Escort child and family to the child’s room, Acknowledges presence of others in room.

129
 and introduce child and family to others in
room.
3. Determine reliability of the person providing Person accompanying child may be not know
information about the child. child’s past medical history or the complete history
of events that led to child admission.
4. Determine whether or not child has had Child’s perceptions of and reactions to current
previous hospitalization and determine child’s events are likely to be strongly affected by previous
perception of those experiences. experiences with hospitalization and healthcare
Obtain information regarding child’s personnel.
temperament in relation to previous hospital Temperament is an important variable when
or healthcare experiences. considering appropriate and individualized
approaches to nursing care for the hospitalized
child.
5. Assist child into bed or crib, noting his or her Child may feel less anxiety if he or she remains in
condition. Have child sit on parent’s lap, in the parent’s arms.
the bed, or in the crib during the assessment.
Make sure side rails are up if child is sitting in
bed or crib. Maintains child safety.
6. Apply identification band to child and to Identification is absolutely necessary throughout
parents (if applicable); cut off extra length if hospitalization. Matching identification band for
identification band is too large for child. child and parents are used as a security measure.
Patient identification is a JACHO National Safety
Goal.
7. Validate mechanism to contact family Provides the staff with contact phone numbers, and
members when they are not present in the ensure that parents can be reached at all times if
hospital. needed.
8. Assess vital signs, including respiration, heart Provide baseline parameters to compare with future
rate, temperature, blood pressure, pulse findings.
oximetry, and pain level.
9. Obtain the following information, as child’s Weight is essential for calculating medication
condition permits: dosage for children. Measurement of height and
 Height – recumbent length should be weight allows for calculation of body surface area.
measured for all children 3 yrs of age and Calculation of head circumference alert healthcare
younger. workers to potential cranial problems of

130
  Weight abnormalities. Abdominal girth is assessed if
 Head circumference – obtain for all children 2 condition involves increasing abdominal girth.
yrs of age and younger. Weight and height information is needed as a basis
 Abdominal girth, if warranted by child’s for making decisions about medication
admitting condition. administration.
10. Obtain nursing history and record assessment Provide baseline assessment data. Provides data
data on admission assessment form adopted from which to identify problems that require
by the hospital. interdisciplinary healthcare interventions.
Provides the staff with contact with phone number,
 Validate mechanism to contact to family and ensures that parents can be reached at all times
members when they are not present at the if needed.
hospital. Provide data from which to begin anticipatory
 Determine and discuss health topics that are guidance education in areas of interest or concern
relevant to the age and development of the to parents.
child and that are of interest or concern to the
patients
11. Notify attending healthcare prescriber of Provide continuity of care and ensure prompt
child’s arrival on unit, along with any attention to the child’s healthcare concerns.
emergent or unusual findings, and obtain
admission orders. If the attending healthcare Establishes relationships with primary care
prescriber is not the primary healthcare providers, and allows for smooth transition of care.
provider, the RN or the attending physician
must notify the primary healthcare provider as
well.

ORIENTING THE CHILD AND FAMILY TO THE UNIT

STEPS RATIONAL
1. Orient and demonstrate use of : Clint and family safety may be affected by
 Call light understanding correct use of bedside equipment.
 Emergency light Ensures that child and family know how to call for
 Bed light assistance.
 TV control
 Bedside table
 Bed control and side rails

131
  Patient supplies (wash basin, toiletry items,
water pitcher, urinal)
2. Instruct child and family regarding use of Ensure that child and family know expectation
bathroom facilities and monitoring intake regarding urine collection and monitoring accurate
and output. intake and output records.
 Show location of bathroom if child is
ambulated.
 If output is to be monitored, show how urine
saved. If child is not toilet trained, ask
parents to wrap up and save all dirty diapers
until output has been measured.
 If input is to be measured, instruct parents to
keep track of all fluid consumed by the child.
 If child is NPO, ensure that child and family
members know this.
3. Explain unit routine, meal schedule, visiting Having information about hospital services and
rules, available services and support system, support systems can help to decrease parents
smoking policy, parking availability, anxiety. It is a JACHO standard that families be
cafeteria hours, and playroom hours. Provide informed of the hospital’s smoking policy.
tour of the unit. Allowing parents to stay at the child’s bedside
Let parent know if they may room-in with during the night will help to reduce the child’s
their child and/ or where they can find fears and avoid separation anxiety.
available sleep facilities.

132
 Provide family members with telephone Facilitate parental involvement in care giving and
numbers to unit and explain unit policy decision-making practice.
regarding who may receive information The child’s parents should be able to access the unit
about the child’s status from the healthcare and determine the status of their child at all time.
providers. Other family members are welcome to call and
Encourage parents to notify the staff when make general inquiries; however, for patient
they need extra formula, snacks, diapers, or confidentiality, specific health information cannot
linens for the child. be shared due to the Health Insurance Portability
and Accountability act of 1996.
Children generally eat small, frequent meals and
thus may require the provision of extra snacks
between the scheduled meal services.

4. Inform the child and family about other care In some healthcare setting, especially teaching
who will be seeing the child during the hospitals, there are number of people who come in
child’s hospitalization. contact with the child and family members.
Reviewing this information in advance will help
5. Review patient’s rights and advance Provide
decrease families
the family’s
withconfusion.
a summary of their rights,
directives as needed with parent and with including the right of privacy, the right to review
child if age appropriate. records, and the right to be informed about care.

133
 6. Determine whether or not family has Ensure medicine control during hospitalization.
brought any medications, supplies, or Prevent child from accidentally being medicated by
assistive/ adoptive devices from home for both the family and the nursing staff. Some
child’s use. Discuss with physician and medications being provided at home to the child are
pharmacy which, if any, of these not on the hospital formulary or are too expensive
medications need to be identified and to obtain during the hospitalization, resulting in the
labeled by the pharmacy for dispensing need to have the home medications used during the
during the hospital stay. Send all other hospital stay.
medication home with parents or to patient
property services.
Label all assistive/ adaptive devices with the
child’s name and medical record number.
Send any unnecessary items home with the Prevents child’s property from getting lost. Some
family. Ensure items retained at the bedside devices may not be needed during child’s hospital
are easily accessible to the child and his or stay.
SECURING VALUABLES
her family.
STEPS RATIONAL/ POINTS OF EMPHASIS
1. Place child’s clothes in assigned locker or Promotes cleanliness and orderliness in the room.
closet, and place child’s toiletries in bedside Prevents child’s clothing and supplies from getting
stand. mixed with those of roommates.
2. Encourage child’s family to take all valuable Family is responsible for all items kept in child’s
and money home whenever possible. room.
Have parents label all the child’s clothing
and possessions left at the bedside. Prevents loss or having items mistakenly taken from
the child’s room and placed in the playroom or other
area, while guaranteeing identification when found.
3. If family is unavailable to take home Account for placement of all valuables and helps
valuables, use to institutional records to list prevent loss.
and place all valuables in patient property
envelope while in the presence of the child or Assuming an item is a diamond or piece of gold may
accompanying adult. Always count money in be a false assessment of the material and subsequent
the presence of another employee. value of the item. Valuables are described in terms of
Describe valuable in general terms, such as what is actually visualized and not presumed about the
“yellow metal” rather than “yellow gold” or quality of the item.
“clear, cut stone” rather than “diamonds.”
134
4. In presence of witness obtain a family or Verifies that witness agrees with stated list of contents
guardian signature on form that documents and actual contents of valuable envelope.
valuables received and placed in envelope. If
family or guardian is unable to sign, have
another person as witness.
5. Deliver envelope to patient property services Valuables should be stored in a locked area to prevent
or store in other secure locked location on the loss and theft. Valuables are always labeled to ensure
unit. they can be returned to correct patient at the end of
Envelope should be labeled with child’s their hospital stay.
name, room number, and patient
identification number.
6. Return’s patients copy of the signed property This is patient’s receipt, which he or she signs when
from to family or guardian. Place chart copy proving ownership, and clerk will also sign to release
in chart. If patient is unable to keep receipt, valuables.
secure receipt to inside front cover of chart
until it can be given to family.

CHILD AND FAMILY EVALUATION AND DOCUMENTATION

 Evaluate child’s and family’s understanding of orientation to the room and unit.
 Determine whether or not the family has other areas of concern at this time.
 Record and document nursing assessment on institutional forms.
 Initiate interdisciplinary plan of care (critical pathway) and review with child and family.

COMMUNITY CARE
 Begin discharge planning and transition management to prepare child for transition to home or to
another healthcare facility.
 Notify relevant community healthcare providers of child’s admission,
 Obtain referrals to additional community healthcare providers as warranted by the child’s diagnosis.
 Instruct child and family to notify the healthcare provider if they have further questions or care need.

135
 ADMISSION OF THE CHILD IN PEDIATRIC INTENSIVE
CARE UNIT

CLINICAL GUIDELINES
 A physician’s order is required for admission to the pediatric intensive care unit (PICU).
 The registered nurse (RN) or licensed practical nurse (LPN) admits all the children to the unit.
 Unlicensed assistive personnel (UAPs) may complete admission tasks that are consistent with their job
descriptions as delegated by the registered personnel.
 The RN is accountable for the nursing assessment and must validate data obtained by the UAP.
 All assessment data gathered become a permanent part of the child’s medical record.
 Children are assign a bed, crib, isolette, warmer, or a bassinet appropriate for their chronologic age,
developmental age, and/ or clinical condition.
 Children should be assigned to room based on gender, developmental age, diagnosis and seriousness of
condition, communicability of illness, and projected length of stay.
 Each child must wear an identification band throughout the length of hospitalization. In the event that it
is not possible to place an identification band on the child’s extremity, other arrangements must be made
to identify the child all time.
 All children are placed on cardiorespiratory monitoring (and additional monitoring as necessary).
Discontinuation of such monitoring is based on further evaluation of the child’s status by the healthcare
prescriber.
 Emergency medications and supplies are kept in a wall-secured, easily accessible location in the PICU.
 Principles of family-centered care should be used by all healthcare providers during the admission
process and throughout the course of the child’s hospitalization.

EQUIPMENTS
To admit the child
 Identification band for child (and parents, if appropriate)
 Scissors
 Measuring tape (for head circumference in patient younger than 2 years of age, recumbent length, and
abdominal girth measurement)

 Scale:
136
 - Infant scale for child 2 years of age and younger
- Standing scale for child 3 years of age and older
- Bed scale is indicated by the child’s condition
 Thermometer
 Sphygmomanometer and blood pressure cuff (appropriate size for child)
 Stethoscope
 Pulse oximeter (as needed)
 Child and family welcome and orientation brochures
 Patient admission documentation forms
 Patient property envelope (if needed)

For assigned room and personal care

 Bed, crib, isolette, warmer, or bassinet.
 Personnel protective gear (gown, gloves, masks, goggles/eyewear).
 Electrocardiogram lead patches
 Intravenous infusion device
 Intravenous pole
 Blankets, linens, bath towels, washcloths
 Washbasin
 Toiletry items (e.g., comb, soap, lotion, toothbrush, toothpaste, as applicable)
 Diapers and wipes (if needed)
 Diaper scale (if needed)
 Bedpan, urinal, or specimen hat (if needed)

Unit – Specific Supplies And Equipment

 Oxygen delivery supplies
- Flowmeter for O2
- Oxygen tubing
- Appropriate-size face mask and resuscitation bag
 Suction supplies:
- Appropriate-sized sterile suction catheter (the catheter diameter should not exceed half the diameter
of the airway)

137
 Age Catheter Size
Neonate to 18 months 5 – 8 French
18 to 24 months 8 – 10 French
2 to 7 years 8 – 10 French
7 to 10 years 10 – 14 French
11 years to adult 12 – 16 French
 Sterile container for sterile fluid
 Sterile gloves
 Sterile normal saline or sterile water
 Water-soluble lubricant
 Portable or wall suction machine with tubing and collection container

Intubation and ventilatory support supplies and equipment

 Appropriate-sized laryngoscope and blades
 Appropriate-sized endotracheal tube
 Ventilator

Cardiorespiratory monitor and recorder supplies:

 Appropriate-sized electrodes
 Cardiorespiratory monitor
 Recording tape

Additional supplies:
 Defibrillator and external pacer
 Noninvasive equipment and monitoring supplies (pulse oximeter)
 Invasive equipment and monitoring (hemodynamic monitor)
 Emergency drug and supplies
 Emergency drug calculation sheet, based on child’s weight, height, and allergy status
 Length-based resuscitation tape (Braslow tape)

CHILD AND FAMILY ASSESSMENT AND PREPARATION

 Very sick children who may require quite and rest or who may be nearing death should not be roomed
near more active and loud children or children requiring extensive personnel and procedure at bedside.

138
 Beyond infancy, children should be assigned to rooms with other children of the same gender and
developmental age.
 Immunocompromised children should be placed in rooms with a positive airflow ventilation system and
should not be placed in rooms with children who have infections.
 A child with communicable disease should be placed in a room with a negative airflow ventilation
system and should not have a roommate.
 Children with cystic fibrosis should not be cohorted in the same room unless their sputum is negative for
Burk-bolderia cepacia to avoid cross-colonization of this potentially devastating organism.
 Children requiring respiratory or contact isolation should be placed in a room with a negative airflow
ventilation system.

PROCEDURE
A. PREPARING THE ENVIRONMENT

STEPS RATIONAL/ POINTS OF EMPHASIS

1) Perform hand hygiene. Reduces transmission of microorganisms.
2) Obtain all necessary equipment and Promote child and family comfort by ensuring that
furniture for the room. Be sure to obtain items needed for the child’s personal care are reality
any special equipment indicated by needs available.
of the child. Prevent delays when immediate treatment must be
initiated because of child’s conditions.
3) If applicable, prepare roommates for Roommate may be occupying some of the space
arrival of new patient in the room. needed for the new patient, or nurse may need to take
measures to help roommate secure his or her privacy in
the room.
4) Check room equipment (e.g. call light, bed Ensuring that all equipment is ready at bedside and in
controls) for proper functioning. good working order prevents delays in admission and
treatment process.

139
5) Prepared bed by adjusting to lowest Proper positioning of bed decreases likelihood of
horizontal position with top sheet and patient falls or back injury to staff assisting the child.
blanket turned down and brakes locked. Crib side rails must lock in place to ensure the child is
6) Prepare bassinet or crib by ensuring that not able to get out of the crib.
rails latch in all position and/ or brakes are Brakes should be in a locked position to prevent
locked. hazardous movement of the bed or crib.

7) Arrange for a translator if necessary. Children and family members may need the aid of a
translator to communicate their concerns and
understand the explanations of the healthcare
providers.

B. ASSESSING CHILD
STEPS RATIONAL/ POINTS OF EMPHASIS
1. Notify healthcare prescriber of child’s arrival Provide continuity of care and ensure prompt attention
to unit, and obtain admissions orders. If the to the child’s healthcare concerns. In the critical care
attending healthcare prescriber is not the setting, the urgent healthcare needs of the child often
primary healthcare provider, the registered precipitate immediate interventions by the healthcare
nurse or the attending physician must notify prescriber to stabilize the child.
the primary healthcare provider as well. Establishes relationship with primary care providers,
and allows for smooth transition of care.
2. Greet child and family: Child will feel more comfortable and will be more
 Determine whether child is addressed by a likely to respond when addressed in a fashion
specific or nickname. common to him or her.
 Introduce yourself by name and title. Explain Clarifies unique roles of healthcare providers.
your role and responsibilities in the care of the
child. Promote friendly welcoming attitude.
 Try to dispel fears and to anticipate family’s
questions.
3. If child is alert, escort child and family to the Orients family to healthcare workers.
child’s room or bed space, and introduce child
and family to primary caregiver.
4. Assist child into bed, noting his or her Provides baseline parameters to compare with future

140
 condition. Extremely ill children may have to finding.
be moved by staff members from transferring
gurney to bed.
5. Perform hand hygiene and don personnel Reduce transmission of microorganisms before
protective gear. continuing patient assessment. Use of protective
apparel is determined by child’s condition.
6. Determine reliability of the person providing Person accompanying child may be not know child’s
information about the child. past medical history or the complete history of events
that led to child admission.
7. Determine whether or not child has had Child’s perceptions of and reactions to current events
previous hospitalization and determine child’s are likely to be strongly affected by previous
perception of those experiences. experiences with hospitalization and healthcare
Obtain information regarding child’s personnel.
temperament in relation to previous hospital Temperament is an important variable when
or healthcare experiences. considering appropriate and individualized approaches
to nursing care for the hospitalized child.
8. Apply identification band to child and to Identification is absolutely necessary throughout
parents (if applicable); cut off extra length if hospitalization. Matching identification band for child
identification band is too large for child. and parents are used as a security measure. Patient
identification is a JACHO National Safety Goal.
9. Validate mechanism to contact family Provides the staff with contact phone numbers, and
members when they are not present in the ensure that parents can be reached at all times if
hospital. needed.
10. Obtain the following information, as child’s Weight is essential for calculating medication dosage
condition permits: for children. Measurement of height and weight
 Height – recumbent length should be allows for calculation of body surface area.
measured for all children 3 yrs of age and Calculation of head circumference alert healthcare
younger. workers to potential cranial problems of abnormalities.
 Weight Abdominal girth is assessed if condition involves
 Head circumference – obtain for all children 2 increasing abdominal girth.
yrs of age and younger. Weight and height information is needed as a basis for
 Abdominal girth, if warranted by child’s making decisions about medication administration.
admitting condition.
11. Assess child’s pain and anxiety level. Provide baseline parameter to compare with future

141
 measurements and pain relief.
12. Place child on cardiorespiratory monitor and Provide baseline parameter to compare with future
pulse oximeter. Assess and obtain vital signs, measurements.
including respirations, heart rate, temperature,
and blood pressure.
13. Obtain head-to-toe assessment, including all Provide baseline numbers and alerts healthcare
body systems. workers to potential problems or abnormalities.
14. Dispose of used equipment and waste in Standard precautions. Reduces transmission of
appropriate receptacles, and perform hand microorganisms.
hygiene.
15. Complete an emergency drug calculation Provide information specific to the child regarding
sheet specific for the child and post at child’s doses for emergency medications. Recalculating this
bedside. information saves time if an arrest situation occurs.
16. Obtain nursing history and record assessment Provide baseline assessment data. Provide data from
data on admission assessment form adopted which to identify problems that require
by hospital. interdisciplinary healthcare interventions.
Provide data from which to begin anticipatory
Determine and discuss health topics that are guidance and education in areas of interest or concern
relevant to the age and development of the to parents.
child and that are of interest or concern to the
parents.

ORIENTING THE CHILD AND FAMILY TO THE UNIT

STEPS RATIONAL/ POINTS OF EMPHASIS

1. Orient and demonstrate use of : Client and family safety may be affected by
 Call light understanding correct use of bedside equipment.
 Emergency light Ensures that child and family know how to call for
 Bed light assistance.
 TV control
 Bedside table
 Bed control and side rails
 Patient supplies (wash basin, toiletry items,

142
 water pitcher, urinal)
2. Instruct child and family regarding use of Ensure that child and family know expectation
bathroom facilities and monitoring intake and regarding urine collection and monitoring accurate
output. intake and output records.
 Show location of bathroom if child is
ambulated.
 If output is to be monitored, show how urine
saved. If child is not toilet trained, ask
parents to wrap up and save all dirty diapers
until output has been measured.
 If input is to be measured, instruct parents to
keep track of all fluid consumed by the child.
 If child is NPO, ensure that child and family
members know this.
3. Explain unit routine, meal schedule, visiting Having information about hospital services and support
rules, available services and support system, systems can help to decrease parents anxiety. It is a
smoking policy, parking availability, JACHO standard that families be informed of the
cafeteria hours, and playroom hours. Provide hospital’s smoking policy.
tour of the unit.
Let parent know if they may room-in with Allowing parents to stay at the child’s bedside during
their child and/ or where they can find the night will help to reduce the child’s fears and avoid
available sleep facilities. separation anxiety. Facilitate parental involvement in
Provide family members with telephone care giving and decision-making practice.
numbers to unit and explain unit policy The child’s parents should be able to access the unit and
regarding who may receive information determine the status of their child at all time. Other
about the child’s status from the healthcare family members are welcome to call and make general
providers. inquiries; however, for patient confidentiality, specific
Encourage parents to notify the staff when health information cannot be shared due to the Health
they need extra formula, snacks, diapers, or Insurance Portability and Accountability act of 1996.
linens for the child. Children generally eat small, frequent meals and thus
may require the provision of extra snacks between the
scheduled meal services.

143
 Inform the child and family about other care In some healthcare setting, especially teaching hospitals,
who will be seeing the child during the there a number of people who come in contact with the
child’s hospitalization. child and family. Reviewing this information in advance
will help decrease the family’s confusion.

 Review patient’s rights and advance Provide families with a summary of their rights,
directives as needed with parent and with including the right of privacy, the right to review
child if age appropriate. records, and the right to be informed about care.

 Determine whether or not family has brought Ensure medicine control during hospitalization. Prevent
any medications, supplies, or assistive/ child from accidentally being medicated by both the
adoptive devices from home for child’s use. family and the nursing staff. Some medications being
Discuss with physician and pharmacy which, provided at home to the child are not on the hospital
if any, of these medications need to be formulary or are too expensive to obtain during the
identified and labeled by the pharmacy for hospitalization, resulting in the need to have the home
dispensing during the hospital stay. Send all medications used during the hospital stay.
other medication home with parents or to Prevents child’s property from getting lost. Some
patient property services. devices may not be needed during child’s hospital stay.
Label all assistive/ adaptive devices with the
child’s name and medical record number.
Send any unnecessary items home with the
family. Ensure items retained at the bedside
are easily accessible to the child and his or
her family.

SECURING VALUABLES

STEPS RATIONAL/ POINTS OF EMPHASIS

1. Place child’s clothes in assigned locker or Promotes cleanliness and orderliness in the room.
closet, and place child’s toiletries in bedside Prevents child’s clothing and supplies from getting
stand. mixed with those of roommates.

144
2. Encourage child’s family to take all valuable Family is responsible for all items kept in child’s
and money home whenever possible. room.
3. Have parents label all the child’s clothing and
possessions left at the bedside. Prevents loss or having items mistakenly taken from
the child’s room and placed in the playroom or other
area, while guaranteeing identification when found.
4. If family is unavailable to take home Account for placement of all valuables and helps
valuables, use to institutional records to list prevent loss.
and place all valuables in patient property
envelope while in the presence of the child or
accompanying adult. Always count money in
the presence of another employee.
5. Describe valuable in general terms, such as
“yellow metal” rather than “yellow gold” or Assuming an item is a diamond or piece of gold may
“clear, cut stone” rather than “diamonds.” be a false assessment of the material and subsequent
value of the item. Valuables are described in terms of
what is actually visualized and not presumed about the
quality of the item.
6. In presence of witness obtain a family or Verifies that witness agrees with stated list of contents
guardian signature on form that documents and actual contents of valuable envelope.
valuables received and placed in envelope. If
family or guardian is unable to sign, have
another person as witness.
7. Deliver envelope to patient property services Valuables should be stored in a locked area to prevent
or store in other secure locked location on the loss and theft. Valuables are always labeled to ensure
unit. they can be returned to correct patient at the end of
Envelope should be labeled with child’s their hospital stay.
name, room number, and patient identification
number.
8. Return’s patients copy of the signed property This is patient’s receipt, which he or she signs when
from to family or guardian. Place chart copy proving ownership, and clerk will also sign to release
in chart. If patient is unable to keep receipt, valuables.
secure receipt to inside front cover of chart
until it can be given to family.

145
CHILD AND FAMILY EVALUATION AND DOCUMENTATION
 Evaluate child’s and family’s understanding of orientation to the room and unit.
 Determine whether or not the family has other areas of concern at this time.
 Record and document nursing assessment on institutional forms.
 Initiate interdisciplinary plan of care (critical pathway) and review with child and family.
COMMUNITY CARE
 Begin discharge planning and transition management to prepare child for transition to home or to
another healthcare facility.
 Notify relevant community healthcare providers of child’s admission,
 Obtain referrals to additional community healthcare providers as warranted by the child’s diagnosis.
 Instruct child and family to notify the healthcare provider if they have further questions or care need.

146
 DISCHARGE OF THE CHILD
CLINICAL GUIDELINES
 A healthcare prescriber’s order is required to discharge a child or transfer a child to a different level of
care.
 A minor must be discharged to his or her parent or legal guardian, unless other arrangements have been
made and are documented in the child’s medical record.
 Written parental informed consent should be obtained to transfer the child to another facility.
 Transfer to another facility is treated as a discharge.
 The healthcare prescriber is notified immediately if a parent or legal guardian wishes to take the child
from the hospital against medical advice (AMA).
 To ensure the child’s safety during transport, use the mode of transport most appropriate to the child’s
age, developmental level, and condition.
 All written instructions for the family are in a language, reading level, and format that the parents
verifies he or she can understood.

EQUIPMENT
If discharging a child to parent or legal guardian
 Medical chart
 Discharge care plan
 Written instruction for home care, including follow-up appointments
 Medication and prescriptions, as appropriate
 Plastic bags for child’s personal belongings

If realizing a child to someone other than a parent or legal guardian:

 The above for discharging a child
 Complete Authorization for Release of a minor form

If transferring a child to another room/unit:

 Medical chart, including care plan or care path
 Medications
 Personnel belongings
 Transfer vehicles (wheelchair, bed, gurney)

147
If transferring a child to another facility:
 The above for discharging a child
 Complete Authorization for Release of a minor form
 Complete Permission to Release Medical Record form
 Copy of medical records, including radiology files, and studies
 Care plan or care path with summary of status in meeting outcomes (goal summary)
 Medications
 Plastic bags for child’s personal belongings
 Transfer vehicles
If transferring a critically ill child to another unit or facility, the following additional equipment is
needed:
 Blood pressure monitor
 Pulse oximeter
 Cardiac monitor/defibrillator
 Bag-valve mask device
 Oxygen tank and tubing
 Basic resuscitation medication and equipment (for inter-facility transport)

If releasing a child against medical advice

 The above for discharging a child
 AMA form
DISCHARGING A CHILD
STEPS RATIONALE
Before The Day Of Discharge Facilitate to smooth transition to home or other
1. Begin discharge planning upon child’s admission facility.
and continue the process throughout the
hospitalization.
2. Collaborate with the healthcare prescriber, other Provide the most comprehensive understanding
multidisciplinary team members, and parent for and approach to discharge needs, existing
planning of discharge. barriers, and available resources.

3. Identify the child’s primary caregivers in home Allows teaching to be done with the appropriate

148
 setting. individuals.
4. Assess the family’s knowledge regarding the Understanding the child’s healthcare needs
child’s illness, possible complications, and care improves the likelihood of successful home care.
and treatments to be continued at home.
5. Monitor the parent’s readiness and willingness to Ongoing teaching assists in knowledge retention
team, and provide teaching regularly. For children and allows repeated opportunities to practice new
with complex care needs, evaluate need for parents skills. Family provision of care provides an
to assume responsibility for providing total care opportunity to evaluate parent proficiency and
before discharge, with nursing staff available to reinforced teaching. And it reinforces parents
assist. competence and decreases anxiety.
6. Review cares and procedures that will need to be Ensure skill proficiency and allows time for
performed at home. Provide demonstration and questions to be answered. Written material
written instruction. Evaluate parents understanding reinforces in-hospital teaching ones the child is at
and perform return demonstration of proficiency, home.
if unable to perform at a safe level, arrange for
alternative providers.
7. Initiate referrals and orders for home care, Aids community of care across the healthcare
supportive therapies, equipments, and supplies, as continuum.
needed, and provide information about available
community healthcare resources.
8. Assess the family’s emotional preparedness for Promotes healthy family coping skills.
discharge. Arrange pre-discharge contact with a
support person or group, as needed.
9. Inform parents of the anticipated date and time of Allows the family to make necessary arrangement
discharge as soon as it is known. Notify Social and helps to prevent last-minute delays.
Services if transportation may be needed.

10. Educates parents regarding the laws pertaining to Increases safety of transport. Children for whom
use of a child restraint system in their motor standard care seat or restrain system may not be
vehicle. Assist in arranging for a special car seat or appropriate include
restrain system, as needed.  Premature and low-birth-weight infants
 Children with tracheostomies or poor head
control
 Children in a body or hip spica cast

149
  Infants/ children requiring prone or supine
positioning.

ON DAY OF DISCHARGE
STEPS RATIONALE/POINTS OF EMPHASIS
1. Review healthcare prescriber’s discharge order Act as a safeguard to double-check the accuracy of
for medication, treatment, equipment, or discharge orders and provides a foundation for final
supplies. discharge teaching.
2. Confirm arrangement for outpatient and Ensure that the family will have what they need to
continuing services, home medical care, and provide ongoing care at home.
equipment to the appropriate vender or agency.
3. Review the discharge care plan with the child Establishes common goals to be met for discharge.
and his or her family.
4. Gather prescriptions and any hospital Helps to promote proper drug administration.
medications that have been relabeled for home
use. Review with family the prescribed
medications, including the proper dose, route,
time schedule, and possible adverse reactions.
5. Review cars and procedures that will need to be Ensure skills proficiency and allows time for
performed at home. Provide demonstration and question to be answered. Written material
written instructions. Evaluate parents reinforces in-hospital teaching ones the child is at
understanding and ability to perform cares. home.
6. Review dietary or activity restrictions that are Helps to increase understanding of why adherence
applicable and the reason they are necessary. to a restriction may promote health.
Provide written instruction.
7. Instruct parent regarding follow-up appointments Promote continuity of care after discharge.
or outpatient procedures that are needed. Provide
written instruction. Assist with scheduling when
appropriate.
8. Conformed transportation arrangements to the Decreased the likelihood of unnecessary discharge
family. Notify Social Services if last-minute delay.
assistant is needed.
9. Verify the child has been cleared for discharge Ensure the proper financial arrangements have been
through the financial and business offices. If not, made with regard to the hospitalization.
150
 refer parent to the appropriate office to arrange
for clearance.
10. Perform a physical assessment of the child. An abnormal finding may warrant a change in the
Notify the healthcare prescriber of any abnormal discharge plan.
findings.
11. Gather child’s belongings, including hospital Ensure that the child goes home with the
hygiene supplies, into a bag. Make every effort appropriate belongings and controls costs for the
to prevent hospital property from being removed family and institution.
with the child’s belongings.
12. Have parent assist child to dress in street Physically prepare the child for transition to home
clothing. or other facility.
13. Obtain parent’s signatures on discharge Verifies that instructions have been discussed and
instruction sheet and instruct them to bring it to received and promotes continuity in follow-up care.
the next follow-up appointment. Ensure parent understanding of home care
Answer any final questions. responsibilities.
14. Follow facility policy for checking identification Acts as a security safeguard.
of the parent or legal guardian before realizing
the child into their care.
15. Ones the child and his or her family have their Ensure safety while exiting the hospital facility.
medications, prescriptions, belongings, discharge
instructions, escort them, either walking or in a
wheelchair, to the front lobby for transport home.
16. Remind parent to use appropriate car seat or Promotes safety.
child restraint system. If the child is going home
with equipment, such as apnea monitor, oxygen,
or suction, instruct parents on how to secure it in
their motor vehicle.
17. Complete discharge summary. Documents care given and child’s condition at
discharge.
18. Ones the child has left the patients care area, Facilitates timely preparation of the room for a new
notify housekeeping and arrange for the room to patient.
be cleaned.

151
TRANSFERRING A CHILD TO ANOTHER UNIT

STEPS RATIONALE/POINTS OF EMPHASIS

1. Determine the need for transfer in collaboration Allows for the most appropriate placement of
with the attending healthcare provider, based on the child within the facility.
changes in child’s conditions and the availability of
specific care and resources.
2. Obtain transfer orders that identify the unit to which Identifies healthcare provider who will be
the child will be transferred and the receiving assuming legal responsibility for the child’s
healthcare prescriber. care.
3. Notify the child and the family about the unit to Minimizes child and family anxiety.
which the child will be transferred, reason for
transfer, and date/time the transfer will occur.
4. Before transporting the child to the new unit, Allows receiving nurse to prepare adequately
provide verbal report to the nurse who will be for the child’s arrival and promotes continuity
assuming care of the child; include the child’s of care between units.
current condition and plan of care, necessary
therapies, medications and treatments, and special
nursing care needs.
5. Ensure that all documentation in the child’s chart is Allows receiving unit to continue care without
complete and accurate. error or delay.
6. Gather the all items in preparation for transfer like Avoids loss of articles during transfer, and
reusable supplies, necessary equipment, medical prevents duplicate patient changes for
record, medications, and child’s personnel medications, equipment, and supplies.
belongings.
7. Obtain assistance, as needed, to transport the child. If the transfer is emergent or the child is in
Additional personnel may be needed based on critical condition, the receiving nurse from the
child’s condition and amount of support equipment. unit of higher level of care may assist with
Report may be delayed for initial stabilization of transport to new unit.
child. Remain with child to assist receiving nurse Accompanying personnel should have
and ensure continuity of care in the unit of higher proficient knowledge and skills to deal with
level of care as needed. rapid changes in the child’s conditions.
8. Notify the receiving unit’s nursing station of the Allows for a smooth transition and completes
child’s arrival, and assist in transporting the child to the transfer process.

152
 the room. Introduce the child and family to the
receiving nurse provides the nurse with the medical
record, equipment, and medications; and answers
any questions regarding the child’s conditions or
care.
9. Notify Admitting and other departments involved in Ensure that child’s medications, meals, and
the child’s care of the unit transfer. therapies continue to be provided without error
or delay. Allows visitors to locate the child.
10. Notify housekeeping when the child’s original Facilitate timely preparation of the room for a
room has been vacated and arrange for the room to new patient.
be cleaned.

TRANSFERRING A CHILD TO ANOTHER FACILITY

STEPS RATIONALE
1. Determine the need for transfer in collaboration Allows for the most appropriate placement of
with the attending health care provider and family, the child.
based on changes in the child’s condition, the
availability of needed care and resources at other
facilities, and the family’s preference of the
available options.
2. In collaboration with the receiving agency to Ensure appropriate level of monitoring to detect
which the child will be transported, determine the potential complications during transport.
most appropriate mode of transport based on the
child’s physical condition. The mode of transport
is based on urgency of the medical condition.
A stable child may be transferred by van or car.
A child requiring more intense physical
monitoring must be transported in on ambulance.
A long distance emergency transfer may require
air transport.
Ensure that appropriate transportation is arranged
in advance.
3. Obtain transfer orders that identify the receiving Identifies health care provider who will be
facility and the receiving health care prescriber. assuming legal responsibility for the child’s

153
 care.
4. Explain to the child (as appropriate) and the family Minimizes child and family anxiety. Family
the purpose of the transfer, the risks and benefits of may wish to meet child or new facility.
the transfer, name and location of the receiving
facility, and how and when the transfer will take
place. Provide family with map, telephone number,
and contact name for new facility.
5. Obtain written informed consent for the transfer. Current regulation requires that informed
Obtain parent or legal guardian signature on the consent be given for inter hospital transfers. If
permission to release medical record form. circumferences do not allow for the informed
Forward the form to the medical record consent process, than both the indication for
department, along with the chart to be copied. transfer and the reason for not obtaining
consent should be documented in the medical
record.
6. Document a summary of nursing care and Facilitate continuity of nursing care and assists
discharge evaluation of achievement of goals for in a smooth care transition.
transfer. Give report, by phone, to the receiving
nursing unit if possible.
7. Perform a physical assessment of the child; notify Abnormal findings may warrant a change in the
health care prescriber of any abnormal findings. transfer plan.
8. Ensure that all documentation in the child’s Allows receiving facility to accurately continue
medical record is complete and accurate. the child’s care.
The child’s medical record should be sent to the
new facility following the original facilities safe Patient confidentiality and how health
guards to protect patient data. Documents may information is transferred is regulated by the
need to be sent before the child’s departure to Health Information Portability and
ensure new facility has full understanding of Accountability Act of 1996.
child’s health status.
9. Gather child’s belongings, including hospital Ensure that child is transferred with the
hygiene supply and any hospital medications that appropriate belongings and control costs for the
have been relabeled for discharge use, in place family and institutions.
than in a bag. Make every effort to prevent hospital
property from being removed with the child’s
belongings.

154
10. Have parent assists the child to dress in personal Physically prepare the child for transfer.
pajamas or streets clothes as appropriate.
11. When transporter arrives, check identification, Facilitate a safe and legally appropriate transfer.
complete the Authorization for Release of a Minor
form, and obtain transporter signature.
12. When the child has left the patient care area, notify Facilitates timely preparation of the room for a
housekeeping and arrange for the room to be new patient.
cleaned.

RELEASING A CHILD AGAINST MEDICAL ADVICE (AMA)

STEPS RATIONALE/POINTS OF EMPHASIS
1. If a parent expresses a desire to take the child from Give health care prescriber an opportunity to
the hospital before discharge and AMA, notify the explain the risks of living, the advantages of
attending health care prescriber immediately. continued hospitalization, and any alternative to
Implement institution- specific guideline to safe be hospitalization such as transfer to another
guard child as health care provider, discuss facility or outpatient treatment.
situation with the family.
2. If the parents persist in the decision to take the Ensure documentation for health care facility and
child form the hospital, present him or her with an provides legal verification of parents informed
AMA form and ask for his or her signature in the choice to leave the facility with their child.
presence of a witness: file the signed form in the
medical record.
If the parent refuses to sign and AMA form, note on Ensure proper legal documentation.
the form, along with the date, time, circumferences
of refusal and name of the person who refused,
obtain the signature of a witness. File the form in
the medical record.
3. Complete a Patient Safety Advisors Event form Provides documentation for review by a quality
according to institutional policy. management department.
4. Document, in the child’s charts, a summary of the Provider fact full account for the child’s
event leading up to end including the incident. permanent medical record. A signed AMA form
does not necessarily release the health care
facility or professionals from legal liability.
5. Complete the discharge procedure as permitted by Assist in facilitating a smooth transition, to

155
 the parent. whom, as the circumstances allow.

CHILD AND FAMILY EVALUATION AND DOCUMENTATION

Discharge (planned or AMA)
- Document the following in the child’s medical record:
Instructions given regarding the child’s illness, drug therapy, diet, activity level, treatments, follow up
appointment, possible complications, and which condition warrant immediate notification of a heath care
prescriber.
- Date and time of discharge and with whom the child was discharged.
- Child’s physical condition at discharge (Physical assessment).
- Evaluation of the care plan, goals, and care path outcomes.

TRANSFER
- For transfer of a child of another room of same unit, document the following in the child’s medical
record:
 Reason for transfer
 Date, time and room to which the transfer took place.
 Child’s tolerance of the transfer.
- For transfer of a child to another unit, document the following in the child’s medical record:
The transferring nurse document:
 Reason for transfer, including changes in child’s condition that may have indicated need for transfer.
 The date, time, unit to which child was transferred, and method of transport.
 Child’s condition at time of transfer.
- The receiving nurse documents:
 The date and time of arrival and method of transport.
 Child’s condition and tolerance of the transfer.
 Care provided.
- For transfer of a child to another facility, document the following in the child’s medical record:
 Reason for transfer including changes in child’s condition that may have indicated need for transfer.
 Date and time for release to the transport personnel; name of person released to.
 Method of transport to the transport vehicle.
 Child’s condition at the time of discharge.
 Notification of primary health care prescriber and ancillary departments regarding child’s transfer.

156
  Evaluation of the care plan goals and care path outcomes.

COMMUNITY CARE
- Communicate home care needs as appropriate, to those agencies or individuals who will be following the
child in the community settings.
- Provide anticipatory guidance to the family about child’s responses to hospitalization, noting the
developmental regression is not uncommon and that the family should; provide support and consistence
routine for the child.
- Instruct the family when to call the health care provider and ensure that the family has the name of
provider and contact information.

157
 MANAGEMENT OF BREAST FEEDING
Breastfeeding is the normal way of providing young infants with the nutrients they need for
healthy growth and development. Virtually all mothers can breastfeed, provided they have accurate
information, and the support of their family, the health care system and society at large. Colostrum, the
yellowish, sticky breast milk produced at the end of pregnancy, is recommended by WHO as the perfect
food for the newborn, and feeding should be initiated within the first hour after birth. Exclusive
breastfeeding is recommended up to 6 months of age, with continued breastfeeding along with appropriate
complementary foods up to two years of age or beyond.

COMPOSITION OF BREAST MILK

 Carbohydrate
Lactose is in a high concentration (6-7g/dl) in breast milk. The galactose is necessary for
formation of galactocerbrosides. Lactose helps in the absorption of calcium and enhances the growth
of lactobacilli in the intestine.

 Proteins
The protein content of breast milk is low (0.9-1.1 g/dl) as the baby cannot effectively
metabolize a high protein load. Most of the protein is lactoalbumin and lactogloubin (60%), which is
easily digested. Human milk contains amino acids like taurine and cysteine which are necessary for
neurotransmission and neuromodulation. These are lacking in cow’s milk and formula.

 Fat
Breast milk is rich in polyunsaturated acids, necessary for the myleination of the nervous
system. It also contains omega 2 and omega 69very long chain)fatty acids which are important for
the formation of prostaglandins and cholesterol ,required as a base for steroid hormones.

 Vitamins and minerals

The quantity and bioavailability of vitamins and minerals is sufficient for the needs of the
baby in the first 4-6 months of life.

 Water and electrolytes

158
 Breast milk has a water content of 88% and hence a breastfed does not require additional
water in the first few months of life even in summer months. The osmolarity of breast milk is low,
presenting a low solute load to the neonatal kidney.

ADVANTAGES OF BREAST FEEDING

A. Helps avoid allergies; immediately available; antibodies are passed from mother to baby through her
milk; nutrients are more easily assimilated Creates close bonding between mother and child; reduces
risk of breast cancer; contributes to optimal brain development; breast milk doesn’t stain
clothing.
B. Comforting for baby; convenient; changes as baby grows; no constipation; Colostrums is the perfect
first food
C. Digests more easily; cannot be duplicated; allows delay of solids; fewer dental problems (cavities
and braces)
D. Easy; enjoyable; enhances relationship with your baby
E. Fulfilling; always fresh; gives you a free-hand for reading, etc; fewer health problems means a
happier baby
F. Giving of yourself; a great way of meeting emotional and physical needs
G. Breastfed babies are healthier and so are their moms; babies are meant to have human milk
H. Inexpensive; immunity factors are only found in breastmilk
I. Joyful experience; ready in a jiffy
J. Spending less time in the kitchen (mixing, washing, sterilizing, warming…)
K. Loving; you can join a fun mother’s group – La Leche League; less spitting-up and stomach upsets
L. Delays the return of postpartum menstruation: something only MOM can do for her baby.
M. Perfect balance of nutrients; night feedings are easier; natural
N. Prevents overfeeding; less diaper odor; reduces the chance of obesity later in life
O. Prolactin helps you feel motherly; helps prevent serious health problems; promotes proper jaw, teeth
and speech development
P. Quiet time together; best quality nutrition; practically unlimited quantity
Q. Relaxing; less rash; recommended by the American Academy of Pediatrics, the Canadian Peadiatric
Society and the World Health Organization; completes the reproductive cycle –conception,
pregnancy, birth, lactation.
R. Satisfies all the senses; superior infant food; saves time, effort, money and resources
S. Always the right temperature; travel is easier; time-tested through the ages

159
 T. Uniquely suited to each baby; contracts uterus helping to expel the placenta and control blood loss;
universality of breastfeeding is a link with mothers all over the world
U. Especially valuable in special situations (prematurity, jaundice); taste of breastmilk varies from skim
to creamy during each feeding
V. Helps mother’s weight loss by using extra calories; no need to worry about baby’s food supply;
encourages normal weight gain for baby; called “white blood” because of the life-giving properties
W. X-tra cuddling builds strong ties of love
X. It’s yummy, of course!
Y. These are only a few of the zillions of advantages of breastfeeding your baby!!!

TECHNIQUE OF BREASTFEEDING
Most mothers can successfully breastfeed. Some mothers are a ‘high –risk’ for problems in
breastfeeding. These are a high –risk for problems in breastfeeding. These include primipara mothers, those
who experienced problems in breastfeeding in previous pregnancy, mother with breast problems like
retracted nipple and mothers who have not been motivated to breastfeed. These mothers need help in the
technique of breastfeeding.

Positioning and Latch-On

It is unclear whether the use of a specific breastfeeding position in the delivery room is correlated
with better outcomes; therefore, it would be prudent to allow the mother to breastfeed in any position that
seems comfortable for her or her infant. Options include the cradle hold, cross-cradle hold, football hold,
side-lying position and Australian hold.

Cradle hold Cross-cradle hold Football hold

160
 Side-lying position Australian hold

The latter position might be more difficult to accomplish if the physician needs to perform a perineal
repair at this time. To achieve a proper latch-on, the mother should support her breast using the C-hold It is
important not to have her fingers too close to the nipple because this can result in distortion of the natural
shape of the nipple. The infant is then brought close to the breast, with the mother just touching the nipple
gently on the baby’s lips. This touch should initiate a reflex causing the infant to open its mouth widely. At
this point, the infant should quickly be brought closer to allow a proper latch-on. If the latch-on is done
correctly, the entire nipple and most of the areola should be in the baby’s mouth. Newborns are often quite
alert during the first hour of life. If a good latch-on is achieved, the infant should be sucking well at the
breast and may continue to do so for about 10 minutes.

Proper latching

SIGNS OF ADEQUATE BREASTFEEDING:

 On-demand schedule of eight to 12 feedings per 24 hours
161
  Infant mouth open wide before latch-on
 Latch-on that includes the entire nipple and most of the areola
 Infant tongue placed under the nipple
 Brief pauses in sucking with audible or visible swallowing
 Infant breathing coordinated with suck and swallow cycle
 Visible movement of temporomandibular joint during active nursing
 Mother supports breast with hand (C-hold) throughout feeding during first six weeks
 Wet diapers at least six to eight times per day
 Adequate infant weight gain, with return to birth weight by two weeks
 Upper areola is more visible than the lower.
 Baby chin touching the breast.

SPECIAL PROBLEMS ASSOCIATED WITH BREAST FEEDING

 Cracked and painful nipples
These are very painful and sometimes make it impossible for the infant to suckle. Milk must
then be expressed by hand for a day or two while the nipple is allowed to heal. There are several
ways to prevent or remedy this condition. Health workers should try out and advise those most
suitable for their area.
They include:
 Making sure the infant’s mouth in the correct position. This means that the gums should be
biting the aveolar area.
 Wetting the nipple with breast milk and feeding small feeds frequently;
 Treating the cracked nipples with oil: this does not need washing off before feeding;
 Squeezing a few drops of orange or lemon on the cracks. This may be painful but it speeds up
the healing.

 Breast engorgement
The milk production increases during the second and third day after delivery. If feeding is
delayed or infrequent, or the baby is not well positioned at the breast, the milk accumulated in the
alveoli. As milk accumulate in the alveoli. As milk production increases, the amount of milk in the
breast exceeds the capacity of the alveoli to store it comfortably. Such a breast becomes swollen,
hard, warm and painful and is termed as an engorged breast.
Breast engorgement can be prevented by
 Early and frequent feeds and correct attachment of the baby to the breast.
162
  Treatment consists of local warm water packs and analgesics to the mother to relieve the
pain.
 Milk should be gently expressed to soften the breast and then the mother must be helped to
correctly latch the baby to the breast.

 Inverted nipples
Flat or short nipples which protract well (become prominent or pull out easily) do not cause
difficulty in breastfeeding. Inverted or retracted nipples make attachment to the breast difficult.
These should be diagnosed in the antenatal period. The mother with these problems need additional
supports to breastfeed their babies.
Treatment is started after birth of the baby. The nipple is manually stretched and rolled out
several times a day. A pump or plastic syringe is used to draw out the nipple and the baby is then put
to the breast.

 Breast abscess
If a congested engorged breast, an infected cracked nipple or a blocked duct and mastitis are not
treated in the early stages, then an infected breast segment may be form a breast abscess. The breast
becomes swollen, red and exquisitely tender. The mother may have high grade fever and raised
blood count.
Mother must be treated with milk expression, analgesics and antibiotics .the abscess may have to be
incised and drained. Breastfeeding must be continued.

ARTIFICIAL FEEDING
Infants must have adequate intake to maintain weight gain along their own growth curve. Infants are
exclusively breast feed or fed human milk for the first 3 to 6 months of life whenever possible.
Contraindicated to breast feeding include galactosemia, maternal use of illegal drugs, nitrated active
tuberculosis, human immunodeficiency virus infection (HIV) and administration of certain drugs
(radioactive isotopes, antimetabolites, and cancer chemotherapy.
Prepared formula can be kept refrigerated for 24 to 48 hours, although it is safest to consume within
the first 24 hours.

ARTICLES FOR ARTIFICIAL FEEDING

 measuring cup
 appropriate formula ,either store breast milk, powdered concentrated liquid, or ready to feed formula
163
  scoop
 bottled water
 additives as prescribed.
 Long handled spoon
 Bottles with appropriate nipples and rings or disposable bottle liners with nipple, rings and support
form.

CHILD AND FAMILY ASSESSMENT AND PREPARATION

 Assess the general health status (including weight and length),developmental age, chronological age
and previous feeding experiences.
 Assess the infant’s oral motor development, particularly if the infant has been intubated, was drug
exposed in utero, or has a congenital defect (such as cleft lip or palate).
 Assess the parent preference to breast feed or bottle feed.
 Assess parents level of comfort with feeding, knowledge about positioning infant with head slightly
elevated during feeding and level of knowledge regarding formula preparation and storage if bottle
feeding and maternal nutrition and fluid intake if breast feeding.
 Determine infant state before feeding and assist infant to achieve quiet alert state.
 Assess financial resources of the family to purchase formula and equipment and whether a social
service referral may be needed.

PROCEDURE
STEPS RATIONALE
1. Gather the necessary supplies Promotes efficient time management and provides and
organized approach to the procedure.
2. Perform hand hygiene. Reduces transmission of microorganisms.
3. Prepare concentrated or powdered Ensures appropriate preparation.
formula exactly as recommended.
4. Ready to feed formulas need only be Ingredients of formula may have settled in the container, so
lightly shaken before use. shaking slightly helps to redistribute all ingredients
equally.
5. Stored breast milk preparation must Handling and use of stored breast milk requires that
be bring first at room temperature. specific guidelines are followed to ensure safety.
6. Warm the Formula slowly to Slow heating is recommended to avoid scalding contents or

164
 comfortable temperature. exploding bottles. Infant burns from overheated bottles can
be severe enough to require hospitalization and even
amputations have been reported.
7. Position supplies so that they are Provides organized approach to the procedure.
readily accessible to the faster.
8. Hold infant on the lap with head Reduces chance of aspiration and otitis media. Facilities
elevated and close to the parent’s bonding.
body.
9. Using bottle: Tilt bottle to keep the Reduces the amount of air ingested and prevents the
nipple full at all times. The nipple potential development of otitis media. Slow flow causes
should have a steady drip, but not a the infant to suck very hard and potentially tire quickly; too
steady stream of flow. fast a stream increases the risk for aspiration.

10. Using a cup, and spoon or Palade

:
 Hold the baby in semi upright
position, rest the cup or Palade
or spoon lightly on the baby’s
lower lip and touch the outer part
of the baby’s upper lip with the
edge of the cup.
 Tip the cup or Palade/spoon, so
the milk just reaches the baby’s
lip,
 Allow the baby to take the milk,
 Do not pour the milk into the
baby’s mouth, end the feeding
when the baby closes her/his
mouth and is no longer
interested in feeding.
11. Stimulate rooting reflex by ribbing Encourages infant to open mouth. Positions nipple
nipple along lower lip or ticking side appropriately.
of cheek. Place nipple on top of
tongue.

165
 12. After 5 minutes or 1-2 oz, stop and Expels ingests air, allows infant to take more formulas, and
burp infant .Burp again at end of decreases potential for reflux and colic like symptoms.
feeding.
13. When feeding is to be discontinued, Ensures safety of infant and prevents aspiration.
assist the mother/parents to place.
14. Discard bottle and formulas Formula may be contaminated with bacteria during
remaining in bottle at end of feeding.
feeding.
15. Perform hand hygiene Reduces transmission of microorganisms.

CHILD AND FAMILY EVALUATION AND DOCUMENTATION

 Evaluate family understanding of nutritional needs of an infant and formula preparation.
 Determine concerns of the parents regarding feeding
 Evaluate infant’s weight gain and document serial measurements on standardized growth chart.
 Evaluate feeding behaviors and infants –parent interaction and attachment behaviors. Provide written
instructions as needed.
 Document the following
 Time of fed
 Type of feeding (human milk or formula)
 Method of feeding(breast or bottle)
EXPRESSION OF BREAST MILK
If a mother is not in a position to feed her baby (e.g. ill mother, preterm baby, working mother, etc.)
or has engorged breasts, she should express her milk in a clean wide mouthed container and this milk should
be fed to her baby. Expressed breast milk can be stored at room temperature for 6 hours in a refrigerator for
24 hours and a freezer at -20 OC for 3 months.

EQUIPMENT
 Clean wide mouthed container
 Mechanical or electrical operated pumps
How often a mother should express milk

166
HOW OFTEN A MOTHER SHOULD EXPRESS MILK
It depends on the reason for expressing the milk, but usually as often as the baby would be breastfeed (at
least 8 to 10 times /day)
 To establish lactation, to feed a low birth weight or sick newborn.
 She should start to express milk on the first day, within six hours of delivery is possible. She may
only express a few drops of colostrums at first, but it helps breast milk production to begin.
 She should express as often as her baby would breastfeed. Hence, it should be done at least every 3
hours, including the night hours. If she expresses only a few times or if there are long intervals
between expressions, she may not able to produce enough milk.
 To sustain her milk supply to feed a sick baby: She should express at least every 3 hours.
 To build up her milk supply: Express very often for a few days (every ½- 1 hours) and at least every
3 hours during the night.
 To leave milk for the baby while she is out at work: Express as much as possible before she goes to
work. It is also important to express while at work to help keep up her supply.
 To relieve symptoms such as engorgement, of breast: Express only as much as is necessary.

PROCEDURE

1. Preparation of container
 Choose a cup, glass or jar
with a wide mouth.
 Wash the cup in soap and
water
 Pour boiling water into the
cup, and leave it for a few
minutes. Boiling water will
kill most of the germs.
 When ready to express milk,
pour the water out of the cup.
2. Massaging the breast before
expression
 Take a wet warm towel and

167
 wrap it around the breast. Let
it be there for 5 min.
 With two fingers, massage the
breast using circular motion of
finger. Use pulp of fingers
only with modest pressure.
Alternately she can use
knuckles of a fist. Massage
the breast towards nipple as if
kneading dough. Massage
should not hurt her.
 Provide massage for 5-10 on
each breast before expression
of milk.
MANUAL EXPRESSION OF MILK
3. Expression of breast milk.
 The mother should wash her
hands thoroughly.
 She shall sit or stand
comfortably and hold the
container near her breast.
 She should think lovingly of the
baby or look at a picture of her
baby.

168
 Ask her to put her thumb
above the nipple and areola,
and her first finger below the
nipple and areola opposite the
thumb. She supports the
breast with her other fingers.
 Ask her to press her thumb
and first finger slightly inward
towards the chest wall. She
should avoid pressing too far
or she may block the milk
ducts.
 Press her breast behind the
nipple and areola between the
fingers and thumb. She must
press on the lactiferous
sinuses beneath the areola.
Sometimes in a lactating
breast it is possible to feel the
sinuses. They are like pods or
peanuts. If she can feel them,
she can press on them.
 Press and release, press and
release. This should not hurt-
if it hurts, the technique is
wrong.
 At first no milk may come,
but after pressing a few times.
Milk starts to drip out. It may
flow in streams if the
oxytoxin reflex is active.
 Press the areola in the same
way from the sides to make
sure that milk is expressed

169
 from all segments of the
breast.
 Avoid rubbing or sliding her
fingers along the skin. The
movements of the fingers
should be more like rolling.
 Avoid squeezing the nipple
itself .pressing or pulling the
nipple cannot express the
milk. It is the same as the
baby sucking only the nipple.
 Express one breast for at least
3-5 minutes until the flow
slows; then expresses the
other side; and then repeats
both sides. She can use either
hand for either breast or
change when they tire.
 In case of using breast pump,
fix the pump cup on to the
nipple.
 Explain that adequate
expression of breast milk
takes 20-30 minutes,
especially in the first few days
when only a little milk is
produced, it is important not
to try to express in a shorter
time.

EXPRESSION OF MILK USING BREAST

PUMP

170
 OG (OROGASTRIC) TUBE INSERTION
Tube is inserted into stomach for feeding for feeding .gastric aspiration and stomach wash or lavage.
The tube may be inserted through the mouth for doing a lavage by nasogastric intubation is preferred for
feeding or prolonged gastric aspiration because of ease of fixing a nasogastric tube. Non-irritating PVP and
plastic tubes can be safely kept in situ for several days. Tip of the patients little finger provides a useful
guide regarding the maximum diameter of the tube that can be passed through the nose.

PURPOSE
 To decompress the stomach and proximal small intestine
 To evaluate blood, secretion and ingested drugs or toxins.
 To control bleeding form gastric and esophageal therapies.
 To administer medications, fluids or nutrition.
 To obtain samples of gastric contents.
 To administer lavage of irrigation.
Enteral tubes may have a single, double or triple lumen, depending on their intended purpose. Intake and
output through the enteral tube is monitored every hour or as determined by institutional policy or the
child’s condition. Enteral tube position and function are evaluated before use of the tube for
diagnostic/therapeutic reasons.

SIZE OF THE OROGASTRIC TUBE ACCORDING TO AGE

• In newborn babies and infants.3,5,6 or 9 FG and
• Older children 9-15 FG size tubes are used for nasogastric intubation.
• For Orogastric intubation, a larger sized tube 9-18 FG is used.

ENTERAL TUBE NUMBER OF LUMENS

Lumens Purpose
Single lumen weighted or non weighted Enteral or transpyloric tube feeding
Double lumen non-weighted tube Gastric decompression
Double lumen non-weighted tube Gastric lavage

EQUIPMENT
171
 Orogastric tube of appropriate size
 Lubricant /Topical anesthetic agent ( as prescribed)
 Stethoscope
 Adhesive tape
 Emesis basin
 Tissues or Towel
 Gloves

CHILD AND FAMILY ASSESSMENT AND PREPARATION

 Assess the child for history of nasal deformity, surgery or trauma ,which may provide information as to
the patency of the nares, whether passage of the tube may be difficult or impossible, or whether tube
may complicate breathing for the child.(Nasogastric tubes are contraindicated in children with a basal
skull fracture)
 Assess the child for a history of varices or recent esophageal or gastric surgery which may complicate
placement of the enteral tube.
 Assess the child for signs and symptoms of gastric distention /irritation.
 Assess the child for presence of orthodontic appliance, if tube is to be inserted through the mouth.
Instruct the child to remove appliance because dislodgement during the procedure and possible
aspiration may occur.
 Assess the child for a history of drug or toxin ingestion.
 Assess the child potential for aspiration, secondary to accumulated gastric secretion and fluids or
impaired gag reflex.
 Assess the child and family cognitive level, readiness and ability to process information.
 Reinforce the need for and identify and discuss the risks and benefits of tube placement, as appropriate
to both the child and family.
 Explain the procedure, as age and developmentally appropriate child and family. Invite the parents to
remain with the child to provide comfort and diversionary measurement.

PROCEDURE
STEPS RATIONALE
1. Check the treatment card of baby for
instruction
2. Wash hand thoroughly and dry with clean Reduces the transmission of microorganism

172
 towel
3. Gather the necessary supplies for tube Promotes efficient time management and
placement provides an organized approach to the
procedure
4. Position the patient and restraint the child as Keeping the child’s hands away from the tube
required. helps prevent the child from pulling of the
Infants /toddlers may need to be restrained tube. Extending the nasal pharynx during
in a supine position before the procedure initial tube insertion may help decrease the gag
begins, either with swaddle type restraints reflex.
or a 2 person securely holding the child.
Older placed in a setting position for
placement, if the child can co-operate or if a
2 care provider can effectively support the
child and keep him/her calm during the
procedure.
If the child in supine position arranges
towels/pillow under the shoulder to initially
slightly extend and elevate the head.
Older children may be placed in a sitting
position with the head slightly extended.
5. Measure the length for Orogastric tube to be Estimates the total length of the tube to be
inserted. Tube is measured from bridge of passed.
the nose to the tragus of ear and to the
xiphisternum. Note mark on tubing to be
passed with a piece of tape on the tube.
6. Place emesis basin and tissues/towel within Allow for easier use, if needed during
easy access. procedure.
7. Place towel over child’s gown Protects clothing from emesis or secretion.
8. Don gloves Standard precaution to reduce transmission of
micro-organism.
9. Lubricated the tube glycerine or sterile Reduce friction and prevents trauma to the
water (never with oil) area.
10. Gently inserted the tube to nose or the Slightly neck Flexion prevents inadvertent
mouth into the esophagus down to the passage into trachea provokes sudden choking

173
 stomach upto the marked length keeping the and coughing.
neck slightly flexed.
11. When enteral tube reaches the pharynx and Swallowing promotes esophageal peristalsis
child gags. Ask child to swallow & in the which facilitates passage of the enteral tube.
infant with a pacifier.
12. Continue to pass enteral tube until measured Advance enteral tube into the stomach,
segment of tube is at the nares opining. Do inserting the enteral tube too. Far may result in
not pass the enteral tube beyond. looping the enteral tube in the stomach,
causing ineffective drainage. Kinking or in
advancing the enteral tube into the duodenum
excessive removal of the bile. Signs of
respiratory distress indicate the enteral tube is
in the respiratory tree. Remove if there are
signs of respiratory distress such as coughing,
gasping, cyanosis.
13. Check the position of the tube in the Ensuring tube in the right place.
stomach and confirmed as follows :
a) Connect a 5 0r 10 ml syringe to the tube
and push air.
b) Auscultation over the epigastrium for
gurgling sounds on injection if air.
c) Aspiration of acidic stomach contents
d) Instillation of 1-2 ml of sterile distilled
water should not provoked coughing
and choking.
14. Allow the child to rest and resume insertion Allows the child to gain control of self again
procedure. and allows the older child to be able to assist
with procedure.
15. Securely affixed on the face with a Helps in fixation of the tube.
Millipore tape.
16. Dispose of equipment and waste in Standard precaution
appropriate receptacle.
17. Remove gloves and perform hand hygiene Reduces transmission of microorganisms

174
CONFIRMATION OF NOSE /OROGASTRIC TUBE PLACEMENT WITH pH
STRIP
Aspirate location Aspirate characteristics pH
Gastric Clear, off white, grassy green, tan brown- <5
tinged, if blood present
Intestinal Bile stained light to dark golden –yellow or >6
brownish
Pulmonary tracheobronchial Watery ,straw-colored mucus >6.5

CHILD AND FAMILY EVALUATION AND DOCUMENTATION

 While tube in place
 Verify tube placement and patency
 Evaluate integrity of skin around nares, area where tape is placed, and of mucous membrane.
Monitor intake and output as indicated.
 Assess for signs of respiratory distress, especially in infants under the age os approximately 2 to 3
months who are obligate nose breathers and have varying ability to breathe through their mouth.
 Provide comfort measure as indicated.

 After the insertion of the Orogastric tube, document the following

 Date and time of insertion
 Size /length of tube used
 Origin of insertion site and verification of location
 Verification method
 Comfort /distraction and /or restraints used during placement.
 Child’s tolerance of the procedure.
 After removal of the tube ,document the following:
 Date and time of removal
 Comfort /distraction or restraints used during removal.
 Child’s tolerance of the procedure.
 While the tube is in place ,document the following
 Intake and output
 Method of tube confirmation and patency (e.g; system is intact, without leaks, kinks or
occlusions)before each use.

175
  Tolerance to therapeutic interventions
 Changes in the tube placement
 Flushing /irrigation volumes with sterile water to maintain patency and frequency.
 Condition of the skin around the nares, mouth and check where the tube is secured.
 Comfort measures
 Change tape as required: consider using skin barrier to protect skin surface from the irrigating effect of
tape.
 Administer frequent oral care; offer throat spray for comfort or ice chips, unless contraindicated per
diet orders.
 Determine whether the child and family have other areas of concern to discuss.

176
 GAVAGE FEEDING
 Enteral feeding may be given a number or routes, including nasogastric or Orogastric tube placement,
gastrostomy tube, PEG, skin –level G-tube device, jeujunal tube, or transpyloric tubes.
 Enteral feedings are indicated for children who are unable to ingest an adequate amount of nutrition
orally. This may include children who are unconscious, ventilated, transitioning from parenteral
nutrition, are unable to swallow, or have primary aspiration.
 The child receiving enteral nutrition must have a functioning gastrointestinal tract for nutrition to be
digested and absorbed.
 Feedings provide by way of the gastrointestinal tract promote the child with a much lower risk for
complications. (e.g: catheter sepsis, thrombophelebitis),and prevent the development or worsening of
malnutrition.
 Placement of the enteral tube must be confirmed before administration of tube feedings.

EQUIPMENT
 Enteral tube
 Towel or wash cloth
 Gloves
 Syringe -50 ml
 Stethoscope
 Prescribed Enteral feed
 Measuring cup

CHILD AND FAMILY ASSESSMENT AND PREPARATION

 Assess the child for symptoms of malnutrition, including weight loss, muscle atrophy, edema, weakness,
lethargy, failure to wean from ventilatory support, or poor wound healing, which may indicate the
severity of malnutrition.
 Assess the child’s gastrointestinal tract, Auscultate foe the presence of bowel sounds, and palpate the
abdomen to ensure that it is soft, non-distended and nontender.
 Obtain the child’s baseline weight: note the presence or absence of edema. Note the child’s weight from
admission and track weight trends, this provides evidence of the effectiveness of nutritional support and
the patient’s response to the nutritional interventions.
 Assess the child for a history of cardiac, renal, hepatic, or pulmonary disease because these may limit the
fluid volume of the type of formula the child’s can receive and the volume of the flushes administered.
177
 Assess the child cognitive level, readiness, and ability to process information of the child and family.
The readiness to learn and process information may be impaired as a result of age, stress or anxiety.
 Reinforce the need and identify and discuss the risks and benefits of enteral tube feedings, as
appropriate, to both the child and family.
 Explain the procedure, as appropriate, both the child and family.

PROCEDURE
STEPS RATIONALE
1. Perform hand hygiene. Reduces transmission of microorganisms
2. Gather the necessary supplies Promotes efficient time management and provides an
organized approach to the procedure.
3. Don gloves. Standard precaution to reduce transmission of
microorganisms.
4. Place child a in a supine position, Discourages aspiration of gastric contents by using
before the procedure begins, with the positioning and gravity to keep formula down when
head of bed up 30 °(if not otherwise feeding.
contraindicated).Older children may
be placed in a sitting position or a
position of comfort.
5. Measures prescribed amount of enteral Prepares formula for administration. Promotes safety for
formula to be infused into clean the delivery of the ordered volume of feeding.
graduated measuring cup or catheter
tip syringe.
6. Place a towel or washcloth under Protect clothing and linens from emesis or secretions.
child’s indwelling enteral tube or
below chin and chest.
7. To verify proper tube placement of Avoids complications associated with inappropriate
nasogastric, Orogastric and naso- administration of feeding.
jejunal tube.
8. For skin-level devices, attach feeding Skin-level –devices require that a feeding tube be
tube extension to enteral devices (as connected to the device to administer the feedings the
needed depending on type of enteral feedings or medications.
device)
9. Attach 60 ml catheter tip syringe with Syringe is used to administer bolus feeding.
178
 plunger removed to the end of the
enteral tube or the end of the feeding
tube.
10. Assess for residual fluid in GI tract for Monitoring residuals aids in prevention of overfeeding
gastrostomy tubes(this is not indicated and detecting early signs of feeding intolerance. Gastric
for jejuna or transpyloric tubes) residuals may be elevated because of formula
 Nasogastric or Orogastric tubes – intolerance, delayed gastric emptying, sepsis or
Use syringe to aspirate for residual underlying gastrointestinal disease process.
fluid.
 Gastrostomy tubes –Use passive
flow by positioning the tube with
an open syringe attached (without
the plunger)below the stomach
level.
 Low-profile gastrostomy tubes –use
the manufacture recommended
decompression/vent tube attached
to an open syringe. Attach
decompression/vent tube to low
profile gastrostomy tube and
position the open syringe to assess
residual. It may be necessary to
gently aspirate the stomach
contents by using the syringe
plunger to determine entire
residual.
11. If residual feedings is obtained and is Continued feeding may cause negative vital sign
grater the one half of the previous changes, vomiting, and potential aspiration. Gastric
feeding volume, hold the present aspirates contain enzymes, electrolyte, and secretions
feeding. Noting color and consistency essential for digestion, so discarding aspirates repeatedly
and notify the prescribing practitioner. could lead to electrolyte imbalance.
If there is a small amount of residual,
return the aspirate and continue with
the enteral feeding procedure.

179
12. Elevate catheter tip syringe to a level Gravity allows any back pressure to be released and
to deliver the feeding over about 15 avoids direct forceful pressure on gastric mucosa.
minutes, gradually adding the total
feeding volume to the syringe. Allow
feeding to flow slowly by gravity;
raising or lowering syringe can adjust
the rate of flow. The flow of feeding
may need to be initiated by placing
plunger into barrel of syringe and
depressing slightly.
13. Observe child during the feeding for Stimulation of the vagal nerve by the enteral tube can
intolerance and complications: cause bradycardia or or apnea. Feeding intolerance can
elevated gastric residuals, emesis, occur with decreased gastric peristalsis secondary to
abdominal distention, bradycardia or, underlying disease process, leading to inability to digest
or apnea. In the sedated or comatose formula.
child, retching may not be observed.
14. After feeding is complete, gently clear Warm water prevents the tube from clogging. Depending
tubing and catheter tip syringe with on child’s age and diagnosis, added free water may be
warm water flush. needed to avoid potential dehydration that can result
from high osmolarity formulas. Free water may also
place some children at risk for fluid overload.
15. If feeding tube is discontinued after Avoids leakage of contents from tubing, preventing
each feeding, pinch or clamp the possible aspiration of contents during removal.
enteral tubing and withdraw the tubing Minimizes risk for vomiting.
with a slow, smooth, steady
movement.
16. Used supples, such as catheter tip Changing enteral feeding set/ disposable supplies every
syringe and feeding extension tubing, 24 hours prevents bacterial overgrowth in set. Date and
can have repeated use for upto 24 time labeling indicates to parent and nursing staff when
hours. Label administration set with supplies should be changed.
date and time when first used; cleanse
thoroughly with warm, soapy water
and rinse well.

180
17. Dispose of equipment and waste in Standard precaution
appropriate receptacle.
18. Remove gloves and perform hand Reduces transmission of microorganisms.
hygiene.

CHILD AND FAMILY EVALUATION AND DOCUMENTATION

 Evaluate enteral tube position and function every hour or as determined by institutional policy or the
child’s condition.
 Observe the enteral tube system to ensure the system is intact, without leaks, kinks or occlusions, at
least once every shift.
 Auscultate the child’s bowel sounds every 4 hours for motility.
 Evaluate the child for gastric residuals every 4 hours while on feedings or as ordered by physician.
Note color, consistency, pH testing, occult blood testing, and whether the residuals were given back
to the child or discarded. Hold feedings for 1 hour if residual are greater than half of the previous
worth of continuous feeding. If feeding residuals continue after feeding is held for an hour, notify
prescriber to obtain further orders.
 Evaluate the child’s intake, output and tolerance to feeding. Monitor for decreased or increased urine
output.
 Evaluate for diarrhea; consider diarrhea as a possible result of the use of hyperosmolar formula,
lactose intolerance, pronged use of antibiotics, or bacterial contamination of formula.
 Evaluate children experiencing persistent diarrhea on enteral tube feeding for any relation to formula
rate and content. Review medications for those that may contribute to diarrhea. Obtain stool to check
for C.difficcile
 Evaluate the child’s weight pattern by weighing the child’s daily.
 Evaluate the need for in- home enteral nutritional support.
 Document the following
 Date and time of feeding administration
 Type and size of enteral tube use.
 Origin of the enteral tube site and distal tip position.
 Verification of tube patency
 Type of feeding, medications or treatment administrated through the enteral tube.
 Amount of intake including flushes and output.

181
  Amount of gastric residuals, color and characteristics of residuals, results of any pH or occult
blood testing, and whether the residuals were given back to the child or discarded.
 Child response to and tolerance of the procedure
 Childs daily weight
 Presence and quality of bowel sounds.
Determine whether the child and family areas of concern to discuss.

182
 TPN
(TOTAL PARENTERAL NUTRITION)
 Parenteral nutrition and intravenous fat emulsion are administered by the registered nurse under the
order of healthcare prescriber.
 Parenteral nutrition are delivered to the neonate, infant or children through centre or peripheral
catheters. Line selection is dependent on composition of the solution: peripherally delivered fluids may
have no greater than 10 % concentration of dextrose or no greater than 5% concentration of protein.
Concentration above these amounts are delivered though central infusion. Also if the solution has a pH
of <5 or >9,0r osmolarity >600mOsm/Lit should be administered through central infusion.

EQUIPMENT
 Appropriate venous device in place
 Electronic infusion device
 Tubing for the infusion device
 In line filter
 For non-lipid-containing solution; 0.2 micron filter containing a membrane that is bacteria and
particulate and air eliminating.
 For lips infusions or total nutrient admixtures that requires filtration :1.2 micron filter containing a
membrane that is particulate retentive and air eliminating .
 Nutrient solution ,usually consisting of amino acids, glucose and electrolytes and /or IVFE solution.
 Flush solution (saline or heparin ) appropriate to size and weight of child
 Additives as ordered by the health care provider.
 Disinfectant solution
 Antiseptic swab or pad

CHILD AND FAMILY ASSESSMENT AND PREPARATION

 Assess knowledge base of family and child regarding what Parenteral nutrition is and why the child is
receiving it.
 Determine family’s knowledge level regarding the child’s underlying condition.
 Determine child’s baseline laboratory values, hydration status, nutritional status and weight and height.
 Assess catheter site for appropriateness (peripheral venous central, depending on concentration of
dextrose and protein), patency and signs of infection.
183
 Assess the child for any signs and symptoms of septicemia.
 Remove Parenteral nutrition solutions from refrigerator at least 1 hour before administration to warm to
room temperature.
 Child should be weighed daily as per institutional policy to ensure the correct amount of fluids and
nutrients are being administered based on child current weight.

PROCEDURE
STEPS RATIONALE
1. Gather the necessary supplies and prepare work Promotes efficient time management and
surface by cleansing with disinfectant solution provides an organized approach to the
.perform hand hygiene. procedure. Reduces transmission of
microorganisms.
2. Place solution bag on clean work surface. Solution Infusing a cold solution may cause
should be at room temperature. hypothermia.
3. Inspect solution. Verify label against health care Reduces chances of child’s receiving incorrect
order for match. Check expiry date. Examine or contaminated solution
solutions and container for clarity, signs of
contamination or particles. Do not infuse if solution
has expired, is cloudy has crystals or has leaks.

4. Identify the child utilizing two different patient Reduces incidence of solution being
identifiers. Match identification with label on the administered to the wrong child.
solution bag.
5. Examine infusion device and site for type, Decrease chances of complications.
placement, patency and signs of infection .any signs
of infection should be immediately reported to the
health care prescriber and the infusion delayed.
6. Maintain aseptic conditions and add additives Reduces transmission of pathogens into
(many pharmacies send the solution complete with solution. Vigorous shaking causes foaming and

184
 additives ,so this step may be eliminated ) per delayed administration.
following steps :
a. Draw up ordered additives
b. Cleanse port with appropriate antiseptic
c. Inject additives into solutions and infusion is
started, no other medications may be added.
d. Gently agitate solution –Do not shake.
7. Set up tubing and pump: Prepare line for infusion.
a. Add o.2 micron filter to tubing
b. Spike solution bag
c. Prime tubing according to manufacture directions.
d. Attach to IV controlled device according to
manufactures directions.
8. Connect tubing to catheter: Decreases potential of introducing pathogens
a. Cleanse catheter port with appropriate antiseptic because there is a greater potential for pathogen
b. Flush infusion device with normal saline growth and contamination as a result of the
c. Secure tubing to device as appropriate or dextrose and protein content of the solution.
recommended by manufacturer. All administration Flushing ensures patency of the line and clears
sets shall be of luer –lock design, including all add any medication from the line.
on devices and tubing junctions.
d. Ensure that all connections are secure.
9. Initiate infusion by setting IV –controlled infusion Ensures accurate delivery of solution.
device to ordered flow are. Start pump

10. Infuse over allocated time period: infusion may be Allows body to metabolizing increasing
started over a longer time (16-18 hours) and amounts of dextrose.
185
 decreased down to 8-10 hours.

11. Gradually increase flow rate of initiation of high Prevents hyperglycemia.

concentration of dextrose and protein.
12. Monitor child regularly during infusion at least Attempts prompt detection of complication.
every hour inpatient facilities and as specified by
health care prescriber at home for
 Metabolic complications; hypoglycemia,
hyperglycemia or electrolyte imbalances, azotemia,
carbon dioxide retention.
 Catheter related problem: breakage, dislodgement,
and occlusion.
 Infection complication: Localized site infection
,sepsis
 Monitor vital signs every 4 hours or as ordered.
13. Monitor blood glucose every 6 hours initially of if The body adapts to high dextrose
signs of hypoglycemic or hyperglycemia are concentrations by producing increasing
present. Contact healthcare prescriber if blood amounts of insulin; when the administration of
glucose is abnormal. the high dextrose concentration is suddenly
interrupted. The child could experience
hypoglycemia episodes because it takes for the
body to react to the change.
14. Decrease infusion rate gradually at end of infusion Enables body to adjust to decreasing dextrose
as ordered. levels, prevents hypoglycemia.
15. Once infusion is complete, turn off pump. Reduces the risk for transmission of pathogens
Disconnect and discard tubing. Cleanse catheter port into the line. Clears line of dextrose solution,
with appropriate antiseptic. Flush catheter with which could potentially cause occlusion or be a
normal saline, amount dependent in child’s and growth medium for bacteria.
catheter size.
16. Dispose of equipment and waste in appropriate Standard precautions .Reduces transmission of
receptacle. Perform hand hygiene. microorganisms.

186
CHILD AND FAMILY EVALUATION AND DOCUMENTATION
 Evaluate child and family understanding of reason for use of parenteral nutrition, lipids and
treatment plan.
 Evaluate family capabilities, if home care is planned.
 Evaluate family understanding of catheter care.
 Document the following: exact solution administered, additives, amounts and duration, with time and
date infusion started, completed and by whom; observations of line ;any complications that occurred
,any side effects, and when health care prescriber was notified.

187
 BREAST FEEDING COUNSELING
The primary aim of the breastfeeding counselor is to enable a mother to breastfeed successfully for
as long as she and the baby want. This may seem to be a simple statement, but hidden in it are quite a
few assumptions and implications.
In particular, what does "successfully" mean? Who defines it? The mother? The counselor? A health
worker? And what about "as long as she and the baby want"? Does the mother really know how long
she wants to feed? Does the baby—and if so, how can the mother tell?
Finally, there may be conflicts arising from the above. Perhaps she wants to give up breastfeeding
but her toddler wants to continue. Perhaps she and her partner disagree about breastfeeding. Perhaps
she has conflicting desires within herself. How can the counselor enable the mother to come to a
decision in such cases?
In the course of her work, a breastfeeding counselor will need to use a number of different strategies.
Two of the most important are information giving and non-directive counseling.
The skill of the counselor lies in knowing when each is appropriate as well as knowing how to give
information or how to counsel. Much of this skill can only be obtained with experience, but this
booklet will help you to appreciate some of the issues involved.
The breastfeeding counseling should be done before discharge;
It can be done in as follows
 A-Ask
 L- Listen
 P –Praise
 A-Advice
 C-Check understanding
A-Ask:
In this counselor will ask and assess the knowledge of the mother. That how much she knows about
breastfeeding. What problem she is facing while feeding the child, whether she is feeding in correct position
or not, Burping in done or not, about exclusive breastfeeding.
L- Listen
In listen-mother will express her problem what she is facing during breastfeeding. And also tell about her
knowledge deficit. So, it is very important to listen her problem.
Active listening requires a commitment on the part of the listener. It is not easy, and cannot be
undertaken when you are distressed or preoccupied yourself. Listening requires that you open yourself to the
intrusions of another. There are five requirements for active listening:

188
  A willingness to give your attention to another person.
 An openness to perceive the other’s feelings and values.
 A readiness to suspend judgment and evaluation.
 A patience to wait for the other’s own expression of her thoughts and feelings.
 A desire for empathy which tries to experience the world as the other experiences it
Without these qualities, your ability to listen will be impaired. Assuming that you have them,
or want to develop them, there are some practical steps which can be undertaken in order to develop
your listening skills:
Listen with undivided attention: Listening itself is easy. The problem lies in trying not to think about
a dozen other things as well. Our natural temptation is to be aware of what else is going on in the
room, or the fact that you’ve got a headache, or even what to cook for supper tonight.
It takes practice and conscious effort to give all your attention to what is being said without
wandering off on your own private journeys. For example:"My husband says that it’ll be easier if I
bottle feed—what with going back to work and all. I’m sure he’s right, it will mean no more sore
nipples, and after all we do need the money.
"This mother is telling you that bottle feeding is best for her and her husband because it will ‘cure’
her sore nipples and make it easier to go back to work. But perhaps she’s also expressing some
feelings about the decision. Did she make it, or did he—the phrase "I’m sure he’s right" make
actually be expressing the exact opposite of what it says. She may also have some reservations about
going back to work. They need the money, perhaps, but does she really want to go back—the phrase
"after all we do need the money" might indicate this.
P –Praise
In the praising, counselor has to praise the positive aspects of the mother towards breastfeeding knowledge
or what she is doing.

A-Advice
In advice counselor has to advice to the mother what she not knowing. For example if breast feeding
position is not known, showing how to hold baby during breastfeeding, advising about to see the signs of
effective suckling. Also, explain the importance of exclusive breastfeeding. Tell her also disadvantage of
artificial feeding.

C-Check understanding
At last check mother whether she has understand or not what has been advised to her. Tell her to show how
to hold the baby during feeding. How to see whether baby is sucking effectively or not.

189
 AXILLARY TEMPERATURE
Temperature is measures to assess the baseline status of each child with in the first hour of admission
and to detect change in child’s status. (e.g. hypothermia ,presence of infection, or other changes in the child
‘s condition. Newborn babies grow better if their core body temperature stays in normal range (36.5-37.5o
C).Arise or drop in body temperature increases the metabolism resulting in both calorie and oxygen
consumption.
Temperature measurement is a very important part of monitoring of a neonate. A variety of devices are
available for measuring the temperature of a newborn and these use different principles to arrive at the
temperature value. Temperature monitoring can be intermittent or continuous, and based on this, the
instruments used also vary.

EQUIPMENT
(Measuring axillary temperature using an electronic/Mercury thermometer)
 Thermometer
 Cotton/towel (for wiping axilla)
 Bowel with Spirit swab
 Gloves

CHILD AND FAMILY ASSESSMENT AND PREPARATION

 Explain to child and family in developmentally appropriate language.(e.g.; “I m going to see how
warm yours body is”),the reason for measuring temperature equipment being used, and how
temperature will be assessed.
 Show child and family equipment you will use.
 Demonstrate on parent (or self) how equipment used.

PROCEDURE
STEPS RATIONALE
1. Perform hand hygiene. Reduces transmission of microorganisms

2. Wipe the axilla or groin with cotton. Shake To make it wipe free from moisture.
down the thermometer down to lower
mercury level.

190
3. Shake down the thermometer. (if using  Down to lower mercury level.
mercury thermometer ) or Remove probe  Indicates that unit is ready for
from holder and note display that use.(digital thermometer )
thermometer is charged
4. Place covered probe in child’s axilla and Positions probe correctly for accurate
holds child’s arm firmly to child’s measurement of body temperature
side.(digital ) Place the bulb of the
thermometer in hollow of axilla or groin with
the stem pointing towards the patient’s chest
or abdomen .bring his arm ,across the chest so
that bulb is in constant touch with skin
surface. If groin temperature is being taken,
flex hip and support it .allow the thermometer
to remain in place for 3minutes.

5. Note temperature when digital display has Ensures that unit will be charged for the next
stabilized and unit emits tone; Note whether use.
measured in Celsius or Fahrenheit in mercury
thermometer.
6. Shake down the mercury thermometer to
below 95 oF, after reading and off the digital
thermometer.
7. Clean the thermometer with spirit swab or Ensures that until will be charged for the next
with disinfection from stem to bulb in use.
rotating motion. Place the thermometer back
to container.
8. Perform hand hygiene. Reduces transmission of microorganisms.

191
9. Do documentation.

CHILD AND FAMILY EVALUATION AND DOCUMENTATION

 If temperature is outside of normal range, note environmental factors; ambient temperature, layers of
clothing, and activity level. Note child’s hydration level, level of consciousness and response to
environment.
 Re-measure temperature if reading is widely out of range or inconsistent with previous measurements.
 Document the following: temperature, route and time obtained; interventions implemented to alter
temperature and child’s response to these.

192
 KANGAROO MOTHER CARE (KMC)
Kangaroo Mother Care (KMC) is a special way of caring of low birth weight babies. It fosters their
health and well being by promoting effective thermal control, breastfeeding, infection prevention and
bonding.
In KMC, the baby is continuously kept in skin-to-skin contact by the mother and breastfed
exclusively to the utmost extent, KMC is initiated in the hospital and continued at home.

DEFINITION
Kangaroo Mother Care (KMC) is a method of caring for newborns infants. In this method the infants is
placed between the mothers breasts in direct skin to skin contact.

COMPONENTS OF KMC ARE:

 Skin-to-skin contact

Early, continuous and prolonged skin-to-skin contact between the mother and her baby is the basic
component of KMC. The infant is placed on her mother's chest between the breasts.

 Exclusive breastfeeding
The baby on KMC is breastfed exclusively. Skin to-skin contact promotes lactation and facilitates the
feeding interaction.

193
 Support to the mother in hospital and at home
A mother cannot successfully provide KMC all alone. She would require counseling along with
supervision from care-providers, and assistance and cooperation from her family members.
 Early discharge &Post-discharge follow up
Early discharge: Studies have shown that KMC cared LBW infants could be discharged from the hospital
earlier than the conventionally managed babies. The babies gained more weight on KMC than on
conventional care.
Less morbidity: Babies receiving KMC have more regular breathing and less predisposition to apnea.KMC
protects against nosocomial infections. Even after discharge from the hospital, the morbidity amongst babies
managed by KMC is less. KMC is associated with reduced incidence of severe illness including pneumonia
during infancy.
KMC is continued at home after early discharge from the hospital. A regular follow up and access to
health providers for solving problem are crucial to ensure safe and successful KMC at home.

BENEFITS OF KMC
Breastfeeding: Studies have revealed that KMC results in increased breastfeeding rates as well as increased
duration of breastfeeding. Even when initiated late and for a limited time during day and night, KMC has
been shown to exert a beneficial effect on breastfeeding.

Thermal control: Prolonged skin-to-skin contact between the mother and her preterm/ LBW infant provides
effective thermal control with a reduced risk of hypothermia. For stable babies, KMC is at least equivalent
to conventional care with incubators in terms of safety and thermal protection.

Other effects: KMC helps both infants and parents. Mothers are less stressed during kangaroo care as
compared with a baby kept in incubator. Mothers prefer skin-to-skin contact to conventional care. They
report a stronger bonding with the baby, increased confidence, and a deep satisfaction that they were able to
do something special for their babies. Fathers felt more relaxed, comfortable and better bonded while
providing kangaroo care.

ELIGIBILITY CRITERIA
BABY
All stable LBW babies are eligible for KMC. However, very sick babies needing special care should be
cared under radiant warmer initially. KMC should be started after the baby is hemo -dynamically stable.
Guidelines for practicing
194
KMC INCLUDE:
 Birth weight >1800 g : These babies are generally stable at birth. Therefore, in most of them KMC can
be initiated soon after birth.
• Once KMC is implemented, nurses and other staff appreciate KMC because of the health benefits to
the babies and the satisfaction expressed by the mothers.
• KMC does not require extra staff.

 Birth weight 1200-1799 g : Many babies of this group have significant problems in neonatal period. It
might take a few days before KMC can be initiated. If such a baby is born in a place where neonatal care
services are inadequate, he should be transferred to a proper facility immediately after birth, along with
the mother/ family member. He should be transferred to a referral hospital after initial stabilization and
appropriate management, one of the best ways of transporting small babies is by keeping them in
continuous skin-to-skin contact with the mother / family member during transport.

 Birth weight <1200 g : Frequently, these babies develop serious prematurity-related morbidity often
starting soon after birth. They benefit the most from in-utero transfer to the institutions with neonatal
intensive care facilities. It may take days to weeks before baby's condition allows initiation of KMC.

MOTHER
All mothers can provide KMC, irrespective of age, parity, education, culture and religion. The
following points must be taken into consideration when counseling on KMC:
i. Willingness: The mother must be willing to provide KMC. Healthcare providers should counsel and
motivate her. Once the mother realizes the benefits of KMC for her baby, she will learn and
undertake KMC.

ii. General health and nutrition: The mother should be free from serious illness to be able to provide
KMC. She should receive adequate diet and supplements recommended by her physician.
iii. Hygiene: The mother should maintain good hygiene: daily bath/sponge, change of clothes, hand
washing, short and clean finger nails.

iv. Supportive family: Apart from supporting the mother, family members should also be
A. encouraged to provide KMC when mother wishes to take rest. Mother would need families
B. cooperation to deal with her conventional responsibilities of household chores till the baby
C. requires KMC.

195
 v. Supportive community: Community awareness about the benefits should be created. This is
particularly important when there are social, economic or family constraints.
D. KMC can be initiated in a baby who is otherwise stable but may still be on intravenous fluids, tube
feeding and/or oxygen.

PREPARING FOR KMC

Counseling: When baby is ready for KMC, arrange a time that is convenient to the mother and her baby.
The first few sessions are important and require extended interaction. Demonstrate to her the KMC
procedure in a caring, gentle manner and with patience.

.
Answer her queries and allay her anxieties. Encourage her to bring her mother/mother in law, husband or
any other member of the family. It helps in building positive attitude of the family and ensuring family
support to the mother which is particularly crucial for post-discharge home-based KMC. It is helpful that the
mother starting KMC interacts with someone already practicing KMC for her baby.

Mother's clothing
KMC can be provided using any front-open, light dress as per the local culture. KMC works well with
blouse and sari, gown or shawl. Suitable apparel that can retain the baby for extended period of time can be
adapted locally.

196
Baby's clothing
Baby is dressed with cap, socks, nappy, and front-open sleeveless shirt or 'jhabala'.

THE KMC PROCEDURE: KANGAROO POSITIONING

• The baby should be placed between the mother's breasts in an upright position.
• The head should be turned to one side and in a slightly extended position. This slightly extended head
position keeps the airway open and allows eye to eye contact between the mother and her baby.
• The hips should be flexed and abducted in a "frog" position; the arms should also be flexed.
• Baby's abdomen should be at the level of the mother's epigastrium. Mother's breathing stimulates the baby,
thus reducing the occurrence of apnea.
• Support the baby’s bottom with a sling/binder.

MONITORING
• Babies receiving KMC should be monitored carefully especially during the initial stages.
• Nursing staff should make sure that baby’s neck position is neither too flexed nor too extended, airway
is clear, breathing is regular, color is pink and baby is maintaining temperature.
• Mother should be involved in observing the baby during KMC so that she herself can continue
monitoring at home.
• Feeding
• The mother should be explained how to breastfeed while the baby is in KMC position. Holding the
baby near the breast stimulates milk production. She may express milk while the baby is still in KMC
position. The baby could be fed with paladai, spoon or tube, depending on the condition of the baby.

197
PRIVACY
KMC unavoidably requires some exposure on the part of the mother. This can make her nervous and could
be de-motivating. The staff must respect mother's sensitivities in this regard and ensure culturally acceptable
privacy standards in the nursery and the wards where KMC is practiced.
Ensure that baby's
 Neck is not too flexed or too extended,
 Breathing is normal, and
 Feet and hands are warm.
 Baby upright between mother’s breasts

TIME OF INITIATION
KMC can be started as soon as the baby is stable. Babies with severe illnesses or requiring special treatment
should be managed according to the unit protocol. Short KMC sessions can be initiated during recovery with
ongoing medical treatment (IV fluids, oxygen therapy). KMC can be provided while the baby is being fed
via Or gastric tube or on oxygen therapy.

DURATION OF KMC
• Skin-to-skin contact should start gradually in the nursery, with a smooth transition from conventional care
to continuous KMC.
• Sessions that last less than one hour should be avoided because frequent handling may be stressful for the
baby.
• The length of skin-to-skin contacts should be gradually increased up to 24 hours a day, interrupted only for
changing diapers.
• When the baby does not require intensive care, she should be transferred to the post-natal ward where
KMC should be continued. The mother continues KMC during sleep and resting. A comfortable chair with
adjustable back may be useful to provide KMC during sleep and rest.
 In the KMC ward or at home, the mother can sleep with the baby in kangaroo position in a reclined
or semi recumbent position, about 15 -30o °s from above the ground. This can be achieved with an
adjustable bed, if available, or with several pillows on an ordinary bed.

198
 It has been observed that this position may decrease the risk of apnea in a baby. A supporting
garment to carry the baby in kangaroo position will allow the mother or the father or the relatives to sleep
even with the baby in the kangaroo position. When the mother and the baby are well adapted to KMC they
can be discharged from the hospital. When mother is not available, other family member such as
grandmother, father or other relative can provide
From hospital to home
Criteria to transfer the baby from nursery to the ward Standard criteria of the unit for transferring baby from
the nursery to the post-natal ward should be as follows:-
• Stable baby
• Gaining weight
• Mother confident to look after the baby

DISCHARGE CRITERIA
The standard policy of the unit for discharge from the hospital should be followed. Generally the following
criterion is accepted at most centers:
• Baby's general health is good and no evidence of infection
• Feeding well and receiving exclusively or predominantly breast milk.
• Gaining weight (at least 15-20 gm/kg/day for at least three consecutive days)
• Maintaining body temperature satisfactorily for at least three consecutive days in room temperature.
• The mother and family members are confident to take care of the baby in KMC and should be asked to
come for follow-up visits regularly.

WHEN SHOULD KMC BE DISCONTINUED?

When the mother and baby are comfortable, KMC is continued for as long as possible, at the
institution & then at home. Often this is desirable until the baby's gestation reaches term or the weight is
around 2500 g. She starts wriggling to show that she is uncomfortable, pulls her limbs out, cries and fusses
every time the mother tries to put her back skin to skin. This is the time to wean the baby from KMC.
Mothers can provide skin to skin contact occasionally after giving the baby a bath and during cold nights.

POST-DISCHARGE FOLLOW UP
Close follow up is a fundamental pre-requisite of KMC practice. Although each unit should
formulate its own policy of follow up. In general, a baby is followed once or twice a week till

199
 37-40 weeks of gestation or till the bay reaches 2.5-3 kg of weight. (Smaller the baby at
discharge, the earlier and more frequent follow-up visits should be).
Thereafter, a follow up once in 2-4 weeks may be enough till 3 months of post-conceptional
age. Later the baby should be seen at an interval of 1-2 months during first year of life. The
baby should gain adequate weight (15-20 gm/kg/day up to 40 weeks of post-conceptional age
and 10 gm/kg/ day subsequently). More frequent visits should be made if the baby is not
growing well or his condition demands.
SUMMARY
Kangaroo Mother Care (KMC) is a special way of caring of low birth weight babies. It fosters their
health and well being by promoting effective thermal control, breastfeeding, infection prevention and
bonding. In KMC, the baby is continuously kept in skin-to-skin contact by the mother and breastfed
exclusively to the utmost extent, KMC is initiated in the hospital and continued at home.

200
 USE OF RADIANT WARMER
Maintaining a stable body temperature is essential to ensure optimal growth. If temperature is
maintained, caloric expenditure and oxygen consumption would be minimal.
Newborn babies, in particular, the preterm and low birth weight are exquisitely predisposed to
hypothermia. No other equipment is identified more than the special care of newborn babies than the
radiant warmers.
Radiant warmers provide intense source of radiant heat energy. They also reduce the conductive heat
losses by providing a warm microenvironment surrounding the baby. The radiant warmer also called
open care system.
The overheated quartz heating element produces heat which is reflected by parabolic reflector on to
the baby on the bassinet. The quantity of heat produced is displayed in the heater output display
panel.
Temperature selection knobs select the desired skin temperature. This information is processed by
the microprocessor inside the control panel and matched against the actual temperature of the baby.
If the temperature of the bay is lower than the set temperature, the microprocessor will send feedback
to the quartz rod heater to increase the heat output till the bay’s temperature reaches the set
temperature. At this point, the heater output will reduced. This is system in which the heater output.
This system in which the heater output is determined automatically based on skin temperature
information is called servo system.
Servo system is the preferred method of running the open care system. The heat output from the
quartz heating rod could also be increased or decreased manually. This is done by the heater output
control knobs. This is called the manual mode of operation.
In the servo mode, whenever the baby’s temperature rises by more than 0.5oC above the set
temperature, a visual /audible alarm is activated. Caregiver must pay attention to sort out the fault.
Often this occurs when the temperature probe comes off the baby’s skin.

PARTS OF OPEN CARE SYSTEM

 Bassinet –For placing the neonate
 Quartz rod –Provides radiant heat
 Skin probe –When attached to the baby’s skin,
displays skin temperature
 Control panel –Has a collection of display and
control features /knobs.

201
  Heater output display –Indicates how much the
heater output is.
 Heater output control knobs –For increasing or
decreasing the heater output manually.
 Temperature selection panel – Select either set
temperature or skin temperature.
 Temperature selection knobs- Select a desired
set temperature.
 Temperature display – Display temperature as
selected, either of the baby’s skin (via skin
probe) or the set temperature.
 Mode selector –Selects manual or servo mode.

EQUIPMENT
 Radiant warmer
 Servo temperature probe

CHILD AND FAMILY ASSESSMENT AND PREPARATION

 Assess child’s clinical history and related symptoms to determine reasons for hypothermia
 Injury to or disease of the hypothalamus or pituitary gland, which can produce changes in the child’s
ability to thermo-regulate.
 Lack of clothing or covers.
 Cold environment
 Diagnosis related
 Dehydration
 Hypoglycemia
 Sepsis
 Wet linen covers
 Pooling of secretion under the body
 Ventilation with cold , dry oxygen and starvation
 Explain to the child and parents what you will be doing to moderate or alter the child’s and parents what
you will be doing to moderate or alter the child’s temperature and make the child more comfortable.
 Encourage parents to be parent in the room and to participate in measures to warm the child.

202
PROCEDURE

STEPS RATIONALE
Pre-interventional measures
1. Perform hand hygiene and gather the Reduces the transmission of microorganisms.
necessary supplies to assess child’s Promotes efficient time management and provide an
temperature. organized approach to the procedure.
2. Determine child’s temperature, compare with Evaluates ° of hypothermia. Signs of hypothermia
normal temperature and observe the child for include pallor, acrocyanosis or central cyanosis,
clinical manifestation of hypothermia. mottling of the skin and signs of respiratory distress.
Consistently cold stressed neonates exhibit poor
weight gain, metabolic acidosis, apnea and
bradycardia.
3. Notify physician /nurse practitioner of child’s Alters physician order, laboratory tests to determine
temperature and if there is evidence of causative agent. Orders for implementing warming
dehydration, hypoglycemia or diagnosis – measures can also be acquired at this time.
related condition that would impact
thermoregulation.
4. Select intervention method to warm the child. Prevents hypothermia, which can increase oxygen
Gather needed equipment to proceed with consumption and cause respiratory distress.
intervention measures. Follow manufactures Warming measures are selected based on Childs
instructions for prewarming selected temperature, age, diagnosis, health care setting
equipment (e.g.: radiant warmer) (emergency department, intensive care unit) and
resources available.
5. Perform hand hygiene before initiating Reduces transmission of microorganisms when
interventions with the child. initiating contact with the child.

Basic warming measures

1. Provide adequate or extra clothing and Decreases heat loss.
blanket to the child. Store blanket and
clothing in a warm place before use.
2. Cover the infant’s head with a head covering The infants head represents a large percentage of the
203
 and feet with socks or booties. Cover the body surface area. Heat can be last rapidly when the
child’s feet with socks or slippers. heat remains uncovered.
3. Ensure that the crib or bed is placed away Prevents loss of heat by convection and radiation.
from window or ventilation systems.
4. Encourage parents to provide kangaroo care Skin to skin contact has demonstrated effectiveness
to the infant and if desired assist them with in stabilizing and often raising the temperature of
this. infants.
USE OF RADIANT WARMER
1. Place the under a prewarmed radiant warmer. Radiant warmers provide heat by an infrared energy
source. Prewarming decreases the heat loss from
conduction from the mattress.
2. Place servo temperature probe on the infant, Servo temperature probe allow monitoring
ensuring that the infant is not lying on the temperature without disturbing the infant and
probe/probe wires. monitoring the trend temperature. Probes provide
more accurate measures of body temperature.

3. Verify probe temperature with electronic or Correlates temperature to ensure accuracy because
mercury thermometer every 2-4 hours as probe temperature will also control the environment
needed. temperatures.
4. Change temperature probe site every 12-24 Probe electrodes can dry out and thus not adhere to
hours or whenever the infant is repositioned the skin well. Poor skin adherence may alter probe
in a manner the results in the infant lying on reading. Accidental dislodgement can lead to
the probe. overheating.
5. Minimize the number of entries into the Entering the warmer changes the ambient

204
 warmers. temperature of the environment.

Radiant warmer should be used in the servo control mode with the abdominal skin temperature
maintained at 36.2oC -370C depending on the birth weight of the baby as shown below
Birth weight (kg) Set temperature( OC)
Less than 1.0 370C
1.0-1.5 36.8oC
1.5-2.0 36.6oC
2.0-2.5 36.4oC
Greater than 2.5 36.2oC

APPLICATION OF SKIN PROBE

Do’s
1. Prepare the skin using an alcohol/spirit swab to ensure good adhesion to the skin.
2. Apply probe over the right hypochondrium area in the supine position.
3. Apply probe in to the flank in the probe position.
4. Check sensor probe regularly so as to ensure that it is in place. Ensure that skin probe is free of contact
with bed.
5. Cover probe with a reflective cover pad, If available (foil covered foam adhesive pad )

Don’t
2. Do not apply to bruised skin.
3. Do not apply clear plastic dressing over probe.
4. Do not use fingernails to remove skin surface probes.
5. Do not reuse disposable probes.

Use of cling warp to decrease insensible water loss

Use of cling warp (transparent polythene used for covering fruits or vegetable for storage ) over the baby,
tied across the panels of warmer ,has been shown to reduce insensible water losses and result in better
thermal control for VLBW (<1.5 kg ) babies.

USEFUL TIPS FOR USE OF RADIANT WARMERS

 Do not use the warmer in a cold room. It works best when the environmental temperature is above 20Oc.
205
 Keeping the warmer where there is lot of air current’s reduces its efficiency.
 The warmer must be pre-warmed around 20 minutes before the arrival of the bay or till the set
temperature is reached with less than 50% of total heater output.
 While using the manual mode in a warmer without a temperature display, record the baby’s temperature
regularly, preferably 2 hourly.
 Train the junior nurses about the proper use of servo and manual modes.
 The manual mode is used for initial preparation of bed for the baby or when rapid warming of severely
hypothermic baby has to be done. However, this may be hazardous as babies may become overheated.
Except in the continuous presence of a nurse who is watching the skin temperature, it is preferable to use
the skin probe with the warmer on servo mode.

CHILD AND FAMILY EVALUATION AND DOCUMENTATION

 Compare child’s temperature with previous readings.
 Evaluate child’s response to warming measures.
 Evaluates parents understanding of methods used to monitor and maintain infant temperature.
 Notify healthcare prescriber if the infant temperature does not maintain stability in response to the
measures used.
 Document the following
 Temperature, route obtained, and device used .include manual readings and readings from warming
device (e.g.: Servo control on radiant warmer.
 Interventions implemented to maintain temperature.
 Child’s response to interventions.
 The set point of radiant warmer temperature, incubator.
 Education provide to the family.
 Family participation in child’s age.
Document that physician was notified of child’s condition and chart specific orders given and completed
at that time.

206
 INCUBATOR
Incubators are useful to keep the baby warm provide isolation, reduce handling, administer oxygen
and increase humidity to reduce evaporative skin losses. When preterm baby is thermodynamically stable, is
best nursed in an incubator.

 Incubator can be used on air mode or manual mode and servo controlled or skin –temperature control
mode. In air mode, desired temperature around the baby is set and the heater output adjusts itself to
maintain it.
 The appropriate set temperature is decided by using the thermo neutral temperature charts based on
gestation and postnatal age of the baby. When ambient temperature is maintained in the thermo neutral
range, the oxygen and caloric consumption of the baby is lowest with enhanced survival.
 The air temperature sensing probe is placed near the baby and care is taken to ensure that it is not
displaced or covered.
 In servo-controlled mode or skin temperature control, skin sensor is attached firmly over the anterior
abdominal wall and set to 36.5 0C.The feedback mechanism heater output to keep the body temperature
of the baby constant. When using servo-controlled mode, care should be taken to ensure that skin probe
does not get dislodged which may lead to dangerous over heating of the baby.
 The baby in the incubator should be preferably nursed clothed and with a cap, mittens and blanket.
 Incubator should not be placed parallel to wall as it hamper air circulation. Double walled incubators (or
baby can be enclosed in a Perspex dome shield) are preferred due to less radiation and convection heat
losses.
 Humidification reduces insensible water losses but is associated with increased risk of nosocomial
infection with pseudomonas and klebsilla. Humidification is mandatory in babies weighing less than 1.0
kg. Humidification chamber is filled with sterile water and 1-2 ml of glacial acetic acid or vinegar is
added to reduce colonization with bacteria. Humidification water must be changes daily.

207
 Baby in the incubator should be nursed through portholes without opening the front panel. Babies on
warmer or in incubators with skin probes, need to have their axillary temperature checked with a clinical
thermometer every 2-4 hours to ensure that it is maintained between 36.5-37 °C. Wide fluctuations in
skin temperature suggest that baby is unstable or ill.
 Incubators and warmers should be maintained in working condition and calibrated every by 4-6 month
by biomedical engineer.
 Strict asepsis should be ensured by proper housekeeping maintenance and cleaning schedule followed by
the nurse. Air filter of the incubator should be changed every 3 month because when there is dirt, it
reduced entry of oxygen and increased buildup of carbon dioxide inside the incubator. The sleeves of
accesses window should be changed daily and washed. Incubator canopy should not be cleaned with
alcohol due to risk of making foggy and opaque.

DISADVANTAGES/RISKS
 Baby can become hyperthermic or hypothermic if temperature is not monitored.
 Baby can become dehydrated.
 Incubator is easily colonized by bacteria.
 Incubator is expensive to buy and maintain.
 Incubator requires reliable source of electricity.
 Personnel trained to care for baby and clean and maintain incubator care required.
 Mother and baby are separated.
 Incubator is more difficult to clean than radiant warmer.

RECOMMENDED INCUBATOR TEMPERATURE

Weight of baby Incubator temperature by age *
35 o C 34 o C 33 o C 32 o C
Less than 1.5 kg 1 to 10 days 11 days to 3 3 to 5 weeks old More than 5 weeks old
old weeks old
1.5 kg to 1.0 kg 1 to 10 days 11 days to 4 weeks old More than 4 weeks old
old
2.1 kg to 2.5 kg 1 to2 days old 3 days to 3 weeks old More than 3 weeks old
More than 2.5 1 to 2 days old More than 2 weeks old
kg
*If incubator is single walled, increase the incubator temperature 1oc for every 7oc difference in
temperature between the room and the incubator.

208
 MANAGEMENT OF THERMOREGULATION & CONTROL
NEWBORN THERMOREGULATION
Thermoregulation is a very important aspect of neonatal care. Those less stable to tolerate
hypothermia include the preterm and/or growth restricted infant and the infant with asphyxia or respiratory
difficulties.

THE NEWBORN HAS SPECIAL REQUIREMENTS FOR TEMPERATURE MAINTENANCE

DUE TO:
1. Larger body surface area in relation to body weight.
2. Blood vessels relatively close to the skin surface.
3. Less adipose tissue and subcutaneous fat
4. Underdeveloped sweating and shivering mechanisms.
5. Increased metabolic processes (non-shivering thermogenesis) produce heat beyond basal production.
6. Heat production consumes a large number of calories.

ALL INFANTS ARE AT RISK INCLUDING:

 Term newborns, especially during the first 12 hours of life
 Near term infants (34 to 37 weeks gestation)
 Preterm infants
 Small for gestational age infants
 Environmental causes (e.g. overheating)
 Infection
 Dehydration
 Medication effects and drug withdrawal
 Infants with disorders of the endocrine, neurologic or cardiorespiratory problems
 Infants with congenital anomalies
 Hypoglycemic infants infant with asphyxia
 Maternal fever during labor
 Maternal hypothyroidism
 Fetal stress manifested as decelerations, meconium-stained fluid, or low apgar scores may indicate
infant is at risk for impairment of thermoregulatory response.

209
MECHANISMS OF HEAT LOSS AND PREVENTIVE MEASURES
The classic modes of heat loss affecting the newborn are conduction, convection, radiation and
evaporation. The disproportionate ratio of surface area to body weight (SA/BW) of the premature infant is
the basis of inefficient heat conservation, combined with a blunted metabolic response. Hypothermia leads
to hypoxemia, acidosis, hypoglycemia, kernicterus and other lethal complications. Mistakes are common.
Attention to minute details is required for stabilization of body temperature at the "neutral temperature zone"
in delivery room, nursery and in transport.

1. Evaporation
• Loss of heat when water evaporates from the skin and respiratory tract
• Highest immediately after birth and with bathing
• Dry baby quickly and remove wet towels/blankets
• Humidify 02

2. Convection
• Heat lost to surrounding moving air
• Depends on difference in air temperature, speed of movement of the air, and amount of skin exposure.
• Cover baby’s head
• Dress baby
• Keep out of drafts
• Warm 02
• Raise surrounding (ambient) temperature

3. Radiation
• Heat lost to surrounding colder solid objects (not in direct contact) independent of air temperature
• Keep incubator, warmer, cot away from outside walls and windows
• Dress baby
210
• Use double walled incubator or Plexiglas heat shield in the incubator
• For infants with temperature control problems, cover three sides of the incubator with aluminum foil
(shiny side in)

4. Conduction
• Heat loss to cold solid objects in direct contact
• Baby will gain heat if placed on warm surface
• Pre-warm incubator/radiant warmer to ensure warm mattress
• Cover x-ray plates and scales
• Pre-warm hands, stethoscopes, blankets and other equipment defends against Cold Stress.
The temperature range in which the basal metabolic rate of the baby is at minimum, oxygen
utilization is least and bay thrives well is known as ‘thermoregulation range of temperature’ or neutral
thermal environment. For each baby, this range of temperature varies depending on weight and postnatal
age.

Normal temperature 36.5 -37 0C

Mild hypothermia (cold stress ) < 36.5 -36 0C
Moderate hypothermia < 36.0 -32 0C
Severe hypothermia <320C

DEFENCES AGAINST COLD STRESS

1. Flexed Position of Healthy Term Infant
• The flaccid/exposed position of the ill/premature baby promotes heat loss

2. Brown Adipose Tissue

• Deposited after 28 weeks principally around scapulae, kidneys, adrenals, neck and axilla
• Lipolysis leads to release of heat to the perfusing blood
• Major means of heat production

3. Peripheral Vasoconstriction
* Core temperature drops only when the baby’s effort to maintain temperature production has failed;
therefore, normal infant temperature does not rule out cold stress.
CONSEQUENCES OF COLD STRESS
Increased Metabolic Use of Calories

211
 • Failure to gain weight or weight loss
Increased Oxygen Consumption
• May lead to hypoxia, acidosis and respiratory distress
Rapid Depletion of Glycogen
• Resulting in hypoglycemia. If allowed to continue the baby may develop shock and disseminated
intravascular coagulation (DIC) leading ultimately to death.

PREVENTION OF COLD STRESS

1. Birthing room (operating room for Caesarean birth) and nursery kept at 24-26°C (75-80°F).
2. Quickly dry baby after birth and wrap in prewarmed blankets. Placing the healthy naked term infant
against mother’s naked body and covering both with prewarmed blankets will also prevent heat loss.
3. Cover the newborn’s relatively large head with wool or stockinet hat.
4. Withhold the initial bath until the baby’s temperature has stabilized at 36.3-37.2°C.
5. Tub bath rather than sponge bath.
6. Assess well newborn temperature per axilla with an electronic thermometer hourly until stable, once per
shift for the first day, and then daily until discharge.

HOW CAN HEAT LOSS BE PREVENTED?

Ten commandant of warm chain
 Warm delivery room
 Immediate drying
 Skin-to-skin contact
 Breast-feeding
 Bathing and weighing postponed
 Appropriate clothing and bedding
 Mother and baby together
 Warm transportation
 Warm resuscitation
 Training/awareness raising
 Kangaroo mother care.

SIGNS OF COLD STRESS

 Lethargy
 Feeding intolerance
212
  Respiratory depression
 Acidosis
 Deceptive bright red colour
MANAGEMENT OF COLD INJURY
1. Rewarm Slowly
• To avoid hypotension
• Set incubator temperature/radiant warmer 1-1.5°C warmer than baby and adjust every 15-30 minutes.
2. Undress Baby
• A cold baby or any baby on a radiant warmer should be naked
• A warm baby in an incubator may be dressed
3. NPO
• Intravenous 10% dextrose/water at 80 ml/kg/day
• Monitor blood sugar
4. Supplemental 02 May Be Necessary
• Monitor colour and blood gases as necessary
* The infant should be rewarmed to 36.3 – 37.2°C prior to transport.

HOW CAN YOU PREVENT HEAT LOSS AT THE TIME OF BIRTH?

Drying Wrapping

Skin to skin contact Breast Feeding

213
EQUIPMENT
 Radiant warmer
 Skin probe
 Warm blankets/towels
 Thermometer
 Hat /cap

PROCEDURE (THERMOREGULATION IN NEWBORN IMMEDIATELY AFTER BIRTH )

STEPS RATIONAL
1. Prior to delivery, increase temperature in This prevents heat loss due to convection.
labor room/recovery room to 75ºF.
2. Pre-warm radiant warmer. This prevents heat loss due to conduction.
3. Place warm blankets/towels on radiant This prevents conductive heat loss.
warmer.
4. Place infant skin to skin with mother and Both will provide a heat giving environment.
warm blankets over her or under a radiant
heat source after birth.
5. Dry infant with warm absorbent blankets This prevents evaporative heat loss.
and/or towels, and immediately replace used
blankets and/or towels with new warm ones.
6. Warm hands and stethoscopes before This prevents heat loss due to conduction.
coming in contact with infant.
7. Keep infant away from air conditioning This prevents heat loss from convection
ducts and other drafts and evaporation.
10. Keep oxygen (if used) directly over This prevents heat loss from convection
infant’s nose and mouth. and evaporation.
9. Place a cap on the infant‘s head and This prevents heat loss from evaporation.
change when soiled or wet.
11. Maintain the infant temperature 36.5 – Place infant next to the mother’s skin with warm
37 oC. blanket covering them. If there is inadequate dress the
baby.
12. Assess baby for signs of hypothermia. Sweating is generally present in baby < 36 weeks.

214
 Usually hyperthermic baby are warm to Baby who attempts to decrease their temperature may
touch and exhibit red skin due to be irritable, lethargic, hypotonic, apenic, poorly feed,
vasodilatation related to release of tachycardia, Tachypnea, weak or absent cry.
excess heat.
12. Assess the baby temperature per axilla
every 30 minute for 2 hours after birth x 4.
13. Transfer baby to nursery and report care
provided on thermoregulatory status.

HOW CAN YOU PREVENT HEAT LOSS IN POST-NATAL WARD?

 Ensure that the baby is kept warm with appropriate clothing and skin to skin contact with mother
 Change wet clothing promptly and keep the baby dry
 Cover the baby adequately
 Keep windows closed and fans off
 Continue breast feeding day and night
 Do not bath the baby
WHAT SHOULD BE THE CLOTHING OF NEONATES?
 Full sleeves shirt
 Pajamas
 Cap
 Gloves
 Stockings
 Swaddle in dry sheet
 A neonate without cap. Socks and gloves in half naked
WHEN WOULD YOU BATHE THE NEWBORN BABY?
Warm room; warm water Bath quickly

Dry quickly and thoroughly Dress warmly and wrap

215
Bathing the infant - if his temperature is normal - not before 6 hours after birth (in case of cultural
practices)

HOW CAN YOU PREVENT HEAT LOSS DURING TRANSPORT?

 Inform NICU at least half an hour before the transfer so that the radiant warmer is switched on to
maintain thermo-neutral environment
 Ensure the temperature is maintained before and during transport of the baby
 The simplest and safest way to transport a newborn is by putting the baby in KMC, if possible
 For unstable babies, a transport incubator is preferred.
 If transport incubator is not available, thermocol box or plastic box with holes for air circulation is a
preferred alternative
 When baby is being transported in transport box/thermocol box, check that water filled bags are
warm, not excessively hot (temp  1020 F) and are not in direct contact with the baby
 If baby is on oxygen ensure that it is adequately warm and humidified
 Wrap babies properly including head, body and feet

THERMOREGULATION IN NURSERY

Keeping low birth weight and sick babies warm in maternity unit

216
HOW WOULD YOU TEACH A MOTHER TO KEEP A LOW BIRTH WEIGHT BABY WARM AT
HOME?

WHAT IS HYPOTHERMIA?

WHERE DOES HYPOTHERMIA OCCUR?

217
WHAT ARE THE CLINICAL MANIFESTATIONS OF HYPOTHERMIA
 The baby may be uncomfortable and restless
 Have cold feet, acrocyanosis and poor feeding
 Look sluggish and inactive
 Have poor suckling and weak cry
 In severe hypothermia;
 The baby may become lethargic and develop slow, shallow and irregular breathing and bradycardia.

 Face and extremities become bright red in colour

 Sclerma may occur on back and limbs or over whole body
 The baby may develop Low blood sugar and metabolic acidosis, generalized internal bleeding and
respiratory distress

HOW CAN A HYPOTHERMIC BABY BE REWARMED?

 Make sure the room is warm.
 Remove cold clothes and replace with warm clothes.
 Rewarm quickly by skin to skin contact and/or a heating device such as, radiant heater or incubator.
 Continue breast-feeding.
 Monitor the temperature at regular intervals.
 Assess for infection.

REWARMING WITH A RADIANT WARMER SKIN MODE

 Place under Warmer
 Set Skin Temperature at 370 C
 Monitor Baby’s temperature, color
 Capillary Refill time

218
WHAT ARE THE COMMON CAUSES OF HYPERTHERMIA?

WHAT ARE THE COMMON CAUSES OF HYPERTHERMIA?

 Environment too hot for the baby
 Baby overdressed.
 Putting a newborn baby too close to a fire or heater and hot water bottle
 Leaving a baby in direct sunlight or in a parked car in hot weather;
 Leaving Baby under heating devices i.e. (not functioning properly /checked regularly, or is exposed
to the sun's rays)
 Sepsis

WHAT ARE THE CLINICAL MANIFESTATIONS OF HYPERTHERMIA?

 Initially the newborn is restless and cries, and then gradually it becomes lethargic.
 Rapid breathing,
 The heart rate (if checked) is fast,
 The skin is hot to touch
 Extremities are red (due to vasodilatation)
 Face is flushed.
219
  Increased metabolic rate and the rate of water loss by evaporation,
 Dehydration due to increase water loses.
 In severe hyperthermia, shock, convulsions and coma may occur.
 Neurological damage if temperature rises above 42°C (107.6°F)
HOW WOULD YOU MANAGE HYPERTHERMIA?
 Assess for infection.
 Move baby away from the source of heat and undress.
 Give baby a bath if necessary.
 Give frequent breast-feeds.
 Monitor temperature.
WHAT ARE THE CAUSES OF FEVER?
 Dehydration.
 Raised environmental temperature in association with immaturity of heat regulating centre and
 Inefficiency of sweating mechanism in the newborn.
WHAT IS THE MANAGEMENT OF FEVER?
 Cool the environment
 Provide extra fluids.
 Give hydrotherapy at times for prompt reduction of body temperature.
 There is no therapeutic utility of an antipyretic agent.
TRAINING AND AWARENESS REGARDING THERMOREGULATION
 Risks of hypothermia. Alert health care providers and families to the
 Teach the principles of thermal protection of the newborn.
 Provide on the job training and supervised practice to ensure that the 10 steps of the warm chain
become part of the routine care of the newborn.
 Demonstrate and provide supervised practice on the appropriate use of equipment for low birth
weight/preterm infants.
HOW CAN THERMAL PROTECTION OF THE NEWBORN BE IMPLEMENTED
EFFECTIVELY IN INSTITUTIONS?
 Establish a policy and set standards of practice.
 Assess existing practice, knowledge, skills and attitude of birth attendants.
 Arrange in-service teaching sessions to review/revise theoretical knowledge and/or on-the-job
training.
 Monitor practices.
220
 MEDICATION ADMINISTRATION
As one time or another, every child needs to receive medication. As with adults, pediatric medication
administration is a critical component of safe & effective nursing care. For most drugs, children require
dosage different from those given to adults. An adult’s body handles drugs differently and may respond to
drug differently than an adult. A child’s body may handle a drug differently in all areas of pharmacokinetics-
absorption, distribution, metabolism and excretion.

DIFFERENCES WITH PEDIATRIC PATIENTS:

1. Many variables with infants and children.
2. In neonates there is an absence of hydrochloric acid, which may interfere with absorption of some
medications.
3. If the child is over 2 years old, giving orange juice will provide an acid medium

VARIABLES WITH ORAL MEDICATIONS:

1. Variable weights and differences in body surface area
2. Greater risk for toxic levels which produce untoward effects.
3. More rapid intestinal transit time in children under 5.
4. Less pancreatic enzymes in infants.
5. Immature kidney function in infants

VARIABLES WITH TOPICAL MEDICATIONS

1. Topical medications maybe absorbed and have systemic effects
2. Larger skin surface area increases amount of absorption
3. Plastic diapers can also increase absorption of topical medication applied to the diaper area
4. Hydrocortisone

PARENTAL TEACHING
1. Many times it is the parents who give medications to their children.
2. Our responsibility is to adequately teach them to do so safely.
3. Must be certain they understand the importance of the safe drug and the correct dose given at the
right time.
COMMON MEASURES AND CONVERSIONS
1. Milligrams to grams / grains

221
 2. Dram—5 ml
3. Ounce—30 ml
4. Teaspoon—5 ml

ADMINISTRATION OF ORAL MEDICATIONS

Infants
1. Give with elevated support to head / shoulders.
2. Plastic syringes are good to give accurate amount (Calibrated to the one hundredth)
3. Depress chin with the thumb
4. Give slowly in the side of the mouth
5. Allow time for swallowing

Toddlers
1. Usually helps to have a parent or someone else available
2. Letting child handle the equipment helps reduce some fear
3. Explain why the medication will help
4. Let child hold the medicine cup if he can cooperate
5. Don’t rush the child.

Pre-school
1. May use chewable as well as suspensions or elixir
2. Loose teeth may pose a problem
3. Often can cooperate better with parents.
4. Letting parents give the medications is acceptable, although nurse is still responsible to prepare the drug
and assist parent in giving it.
School – aged Children
1. Usually can take pills and capsules
222
2. Need to be encouraged to swallow water immediately
3. Ability to cooperate may vary and is often unpredictable—be prepared to allow more time in giving
medications to your pediatric patients

Adolescents
1. Should be prepared to give explanations to adolescents specific to level of understanding.
2. Teach therapeutic effects as well as side effects to report
3. Stay with the patient until medications are consumed
4. Expect that there may be mood swings
5. Consider such adolescent issues as drug addictions or use of contraceptives which may cause drug
interactions.
OTHER ROUTES OF ADMINISTRATION

Eye drops or ointment

 Instill in lower conjunctival sac.
 Ointment from inner to outer canthus.

Nose drops
 With head tilted upward
 Maintain position for 1 minute

Ear drops—warm first

 Pull pinna down and back < 3 years
 Massage area in front of ear
 Maintain position with affect ear up 5 minutes

Rectal medications
 Use side lying position
 Insert lubricated suppository up to first knuckle
 Hold buttocks together—1-2 minutes

Intramuscular Medications
 Fewer medications are given by this route due to potential for pain.
 Medications typically given IM
223
 Newborn—Vitamin K
 Immunizations
 At times antibiotics
 Vastus Lateralis muscle for newborns, infants and young children

Intravenous Medication
Benefits:
 Quick response and effectiveness
 Less traumatic than IM

Concerns:
 Extra caution to watch for irritation to small veins
 Extra caution to check for SDR with direct IV route

Intravenous sites
 Scalp veins best for infants & toddlers
 Other sites—hand, foot antecubital fossa
 Infusion control—fluid overload
 Infusion pumps needed
 Volume control drip chamber

224
 INTRAMUSCULAR INJECTION
CLINICAL GUIDELINES
1. A healthcare prescriber orders medications.
2. Medications are administered by a registered nurse (RN), a licensed practical nurse (LPN), or
physician who is knowledgeable about the medication and techniques of administering an
intramuscular injection to a child.
3. Principles of pharmacologic management are followed.
4. Medications are given intramuscularly (TM) for rapid drug absorption because muscle has a rich
blood supply. The IM route is more painful than other routes because muscle has more nerves.
5. Medications are administered through the least traumatic route when possible. Consider
oral or intravenous access, when available or alternative less painful routes over IM administration.
6. Medications are administered within 1 hour of prescribed time.
EQUIPMENT
1. Correct medication
2. Syringe, appropriate size
3. Needle, appropriate gauge and length
4. Non-sterile gloves
5. Alcohol swab
6. Cotton ball or gauze
7. Adhesive bandage
8. Fun bandages (optional)
9. Stickers (optional)

CHILD AND FAMILY ASSESSMENT AND PREPARATION

 Assess the child's previous experience with receiving injections. Prepare the child, as appropriate to
cognitive level and parents for the injection before administration.
 Provide therapeutic play as indicated, or involve -a child life specialist, to allow the child to work
through any fears of injections and master control of the situation.
 Explain the medication's actions and side effects.
 Assess for allergies. If latex allergies are present, implement latex precautions. Notify health-care
prescriber of any drug allergy. Label child's record and apply identification band indicating allergies.
 Assess child's age, muscle mass and other physical limitations that will impact choice of site for IM
injection.

225
 Use a topical anesthetic (e.g., EMLA, LMX4, vapocoolant), when time allows, to reduce pain and
trauma of injection
 Assess the need for restraint and obtain additional help to support the child, as indicated.
 Tell the child that his or her job is to stay as still as possible but that it is okay to yell or cry. Enlist the
child's cooperation by having the child hold the bandage

Site Age Needle Volume Insertion Comments

length (ml) angle (°s)
(inches)
Infant 5/3 0.5 • Recommended by AAP
for infants younger than 7
Toddler 5/8-1 0.5-1 months of age.
LATERALIS

• Relatively free from major

72-90
Preschool-aged 1 1 nerves and blood vessels.
VASTUS

• Muscles easy to identify.

School age 1 1.5-2 • More painful than other
sites.
Infant 5/8 0.5 • Research suggests may be
appropriate site for
Toddler 5/8-1 1 infants.
• Recommended for infants
Preschool-aged 1 1.5 older than 7 months of
VENTROGLUTEAL

72-90,
age.
directed
School age 1-1.5 1.5-2 • Free form major nerves
towards
and blood vessels .less
ileac crest
subcutaneous tissue to that
injection into muscle is
more likely.

Infants not • Muscle mass limited

recommended • Avoid irritating solutions
Toddler 5/8-1 0.5 and repeated injections in
Preschool aged site.
72-90,
School aged 5/8-1 0.5-1 • More rapid medications
pointed
absorptions than gluteal
slightly
regions
towards
• Radial nerve lies under the
DELTOID

acromium
deltoid muscle.
• Site not well developed.
• Should not be used in
children.
Infants Not - Perpendicul • Site not well developed in
DORSOGLU

Toddler recommend ar to the children younger than 5

Preschool aged er surface on years of age
which the • Can accommodate larger
TEAL

School aged ½-1½

child is injection volume than
lying other muscles
226
 • Close to sciatic nerve and
superior gluteal artery.

PROCEDURE

STEPS RATIONAL
1. Verify the order with the medical record. Detects possible transcription errors.
2. Perform hand hygiene. Reduces transmission of microorganisms
3. Obtain medication and read the label to To decrease chance of medication error , patient, route,
verify with the order. Check for expiration dose, frequency and time to be administered must be
date; if expired, do not administer verified each time a medication is given
4 a. Check the amount of medication to be Large volume of medications injected in to a small
administered to determine syringe size and muscle can result in leakage of medication out of the
Appropriateness for the child. Limit volume muscle and muscle atrophy
according to the age of the child and the
size of the muscle used
4 b. Use a low-dose 1-mL syringe to give Ensures dosage accuracy
volumes of less than 0.5ml
6 Choose appropriate needle length for the The needle must be long enough to enter the muscle
site and muscle size. Select gauge based on mass minimizes the injury to the tissue and leakage in to
what is available for the appropriate needle the subcutaneous tissue, larger gauge needles have d
length for the child and medication narrower bore and thus produce a jet under high
viscosity. Usually, a 22- or 23gauge needle pressure, which causes more damage to the tissue.
is appropriate, but viscous medication
requires a larger bore/smaller gouge needle.
6 a. Draw up the medication in the medication The sight of the needle can increase the child's anxiety.
room. Draw up correct amount of Medications must be measured accurately because a
medication into the syringe. small error in amount could in dangerous dosage
6 b. If there is a large volume of medication,
more than one injection may need to be
given
7. Don gloves Standard precaution to reduce transmission of micro-
organisms

227
8. Verify medication with electronic record or Ensures proper identification of the child.
take medication record and syringe with
medication to the child to administer.
Verify the child's identity by comparing
name on medication (if verified
electronically) or on medication record with
child's identification band and any other
patient identifier required by the institution.
9. Evaluate the child's muscle mass and choose Decreases risk for complications associated with giving
the most appropriate site. If multiple IM injections, which may result from inappropriate site
injections are to be given, rotate injection selection. Rotating sites reduces potential of tissue
sites. damage.
10. Position and restrain the child securely. Positioning may help relax the muscles, causing less
pain (e.g., for ventro-gluteal injection, place child on his
or her side with upper leg flexed and over top of lower
leg). Restraint decreases chance of injury from child's
movement; even cooperative children have a tendency to
move during injections.
11 Cleanse the site with alcohol wipe and Decreases microorganisms and minimizes pain at the
allow drying. site of injection.
12 a. Insert the needle quickly ate 72- to 90-° Facilitates needle entry into the muscle. Aspiration
angle. Aspirate to check for blood; if prevents intravenous or intra arterial administration.
present, remove needle, replace with a Slow injection may reduce local damage and pain.
sterile one, and start over. Slowly inject Alcohol over an injection site may sting and prolong
the medication. Withdraw the needle and bleeding Using a new needle avoids medication being
apply pressure over the site with a dry on the outside of the needle and coming in contact
cotton ball or gauze. with tissue as the needle is inserted. Pulling the skin
12 b. To inject using the 7-track method: Use a and sub-
new sterile needle. Pull the skin with your cutaneous layers displaces them out of alignment with
non-dominant hand laterally or downward the underlying muscle to trap the drug in the muscle
away about f inch (1.25 cm) from the after the structures return to their normal position.
injection site; insert the needle into the Aspiration prevents intravenous or intra arterial
muscle at a 90-° angle at the site where administration. Waiting before
you initially placed your finger to displace Withdrawing the needle after injection helps ensure

228
 the skin. Aspirate for blood return; if dispersion of the medication.
blood is aspirated discontinue the
procedure; if no blood appears, inject the
drug slowly. Wait 10 seconds, if possible,
before withdrawing the needle; withdraw
the needle slowly. Release the displaced
skin and subcutaneous tissue to seal the
needle track.
13. Place adhesive bandage over site. Young children may feel that their insides will leak out
the injection site if a bandage is not used.

14. Remove gloves and perform hand hygiene. Reduces transmission of microorganisms.
15. Comfort the child and have the parent Promotes positive relationship and decreases long-
comfort the child after the injection. term negative effects of painful procedures.

16 Return to the room a short time later for Playing or other fun activities will help the child not
positive interaction with the child. Assess for associate the nurse with only painful procedures.
Provides opportunity to further evaluate the child's
signs of adverse reaction to medication.
physical and emotional response to the procedure.

STEPS FOR LOCATING INTRAMUSCULAR INJECTION SITES IN CHILDREN

A) Ventrogluteal- Place your index finger on the anterior superior iliac spine, middle finger on the superior
iliac crest, and your palm on the greater trochanter (use your right hand for the child's left hip and vice
versa). Inject into center of the "V" formed by the index and middle fingers.
B) Vastus lateralis- First, identify the middle third of the femur. Next, identify the area between two
imaginary lines drawn from the greater trochanter to knee-one line midanteriorly and one midlaterally.
Injection site is located between the lines in the middle third of the midlateral anterior thigh. Flexing the
knee may promote relaxation of the muscle.
C) Deltoid- Identify site about two fingerbreadths below acromial process and just above axilla. Inject into
upper third of deltoid muscle.
D) Dorsogluteal- Not recommended in children younger than 5 years of age or those with insufficient
muscle mass. Place child on abdomen and have him or her point the toes inward. Draw an imaginary line

229
 between the posterior superior iliac spine and the greater trochanter. Inject in the upper outer region
above this line into the gluteus medius muscle.

CHILD AND FAMILY EVALUATION AND DOCUMENATTION

 Healthcare provider must monitor child for 15 minutes after IM injection of drugs that may potentially
cause a reaction for side effects or allergic reactions (e.g., respiratory distress).
 Evaluate the child for change in vital signs, hemodynamic status, and other signs as appropriate after
medication administration to assess the effects of the medication.
 Evaluate child's response to the procedure and what comfort techniques were used.
 Evaluate child and family's understanding of medication.
 Determine whether the child and family have additional areas of concern to discuss.
Document the following:-
1. Date and time administered
2. Type of medication
3. Dose
4. Route and site given
5. Adverse effects, if any, and, if so, notification of physician
230
 6. Child's response to and tolerance of procedure
7. Teaching and information given to child and parents

COMMUNITY CARE
 Provide parents instructions about expected response to IM medication administration (e.g., diphtheria,
tetanus, pertussis [DTaP] may cause pain and swelling at the injection site) and self-management
techniques (e.g., acetaminophen).
 If IM medications are to be given in the home, teach the family the following:
- Sites for IM administration
- Method to draw up medication
- Technique to administer medication
- Signs of adverse reaction
- Storage of medication
- Safe storage of supplies (including putting needles and syringes out of reach of small children)
- Safe disposal of needles and syringes
- Name of medical supply vendor to obtain necessary equipment
- Needle disposal container
- Refrigeration (if needed to store medication)
- Healthcare prescriber consent if child is also to be given medication at school
Identify problems that may prevent the child from obtaining the medications (e.g., inability to pay for
medications, lack of transportation to pick them up). Assist family to resolve identified problems or refer to
social services (e.g., apply for public health insurance [Medicaid], identify vendors who deliver).
Ensure that all medications have childproof caps and are kept beyond reach of children.
Advise family members of guidelines regarding when they can still give medication if they forget to give a
dose, to not give two doses together, and to call the physician or pharmacist if they have questions about
dosing.
Encourage selection of medications that can be given in the fewest number of doses per day to
decrease potential of missed doses.
Instruct the family to contact the healthcare provider if
Child develops rash over body
• Child develops fever
• IM site becomes hard, reddened, weeping, or tender to pressure/movement
Child has other reactions during therapy

231
 INTRAVENOUS INJECTION
Medications are administered by a registered nurse (RN) or physician who is knowledgeable about
intravenous medications and techniques of administering intravenous medications to a child, based on the
type of medications and scope of practice as defined. Medications are given by the intravenous route for
rapid absorption when an IV line is in place. the route is less traumatic than other route when an IV line is in
place.
Medications are administered within 1 hour of prescribed time.

EQUIPMENT
1. Existing intravenous access
2. Correct medication
3. Syringe, as needed
4. Needleless access device
5. Alcohol pad or swab
6. Gloves
7. IV tubing with volume-control chamber or piggy back setup
8. IV pump or syringe pump
9. IV tubing cap, as needed to maintain sterility of tubing

FAMILY ASSESSMENT AND PREPARATION

 Assess child's height, weight, age, and hydration status, factors to consider when calculating medication
dosage and fluid requirements.
 Assess child's previous experiences with receiving TV medications.
 Assess child's and parents' understanding of the need for the N medications that will be administered.
 Prepare the child, as appropriate to cognitive level, and parents before medication administration.
Explain the medications actions and side effects.

232
 Utilize therapeutic play, as indicated, to allow the child to work through his or her fears and master
control of the situation.
 When the child has an established intravenous access, intravenous medication is less traumatic than
subcutaneous or intramuscular injection. However, the use of the needle and syringe may create similar
fears for the child; preparation of the child and parents and use of needleless systems may alleviate much
of this
 Assess for allergies. If latex allergies present, implement latex precautions. Notify healthcare prescriber
of drug allergy. Label child's record and apply identification band indicating allergies. Assess existing
vascular access for patency and signs of complications with line (e.g., redness, swelling, fluid leaking
from site indicating phlebitis or infiltration). If line is not patent or signs of complications exist, establish
vascular access before administering medication.

PROCEDURE

STEPS RATIONALE
1 Verify the medication order with the Detects possible transcription errors.
medical record
2. Perform hand hygiene. Reduces transmission of microorganisms.
3. Obtain medication and read the label to To decrease chance of medication error, check patient,
verify with the order. Check for route, dose, frequency, and time to be administered each
expiration date; if expired, do not time a medication is given.
administer.
4. Prepare the medication in the medication The sight of the needle can increase the child's anxiety.
room. Draw up correct amount of Medications must be measured accurately because a
medication into the syringe; reconstitute small error in amount could result in dangerous dosage
powders as indicated. variation.

5. Determine the best method of IV The method of administration is determined by the

administration 'Ica, the medication and volume to be infused, amount of time for infusion,
child. Whatever method is used, the infusion site, and size of the child Medications must be
medication must be completely infused administered within 1 hour to maintain therapeutic drug

233
 within 1 hour unless otherwise specified. levels and to ensure that the medication does not degrade
before administration.
6. Verify the medication with the electronic Ensure proper identification of the child
medication record or take the medication
record and syringe with medication and
any other IV equipment needed (e.g., IV
pump) to the child to administer. Verify
the child's identity by comparing name on
medication (if verified electronically) or
on medication record with child's
identification band and any other patient
identifier required by the institution.
7. Explain to the child and family that you Keeps family members informed of therapy; may help
are going to administer the medication, reduce their anxiety
as previously explained.
8. Verify that IV access is patent and Ensures IV access without infiltration.
without complications (e.g., edema,
redness, tenderness).
9. If the child has an intermittent lock: Reduces transmission of organisms.
a. Cleanse the needleless injection cap with Accesses system.
70% alcohol. Flushes the tubing and verifies IV potency.
b. Insert the syringe with normal saline using Initiates medication infusion
appropriate needleless system adapter.
c. Slowly infuse 1mL of normal saline.
d. Connect medication; follow step 10, 11,
12, or 13 as appropriate for selected
method.
10. For medication administration through Reduces transmission of organisms
IV push: Using the port closest to the insertion site allows
a. Cleanse the top of the needleless injection medication to be administered in the proper amount of
cap with 70% alcohol. . time. Using a site high up on the IV tubing may result in
b. Insert the syringe with medication, using the infusion taking place an hour or more later for a
appropriate needleless system adapter if slowly infusing IV.
required, into the port closest to the IV Injecting the medication slowly reduces pain and

234
 insertion site. decreases adverse reactions
c. Inject the medication slowly over the time
specified.
11.For medication administration through a Medication that is too concentrated may damage the
volume-control chamber vein and increase pain during
a. Fill the container using fluid from hanging infusion, Mixture of incompatible medications and IV
IV bag, with amount of fluid required for solutions may result in a precipitate forming. When
dilution; calculate in the fluid volume of calculating dilution amounts, consider the child's 24-
medication itself (e.g., if medication is to hour requirements, fluid status, hourly rate, number of
be diluted in 50 ml and was dispensed in other medications, and flushes required; use the
5 ml, add 45 ml of IV fluid to volume- minimum amount of fluid for dilution in children at risk
control chamber). for fluid volume overload.
Reduces transmission of organisms.
b. Cleanse the diaphragm used for Makes medication available for infusion.
medication administration located on the
top of the chamber with 70% alcohol.
c. Inject the medication into the chamber. Minimizes adverse effects associated with high serum
d. Set the infusion rate to infuse medication drug levels if infused too rapidly.
volume and flush over the desired time
(antibiotics are usually given over 30 to
60 minutes) and start infusion.
12.For medication administration through a Reduces transmission of organisms.
small-volume container: Ensures correct medication for infusion.
a. Cleanse the container diaphragm used for Allows means of medication administration.
medication insertion with alcohol.
b. Inject the medication into the bag/bottle or Infusing into port closest to child allows quicker infusion
obtain premixed medication bag/bottle. into the child; prevents further dilution of the
c. Connect administration tubing to small medication.
volume bag/bottle (flush line with fluid
if not already primed).
d. Cleanse the port closest to the IV insertion
site with 70% alcohol and connect
medication administration tubing to main
IV at Y-connector closest to IV site.

235
e. Set the infusion rate to infuse medication Minimizes adverse effects associated with high serum
volume and flush over the desired time drug levels if infused too rapidly.
(antibiotics are typically given over 30 to
60 minutes) and start infusion.
13. For medication administration through a Children can develop fluid overload if too much fluid is
syringe pump Obtain syringe of used.
medication as dispensed from pharmacy Removes air from tubing and provides means of
or dilute infusion.
Medication (if necessary) in the
appropriately sized syringe. Allows for small fluid volumes to be infused over a
b. Prime infusion tubing, if needed, and specified amount of time. Reduces transmission of
attach infusion tubing to the syringe. microorganisms
c. Attach the syringe to the IV-controlled
infusion device.
d. Cleanse the part closest to the IV insertion
site with 70% alcohol and connect Minimizes adverse effects associated with high serum
closest to IV site medication drug levels if infused too rapidly.
administration tubing to main IV at Y
connector
e. Set the IV-controlled infusion device to
infuse medication volume and flush over
the correct time and start infusion.
14. Dispose of equipment and waste in Standard precautions. Reduces transmission of
appropriate receptacle. Perform hand microorganisms
hygiene.
16. Monitor the child initially and every 15 IV medication enters the vascular system rapidly.
minutes during the infusion for adverse Monitoring provides early detection of adverse reactions.
reactions such as respiratory distress, Onset of anaphylaxis or toxic side effects may occur at
change in vital signs, hemodynamic any time
status, and so on.
16. Flush medication from tubing at the Facilitates infusion of all medication into the child so
completion of administration; flush none is left that could interact with other medications or
amount is dependent on tubing volume. solutions. Maintains sterility of tubing until next infusion
After infusion of medication and flush is of medication. Tubing used for intermittent infusions

236
 complete, disconnect infusion tubing. should be replaced when the
Attach sterile tubing cap to end of main line tubing is changed or whenever the integrity of
infusion tubing. either line is compromised

METHODS TO ADMINISTER INTRAVENOUS MEDICATIONS

METHOD INDICATIONS FOR USE

IV push Used with small volumes that are injected over a relatively short period
of time, usually 1-5 min
Volume control chamber Used when the medication can be diluted in the established N fluids;
(Soluset, Buretrol, Volutrol) volume for dilution is usually restricted to 150 ml or less
Small-volume container( IV Pharmacy may dispense in small-volume container if child can tolerate
bag/bottle containing small larger amounts of fluid; an option when the dilution fluid must be
volumes) different from the established infusing IV fluids and a small-volume
IV-controlled infusion device is unavailable.
Syringe pump Used to infuse medication over a specified period of time using smaller
volume infusion tubing, which requires less fluid to get medication to
child. May be used with intermittent IV locks or piggybacked into an
existing IV

CHILD AND FAMILY EVALUATION AND DOCUMENTATION

 Provide parents instructions on expected response to IV medication administration.
 Evaluate child's response to the procedure, monitoring for potential side effects or adverse reactions.
Discontinue medication infusion immediately if infiltration occurs or child displays allergic reaction to
medication, and notify healthcare prescriber.
 Evaluate child and family's understanding of medication.
 Determine whether the child and family have additional areas of concern to discuss.

Document the following:

1. Type of medication
2. Dose
3. Route given
4. Date and time administered

237
 5. Dilution and flush fluid amounts; include these amounts in the calculation of the child's 24-hour
fluid intake
6. Appearance of access site
7. Child's response to and tolerance of procedure
8. Presence or absence of adverse effects and notification of healthcare prescriber of such
9. Teaching and information given to child and parent

INTRAVENOUS CANNULATION AND THERAPY

Initiation of intravascular therapy (calculation based on age, height, weight, or body surface area) is
on order of a physician or healthcare prescriber. Peripheral intravenous (IV) catheters are placed by a
physician, registered nurse (RN), licensed practical nurse (LPN), or appropriately certified technician.
Placement is accomplished by cannulating a superficial vein with a sterile needle/catheter.
Peripheral IV catheters are used for direct administration of primed IV fluids, intermittent use with
medications and blood products, parenteral nutritional supplement, and occasional venous blood draws for
laboratory analysis. Peripheral IV catheters in children may remain in place as long as there are no signs of
complications; they do not need to be changed on a routine basis.

Disposable catheters of various lengths and sizes are available from several manufacturers. Infants
and children with small veins may tolerate large-volume IV rates with small-bore (20- to 24-gauge)
catheters. The practitioner placing the IV catheter is knowledgeable regarding normal anatomy and
physiology of children and selecting appropriate sites. The choice of access depends on the hemodynamic
status of the child, the expertise of the nurse, the availability of supplies, the general condition of the
vasculature, and the nature of the fluid being infused. The practitioner placing and monitoring the IV
catheter is knowledgeable regarding complications associated with IV lines, including infiltration,
hematoma, phlebitis, thrombosis. bacteremia, septicemia, nerve damage, and mechanical problems. Local
anesthesia is used for catheter placement in nonemergent situations.

238
EQUIPMENT
1. Local anesthetic: topical agents (e.g., EMLA cream, LMX4, Numby Stuff iontophoresis or injectable
buffered lidocaine for non emergent insertion
2. IV catheter of appropriate size and length
3. Tourniquet or rubber band
4. Non-sterile examination gloves
5. Antiseptic swabs or pads: 2% chlorhexidine-based preparation is preferred, tincture o iodine, an
iodophor (e.g., povidone-iodine), or 70% alcohol can be used.
6. Sterile, saline-filled, 3-mL syringe
7. short T-infusion primer set
8. Dressing materials: cotton or gauze and tape or semi- permeable transparent dressing is to be
clamped
9. Heparinized saline as ordered, if and not used for continuous infusion
10. IV fluid as prescribed
11. IV administration tubing
12. IV controlled infusion device (follow manufacturer's Actions for use)

POTENTIAL SITES OF INTRAVENOUS ACCESS

239
CHILD AND FAMILY ASSESSMENT AND PREPARATION
1. Assess the cognitive level, readiness, and ability to process information of the child and family.
Readiness to learn and ability to process information may be impaired as a result of age, stress, or
anxiety.
2. Discuss the purpose of venipuncture; reinforce the need for and identify and discuss the risks and
benefits of IV placement with the child and family.
3. Assess for chlorhexidine allergy; present, use alternative antiseptic agent.
4. Assess presence of or risk factor for latex allergy; if present implement latex precautions.
5. Elicit the child’s input (as developmentally appropriate) in IV site selection, avoiding dominant hand (if
appropriate). Explain the amount of discomfort the child can expect with IV insertion and encourage
cooperation and understanding.
6. Explain to parents what they can do to comfort and support child during the procedure.

240
7. Explain the signs and symptoms that may indicate the need for IV catheter site change after the original
catheter is placed. This enables the patient or family to recognize when the IV is not functioning
properly and when to notify the nurse.
8. Assess the child's age, general size, and overall skis condition. Observe for peripheral skin grafts or
shunts. Cellulitis, vascular surgeries, thrombosis, or peripheral vascular disease, which aid in the
selection of an appropriate IV site for the child. Identify the catheter insertion site before beginning the
procedure.
9. Apply topical or local anesthetic agent before IV insertion.

PROCEDURE OF IV INSERTION

STEPS RATIONALE
1. Identify vein and insertion site. If a topical Reduces pain during insertion.
anesthetic agent is to be applied, choose the IV Obtain the assistance of an additional person to
insertion site and allow the agent to remain on the hold the child securely to prevent unnecessary
skin for appropriate length of time (e.g., 1 hour for attempts and to prevent dislodging the catheter
EMLA cream, about 15 minutes for as needed.
iontophoresis). Promotes efficient time management and
Remove topical anesthetic cream with soft cloth provides an organized approach to the
before beginning procedure. If using buffered procedure. Reduces transmission of
lidocaine, inject and wait 1 minute before catheter microorganisms.
insertion. Readies supplies for ease of insertion.

2. Gather necessary equipment and supplies for IV Standard precaution to reduce transmission of
catheter placement, select catheter size based on microorganisms and maintain asepsis.
assessment of identified insertion site. Perform
hand hygiene.
Increases venous pressure and allows better
3. Open and prepare all supplies. Prime short T- visualization of vessel to be cannulated
infusion primer set with sterile normal saline and care reminder
leave saline-filled syringe attached to primer set.
For scalp veins in infants and neonates, a large
4. Don gloves. rubber band works well around the head, with a

241
 gauze pad under the rubber band to grasp and
5. Apply tourniquet above the proposed IV puncture pull up once the IV is inserted; the band is then
site. cut in two to release. Touching of a child's head
by strangers may be offensive to some Asians.
6a. Cleanse the skin over the chosen insertion site Explain the need to touch the child's head to the
with antiseptic swab: 2% chlorhexidine or other parents before starting the IV.
appropriate antiseptic swab, working from the center
outward in a circular motion and allow area to dry for Decreases number of organisms on the skin.
30 seconds.
Prevents further absorption of antiseptic
6b. For neonates, remove antiseptic solution with solution and tissue damage.
sterile saline or water. Holds extremity steady and causes the least
amount of discomfort during insertion,
7. Hold extremity of insertion site with non-dominant Care reminder
hand. Using dominant hand, remove the protective When placing IV lines in extremities, access
sheath over the catheter and puncture the skin of the the most distal site first, using the non-
IV insertion site at a 45-° angle with the bevel of the dominant hand. Do not use the antecubital
catheter needle up, parallel to the vein. veins until other sites have been exhausted
because catheters in the antecubital region, or
8. Reduce the angle of the catheter needle and insert any joint, can be easily disturbed by joint
1/8 to1/4 inch into the vein until retrograde blood flow flexion and the immobilization required may
appears in the catheter. cause joint stiffness and pain. Allow an older
child a choice of catheter placement sites.
9.Release tourniquet.
Allows for insertion into the vein lumen
without puncturing the posterior wall of
the vein.

Prevents rupture of vein as needle is advanced

into vein lumen.
Establishes catheter in vein.

242
10. Advance catheter into vein while gently removing
inner needle from catheter, leaving only catheter Provides direct entrance for IV fluids to flow
sheath in place. through catheter, while assessing patency of
catheter.
11. Stabilize catheter in place with non-dominant
hand and connect primed short T-infusion set to If needle of catheter has punctured the vein
catheter hub. wall, fluid will fill into surrounding tissue,
causing localized edema or hematoma
12. Initiate flow of saline through the catheter and formation.
assess for signs of infiltration.
Prevents catheter movement and accidental
dislodgment. Transparent dressings provide
greater visualization of site.
13. Secure catheter in place with gauze and tape Provides fluid delivery as prescribed.
dressing or semi permeable transparent dressing to Care reminderAlthough saline locks are
site so that it is covered occlusively. common practice in adults, evidence in
pediatrics is contradictory and does not support
14.Begin IV fluids as prescribed and regulate IV discontinuing use of heparin. This may be
infusion or place catheter to 'xrin or saline lock" for related to the smaller lumen sizes of catheter s
intermittent infusions, as prescribed. used.
Secure connections may prevent air
embolizations or migration at the catheter

In the young child, cover the insertion site with

15. Secure the line with additional tape and arm board surgical netting to keep out of sight. Use arm
as needed to prevent accidental removal board as needed to prevent excessive
movement.
Standard precautions.
16. Discard used supplies.
Reduces transmission of microorganisms

17. Perform hand hygiene.

243
MAINTENANCE OF INFUSION
STEPS RATIONALE
1. Assess the IV site every hour for complications ; Ensures prompt detection of complications.
discontinue the IV as indicated.
2. Hang no more than 4 hours' worth of IV fluid at any one Prevents accidental fluid overload and
time during fluid infusion or infuse fluid via a controlled reduces complications from IV infiltration
infusion device. For peripheral IV catheters not used for
continuous infusion.
3a. Change the IV tubing using aseptic technique no more Limits bacterial contamination of infusion
frequently than every 72 hours or when contamination occurs tubing
or is suspected.
3b. Label the IV tubing with time, date, and initials of person Identifies proper change times.
who hung tubing.
4o. Change the IV access site dressing when the site appears Limits bacterial contamination.
soiled, damp, or loose, using aseptic technique, while
observing proper wound site core.
4b. Label the dressing with the time, date, and initials of the Identifies lost dressing change and
person who reapplied. personnel responsible.

COMPLICATIONS OF INTRAVASCULAR THERAPY: PERIPHERAL ACCESS

PROBLEM INTERVENTIONS
Bacteremia: Indicates presence of bacteria in Do not apply compresses because this may potentiate
the blood and possible contamination of the infection.
IV system Notify healthcare prescriber and obtain orders for
antibiotics.
Bleeding: Mild bleeding at IV insertion site Apply gauze dressing after initial placement of IV and
may occur for first 24 hours after placement change first dressing in 24 hours.
• Limit movement of extremity using arm board as
necessary
. • If bleeding increases or persists past first 24 hours,
notify healthcare prescriber.

244
Infiltration: Infiltration is the unintended • IV site checks are to include assessment along the path
administration of medication or solution into of the catheter.
the interstitial and tissue surrounding the vein. • Measure the circumference of the extremity above the
An increase in circumference of the extremity IV site and compare serial measurements.
may indicate an infiltration is present. • If infiltration occurs, discontinue infusion. Notify
Treatment of an infiltration is dependent on healthcare prescriber of infiltration, solution, or
the properties of the infiltrated medication or medications infusing at time of infiltration, and site
solution, the manufacturer's guidelines for that appearance.
agent, and the severity of the infiltration. • Obtain healthcare prescriber order for agent to treat
infiltration of a vesicant as needed.
• Immediately elevate extremity to promote venous
return; maintain elevation for 24 to 48 hours.
Hematoma: Indicating undue trauma to the • Apply warm compress to extremity for discomfort.
vessel wall or extravasations of blood into the • If symptoms increase, discontinue IV use at the site.
extravascular space. • May be caused by excessive movement, loose tape, or
Mechanical: Can be indicated by catheter excessive amount of give in the IV tubing.
migration, breaks in the catheter or connective • Encourage limitation of limb or extremity movement. •
tubing, or accidental catheter removal. Place IV site extremity on an arm board and securely
fastens catheter and tubing.

Nerve damage: Indicates trauma to adjacent • May be caused by excessive movement.

nerve during insertion of IV.
Phlebitis: An inflammation of the vein • Apply warm compress to extremity to ease discomfort.
usually caused by mechanical irritation from • If symptoms increase, if there is streak formation, or if
catheter trauma or early signs of infection. palpable cord is present, notify healthcare prescriber.
Some catheter materials are associated with
increased risk for phlebitis. An increase in
circumference of the extremity may indicate
an infiltration is present.
Septicemia: Indicates systemic infection • Do not apply compresses because this may potentiate
related to presence of blood-home infection. infection.
• Notify healthcare prescriber and obtain orders for

245
 antibiotics.

REMOVAL OF IV CATHETERS
STEPS RATIONALE
Perform hand hygiene and gather the necessary supplies. Hand hygiene reduces the transmission of
microorganisms. Assembly of all necessary
equipment facilitates quick and efficient
removal of the IV catheter.
2Don gloves. Standard precaution to reduce transmission
of microorganisms and maintain asepsis.

3. Close clamp on IV administration set and turn IV Stops flow of fluids and prevents potential
controlled infusion device off; ensue that IV short T - infiltration while removing peripheral
infusion set is clamped. catheter.
4- Remove old tape and dressing from around insertion site. Allows access to insertion site.
KidKare. Use of an adhesive remover may ease the trauma
of tape removal. In preterm infants, slow careful removal
with warm water and cotton balls is recommended. Mineral
oil or emollients may facilitate adhesive removal; do not use
if reapplication of tape is necessary.

5. Using gauze pad or cotton ball, apply slight pressure over Facilitates removal of catheter.
insertion site while withdrawing peripheral IV catheter.

CHILD AND FAMILY EVALUATION AND DOCUMENTATION

 Evaluate the IV site every hour for site appearance and signs of complications: note presence or absence
of redness, swelling, drainage, tenderness, or streaking; initiate steps to intervene if complications are
present and document this assessment.
 Label the IV tubing with time, date, and initials when it is hung to ensure proper change times.
 Label the IV site dressing with time, date, and initials when it is applied.
246
Document the following:
 Date and time of IV insertion, insertion site, type and gauge of catheter used (e.g., butterfly catheter,
Quik catheter), any difficulty in placing the catheter, number of attempts, child's tolerance of the
insertion, and identification of the person inserting the device
 Date, time, type, and amount of flush solution used; presence or absence of blood return; and any
resistance to flushing
 Teaching provided regarding potential complications associated with treatment
 Determine whether the child and family have other areas of concern to discuss

COMMUNITY CARE
1. If the child is to be discharged home with an IV, begin discharge planning with a home health nurse as
early as possible.
2. Communicate to the home care provider: type of line (including manufacturer and size if known), date
of insertion, dressing change and flush protocol taught healthcare setting and notification of any
complications after placement.
3. Instruct parents in hand washing, dressing changes, flushing the IV line, medication administration and
syringe pump use as applicable, disposal techniques for syringes and age and developmentally
appropriate methods to maintain the IV line.
4. Before discharge, the family should verbalize knowledge of the most common complications of IV
therapy (i.e., sepsis and accidental removal), what to look for and actions to take in the event of
complications.
5. Instruct the family to contact the healthcare provider if
• IV insertion site remains reddened or oozes fluid or blood
• IV becomes dislodged
• Child develops a fever

247
 CALCULATION OF DOSAGES
For most drugs, children require dosage different from those given to adults. An adult’s body handles
drugs differently and may respond to drug differently than an adult. A child’s body may handle a drug
differently in all areas of pharmacokinetics- absorption, distribution, metabolism and excretion.

Safe Dose Ranges

 Important nursing responsibility to determine SDR.
 Most medications are prescribed for each child specifically to his/her weight.
 Body surface area is used to determine SDRs.

Steps in determining SDR:

 Look up drug reference for recommended pediatric doses.
 Compare to ordered amount for this child

Evaluation:
 Less than therapeutic
 Safe dose amount
 In excess of safe dose range

Calculating the safe dose

 Ratio/Proportion
 To make conversions
 To determine amount to give what’s order

WHY DRUG CALCULATION IS NECESSARY IN CHILDREN

 The responses of the child’s organ to the effect of drugs also may vary because of the immaturity of
child’s organ
 A child’s body may handle a drug differently in all areas of pharmacokinetics- absorption, distribution,
metabolism and excretion.
 Most of the time a child requires a smaller dose of a drug to achieve the comparable critical
concentration.
 Children are more sensitivity to drugs than other patients & they show greater individual variation.
 Drugs sensitivity in very young results from organ system immaturity

248
 Because of heightened drug sensitivity patients in pediatric group are at increased risk of adverse drug
reaction.

PHARMACODYNAMICS AND PHARMACOKINETICS IN CHILDREN

Although a drug’s mechanism of action is the same in any individuals, the physiology immaturity
of some body system in a child can affect a drug’s pharmacodynamics. As a result, the body may not
respond to the drugs as intended. The intended effects may be enhanced or diminished, necessitating a
change in the dosage to ensure optimal effectiveness without increasing the child’s risk for toxicity content.

Pharmacokinetic: - the child’s age, weight, body surface area, and body composition also can affect the
drug’s pharmacokinetics.

a) Absorption: - during the absorption process, drugs move from the administration site into the blood
stream. In infants and young children, the absorption of orally administered medication is affected by
slower gastric emptying, increased intestinal motility, a proportionately larger small intestine surface
area, higher gastric pH & decreased lipase & amylase secretion compared with adults
Intramuscular absorption in infants and young children is affected by amount of muscle mass,
muscle tone and perfusion, as well as vasomotor instability. Similarly decreased perfusion alters
subcutaneous absorption.
Absorption by these routes is erratic and may be decreased. In contrast, topical absorption of
medication is increased in infants and young children because the stratum corneum is thinner and well
hydrated.

b) Distribution: - (movement of a drug from the blood to interstitial spaces and then into cells) of medication
is also altered in infants and young children. Medication distribution in children is affected by:-
- Higher percentage of body water than adults.
- More rapid extracellular fluid exchange.
- Decreased body fat.
- Liver immaturity, altering first-pass elimination.
- Decreased amount of plasma proteins available for drug binding.
- Immature blood-brain barrier, allowing permeation of certain medication.
c) Metabolism: - of medication in children is altered because of differences in hepatic enzyme production
and the child’s increased metabolic rate.

249
d) Biotransformation: - (the alteration of chemical structure from their original form, which allows for the
eventual excretion of the substance) is affected by the same variations affecting distribution in children.
In addition, the immaturity of the kidneys until the age of 1 to 2 years affects renal blood flow,
glomerular filtration, and active tubular secretion. This results in a longer half life and increases the
potential for toxicity of drugs primarily excreted by the kidney

DETERMINATION OF CORRECT DOSE

Administering the correct dose is a key component of medication administration. Many drug
references list recommended pediatric dosages, and nurses are responsible for checking doses to ensure that
they are appropriate for the child.
Two common methods for determining pediatric doses are based on the unit of drug per kilogram
of body weight or body surface area (BSA).
a) Dose determination by Body weight: - the most common calculation of drug is based on body weight.
The recommended dosage is usually expressed as the amount of drug to be administered over a 24 hour
period (mg/kg/day) or a single dose (mg/kg/dose).
Guidelines to determine the correct dose by body weight:-
- Weigh the child.
- If the child’s weight is in pounds, convert it to kilograms (divide the child’s weight in pounds
by 2.2)
- Check a drug reference for the safe dose range (e.g. 10-20 mg/kg of body weight)
- Calculate the low safe dose.
E.g. - 10-20 mg/kg & the child weight is 30 kg.
Set up a proportion using the low safe dose range.
10 mg/1 kg = x mg/30 kg
Solve for x by cross multiplying
1 x x = 10 x 30 = 300 mg
- Calculate the high safe dose
E.g. - 10-20 mg/kg & the child weight is 30 kg.
Set up a proportion using the high safe dose range.
20 mg/1 kg = x mg/30 kg
1 x x = 20 x 30 = 600 mg
Compare the safe dose range (for this example 300-600 mg) with the ordered dose. If the dose falls
within the range, the dose is safe. If the dose Solve for x by cross multiplying
- Falls outside the range notify the prescriber.

250
b) Dose determination by Body surface area:- Calculating the dosage based on BSA takes into account
the child’s metabolic rate and growth. It is commonly used for chemotherapeutic agents. Some
recommended medication doses may read “mg/BSA/dose”. To determine the dose using BSA. The
child’s weight should be known and it is plotted into a namogram. A namogram is a graph divided into
three column:- height (left column), surface area (middle column), and weight (right column).

Guidelines to determine the correct dose by body weight:-

- Weigh the child.
- Determine the child’s height.
- Using the namogram, draw a line to connect the height measurement in the left column and
the weight measurement in the right column.
- Determine the point where this line intersects the line in the surface area column. This is the
BSA, expressed in meters squared (m2).
Once the BSA is determined calculate the safe dose range.

FORMULAS USED FOR CALCULATING PEDIATRIC DOSAGE

1. Fried’s Rule:- Applies to children younger than 1 yr of age. The rule assumes that an adult dose would
be appropriate for a child who is 12.5 yrs old

Infants age (in months)

Child dose = X average adult dose
150 months

2. Young’s Rule: - which applies to children 1 to 12 yrs of age.

Child’s age (in years)

Child dose = X average adult dose
Child’s age (in yrs) + 12

3. Clark’s Rule:- uses the child’s weight to calculate the appropriate dose & assumes that
the adult dose is based on 150 lb person.

Weight of child (in pounds)

251
 Child dose = X average adult dose
150 pounds

4. Surface area calculation: - The child’s surface area may also be used to determine the approximate
dosage that should be used. For this, the child’s surface area is determined with the use of namogram.
Surface area (in m2)
Child dose = X average adult dose
1.73

CALCULATING DOSAGE
Because there are several systems of measurement available that might be used when ordering a
drug and because drugs are made available only in certain forms or dosages, it may be necessary to calculate
what the patient should be receiving when interpreting a drug order.
a) Oral drugs:- the easiest way to determine is to set up a ratio and proportion equation.

Amount of drug available amount of drug prescribed

=
One tablet or capsule no. of tab. Or cap. to give

b) Parenteral drugs:-

Amount of drug available amount of drug prescribed

=
Volume available volume to be administered

c) Intravenous solutions:- most of the IV delivery system come with a standard controlled a micro-drip,
by which each milliliter delivered contains 60 drops. Macro-drip system, which deliver 15 drops/ml
are also available, they are usually used when a large volume must be delivered quickly.
The formula to calculate drops of fluids to administer per minute is:
ml of solution prescribed/hr
Drop/min = X drop factor (drop
60 min/hr delivered per ml)

252
PRINCIPLES OF MEDICATION ADMINISTRATION
“Six Rights” of drug administration
1. 1. The Right Medication – when administering medications, the nurse compares the label of the
medication container with medication form.
The nurse does this 3 times:
a. Before removing the container from the drawer or shelf
b. As the amount of medication ordered is removed from the container
c. Before returning the container to the storage

2. Right Dose –when performing medication calculation or conversions, the nurse should have another
qualified nurse check the calculated dose.

3. Right Client – an important step in administering medication safely is being sure the medication is
given to the right client.
To identify the client correctly: The nurse check the medication administration form against
the client’s identification bracelet and asks the client to state his or her name to ensure the client’s
identification bracelet has the correct information.

4. Right route – if a prescriber’s order does not designate a route of administration, the nurse consult
the prescriber. Likewise, if the specified route is not recommended, the nurse should alert the
prescriber immediately.

5. Right time
a. The nurse must know why a medication is ordered for certain times of the day and whether the
time schedule can be altered
b. Each institution has are commended time schedule for medications ordered at frequent interval
c. Medication that must act at certain times are given priority (e.g. insulin should be given at a
precise interval before a meal )

6. Right documentation –Documentation is an important part of safe medication administration

a. The documentation for the medication should clearly reflect the client’s name, the name of the
ordered medication, the time, dose, route and frequency
b. Sign medication sheet immediately after administration of the drug.

253
CLIENT’S RIGHT RELATED TO MEDICATION ADMINISTRATION
I- A client has the following rights:
a. To be informed of the medication’s name, purpose, action, and potential undesired effects.
b. To refuse a medication regardless of the consequences.
c. To have a qualified nurses or physicians assess medication history, including allergies.
d. To be properly advised of the experimental nature of medication therapy and to give written consent
for its use.
e. To received labeled medications safely without discomfort in accordance with the six rights of
medication administration.
f. To received appropriate supportive therapy in relation to medication therapy.
g. To not receive unnecessary medications.

II – Practice Asepsis – wash hand before and after preparing the medication to reduce transfer of
microorganisms.
III – Nurse who administer the medications are responsible for their own action. Question any order
that you considered incorrect (may be unclear or appropriate)
IV – Be knowledgeable about the medication that you administer
“A fundamental rule of safe drug administration is: “never administer an unfamiliar medication”
V – Keep the Narcotics in locked place.
VI– Use only medications that are in clearly labeled containers. Relabeling of drugs are the
responsibility of the pharmacist.
VII – Return liquid that are cloudy in color to the pharmacy.
VIII – Before administering medication, identify the client correctly
IX – Do not leave the medication at the bedside. Stay with the client until he actually takes the
medications.
X – The nurse who prepares the drug administers it. Only the nurse prepares the drug knows what the
drug is. Do not accept endorsement of medication.
XI – If the client vomits after taking the medication, report this to the nurse in-charge or physician.
XII – Preoperative medications are usually discontinued during the postoperative period unless ordered
to be continued.
XIII- When a medication is omitted for any reason, record the fact together with the reason.
XIV – When the medication error is made, report it immediately to the nurse in-charge or physician. To
implementation necessary measures immediately. This may prevent any adverse effects of the drug.

254
MEDICATION ADMINISTRATION
1. ORAL ADMINISTRATION
Advantages
a. The easiest and most desirable way to administer medication
b. Most convenient
c. Safe, does nor break skin barrier
d. Usually less expensive

Disadvantages
a. Inappropriate if client cannot swallow and if GIT has reduced motility
b. Inappropriate for client with nausea and vomiting
c. Drug may have unpleasant taste
d. Drug may discolor the teeth
e. Drug may irritate the gastric mucosa
f. Drug may be aspirated by seriously ill patient.

Drug Forms for Oral Administration

a. Solid: tablet, capsule, pill, powder
b. Liquid: syrup, suspension, emulsion, elixir, milk, or other alkaline substances.
c. Syrup: sugar-based liquid medication
d. Suspension: water-based liquid medication. Shake bottle before use of medication to properly mix it.
e. Emulsion: oil-based liquid medication
f. Elixir: alcohol-based liquid medication. After administration of elixir, allow 30 minutes to elapse
before giving water. This allows maximum absorption of the medication.
“NEVER CRUSH ENTERIC-COATED OR SUSTAINED RELEASE TABLET”
Crushing enteric-coated tablets – allows the irrigating medication to come in contact with the oral or
gastric mucosa, resulting in mucositis or gastric irritation.
Crushing sustained-released medication – allows all the medication to be absorbed at the same time,
resulting in a higher than expected initial level of medication and a shorter than expected duration of
action

2. SUBLINGUAL
a. A drug is place under the tongue, where it dissolves.
b. When the medication is in capsule and ordered sublingually, the fluid must be aspirated from the

255
 capsule and placed under the tongue.
c. A medication given by the sublingual route should not be swallowed, or desire effects will not be
achieved
Advantages:
a. Same as oral
b. Drug is rapidly absorbed in the bloodstream
Disadvantages
a. If swallowed, drug may be inactivated by gastric juices.
b. Drug must remain under the tongue until dissolved and absorbed

BUCCAL
a. A medication is held in the mouth against the mucous membranes of the cheek until the drug
dissolves.
b. The medication should not be chewed, swallowed, or placed under the tongue (e.g. sustained release
nitroglycerine, opiates, antiemetic, tranquilizer, sedatives)
c. Client should be taught to alternate the cheeks with each subsequent dose to avoid mucosal irritation
Advantages:
a. Same as oral
b. Drug can be administered for local effect
c. Ensures greater potency because drug directly enters the blood and bypass the liver
Disadvantages:
 If swallowed, drug may be inactivated by gastric juice

TOPICAL – Application of medication to a circumscribed area of the body.

1. Dermatologic – includes lotions, liniment and ointments, powder.
a. Before application, clean the skin thoroughly by washing the area gently with soap and water, soaking
an involved site, or locally debriding tissue.
b. Use surgical asepsis when open wound is present
c. Remove previous application before the next application
d. Use gloves when applying the medication over a large surface. (e.g. large area of burns)
e. Apply only thin layer of medication to prevent systemic absorption.

OPHTHALMIC - includes instillation and irrigation

a. Instillation – to provide an eye medication that the client requires.

256
b. Irrigation – To clear the eye of noxious or other foreign materials.
c. Position the client either sitting or lying.
d. Use sterile technique
e. Clean the eyelid and eyelashes with sterile cotton balls moistened with sterile normal saline from the
inner to the outer canthus
f. Instill eye drops into lower conjunctival sac.
g. Instill a maximum of 2 drops at a time. Wait for 5 minutes if additional drops need to be administered.
This is for proper absorption of the medication.
h. Avoid dropping a solution onto the cornea directly, because it causes discomfort.
i. Instruct the client to close the eyes gently. Shutting the eyes tightly causes spillage of the medication.
j. For liquid eye medication, press firmly on the nasolacrimal duct (inner cantus) for at least 30 seconds
to prevent systemic absorption of the medication.

OPTIC INSTILLATION – to remove cerumen or pus or to remove foreign body

a. Warm the solution at room temperature or body temperature, failure to do so may cause vertigo,
dizziness, nausea and pain.
b. Have the client assume a side-lying position (if not contraindicated) with ear to be treated facing up.
c. Perform hand hygiene. Apply gloves if drainage is present.
d. Straighten the ear canal:
 0-3 years old: pull the pinna downward and backward
 Older than 3 years old: pull the pinna upward and backward
e. Instill eardrops on the side of the auditory canal to allow the drops to flow in and continue to adjust to
body temperature
f. Press gently but firmly a few times on the tragus of the ear to assist the flow of medication into the
ear canal.
g. Ask the client to remain in side lying position for about 5 minutes
h. At times the MD will order insertion of cotton puff into outermost part of the canal. Do not press
cotton into the canal. Remove cotton after 15 minutes.

NASAL – Nasal instillations usually are instilled for their astringent effects (to shrink swollen mucous
membrane), to loosen secretions and facilitate drainage or to treat infections of the nasal cavity or
sinuses. Decongestants, steroids, calcitonin.
a. Have the client blow the nose prior to nasal instillation
b. Assume a back lying position, or sit up and lean head back.

257
 c. Elevate the nares slightly by pressing the thumb against the client’s tip of the nose. While the client
inhales, squeeze the bottle.
d. Keep head tilted backward for 5 minutes after instillation of nasal drops.
e. When the medication is used on a daily basis, alternate nares to prevent irritations

INHALATION – use of nebulizer, metered-dose inhaler

a. Semi or high-fowler’s position or standing position. To enhance full chest expansion allowing deeper
inhalation of the medication
b. Shake the canister several times. To mix the medication and ensure uniform dosage delivery
c. Position the mouthpiece 1 to 2 inches from the client’s open mouth. As the client starts inhaling, press the
canister down to release one dose of the medication. This allows delivery of the medication more accurately
into the bronchial tree rather than being trapped in the oropharynx then swallowed
d. Instruct the client to hold breath for 10 seconds. To enhance complete absorption of the medication.
e. If bronchodilator, administer a maximum of 2 puffs, for at least 30 second interval. Administer
bronchodilator before other inhaled medication. This opens airway and promotes greater absorption of the
medication.
f. Wait at least 1 minute before administration of the second dose or inhalation of a different medication by
MDI Instruct client to rinse mouth, if steroid had been administered. This is to prevent fungal infection.

RECTAL – can be use when the drug has objectionable taste or odor.
a. Need to be refrigerated so as not to soften.
b. Apply disposable gloves.
c. Have the client lie on left side and ask to take slow deep breaths through mouth and relax anal
sphincter.
d. Retract buttocks gently through the anus, past internal sphincter and against rectal wall, 10 cm (4
inches) in adults, 5 cm (2 in) in children and infants. May need to apply gentle pressure to hold buttocks
together momentarily.
e. Discard gloves to proper receptacle and perform hand washing.
f. Client must remain on side for 20 minute after insertion to promote adequate absorption of the
medication.

258
PARENTERAL- administration of medication by needle.
Intradermal – under the epidermis.

a. The site are the inner lower arm, upper chest and back, and beneath the scapula.
b. Indicated for allergy and tuberculin testing and for vaccinations.
c. Use the needle gauge 25, 26, 27: needle length 3/8”, 5/8” or ½”
d. Needle at 10–15 ° angle; bevel up.
e. Inject a small amount of drug slowly over 3 to 5 seconds to form a wheal or bleb.
f. Do not massage the site of injection. To prevent irritation of the site, and to prevent absorption of the
drug into the subcutaneous.

Subcutaneous – vaccines, heparin, preoperative medication, insulin, narcotics.

The site:
 outer aspect of the upper arms
 anterior aspect of the thighs
 Abdomen
 Scapular areas of the upper back
 Ventrogluteal
 Dorsogluteal
a. Only small doses of medication should be injected via SC route.
b. Rotate site of injection to minimize tissue damage.
c. Needle length and gauge are the same as for ID injections
d. Use 5/8 needle for adults when the injection is to administer at 45 ° angle; ½ is use at 90 ° angle.
e. For thin patients: 45 ° angle of needle
f. For obese patient: 90 ° angle of needle
g. For heparin injection:
h. do not aspirate.
i. Do not massage the injection site to prevent hematoma formation
j. For insulin injection:
k. Do not massage to prevent rapid absorption which may result to hypoglycemic reaction.
l. Always inject insulin at 90 °s angle to administer the medication in the pocket between the

259
subcutaneous and muscle layer. Adjust the length of the needle depending on the size of the client.
m. For other medications, aspirate before injection of medication to check if the blood vessel had been
hit. If blood appears on pulling back of the plunger of the syringe, remove the needle and discard the
medication and equipment.

Intramuscular:
a. Needle length is 1”, 1 ½”, 2” to reach the muscle layer
b. Clean the injection site with alcoholized cotton ball to reduce microorganisms in the area.
c. Inject the medication slowly to allow the tissue to accommodate volume.

SITES:
Ventrogluteal site
a. The area contains no large nerves, or blood vessels and less fat. It is farther from the rectal
area, so it less contaminated.
b. Position the client in prone or side-lying.
c. When in prone position, curl the toes inward.
d. When side-lying position, flex the knee and hip. These ensure relaxation of gluteus
muscles and minimize discomfort during injection.
e. To locate the site, place the heel of the hand over the greater trochanter, point the index
finger toward the anterior superior iliac spine, then abduct the middle (third) finger. The
triangle formed by the index finger, the third finger and the crest of the ilium is the site.

Dorsogluteal site
a. Position the client similar to the ventrogluteal site
b. The site should not be use in infant under 3 years because the gluteal muscles are not well
developed yet.
c. To locate the site, the nurse draws an imaginary line from the greater trochanter to the posterior
superior iliac spine. The injection site id lateral and superior to this line.
d. Another method of locating this site is to imaginary divide the buttock into four quadrants. The
upper most quadrant is the site of injection. Palpate the crest of the ilium to ensure that the site is
high enough.
e. Avoid hitting the sciatic nerve, major blood vessel or bone by locating the site properly.

Vastus Lateralis

260
 a. Recommended site of injection for infant
b. Located at the middle third of the anterior lateral aspect of the thigh.
c. Assume back-lying or sitting position.

Rectus femoris site –

located at the middle third, anterior aspect of thigh.

Deltoid site
a.Not used often for IM injection because it is relatively small muscle and is very close to the
radial nerve and radial artery.
b. To locate the site, palpate the lower edge of the acromion process and the midpoint on the
lateral aspect of the arm that is in line with the axilla. This is approximately 5 cm (2 in) or 2 to 3
fingerbreadths below the acromion process.
IM INJECTION –
Z tract injection
a. Used for parenteral iron preparation. To seal the drug deep into the muscles and prevent permanent
staining of the skin.
b. Retract the skin laterally, inject the medication slowly. Hold retraction of skin until the needle is
withdrawn
c. Do not massage the site of injection to prevent leakage into the subcutaneous.

GENERAL PRINCIPLES IN PARENTERAL ADMINISTRATION OF MEDICATIONS

1. Check doctor’s order.
2. Check the expiration for medication – drug potency may increase or decrease if outdated.
3. Observe verbal and non-verbal responses toward receiving injection. Injection can be painful.
Client may have anxiety, which can increase the pain.
4. Practice asepsis to prevent infection. Apply disposable gloves.
5. Use appropriate needle size. To minimize tissue injury.
6. Plot the site of injection properly. To prevent hitting nerves, blood vessels, bones.
7. Use separate needles for aspiration and injection of medications to prevent tissue irritation.
8. Introduce air into the vial before aspiration. To create a positive pressure within the vial and allow
easy withdrawal of the medication.
9. Allow a small air bubble (0.2 ml) in the syringe to push the medication that may remain.
10. Introduce the needle in quick thrust to lessen discomfort.

261
11. Either spread or pinch muscle when introducing the medication. Depending on the size of the
client.
12. Minimized discomfort by applying cold compress over the injection site before introduction of
medicati0n to numb nerve endings.
13. Aspirate before the introduction of medication. To check if blood vessel had been hit.
14. Support the tissue with cotton swabs before withdrawal of needle. To prevent discomfort of
pulling tissues as needle is withdrawn.
15. Massage the site of injection to haste absorption.
16. Apply pressure at the site for few minutes. To prevent bleeding.
17. Evaluate effectiveness of the procedure and make relevant documentation.

Intravenous
The nurse administers medication intravenously by the following method:
1. As mixture within large volumes of IV fluids.
2. By injection of a bolus, or small volume, or medication through an existing intravenous infusion
line or intermittent venous access (heparin or saline lock)
3. By “piggyback” infusion of solution containing the prescribed medication and a small volume of
IV fluid through an existing IV line.
a. Most rapid route of absorption of medications.
b. Predictable, therapeutic blood levels of medication can be obtained.
c. The route can be used for clients with compromised gastrointestinal function or peripheral
circulation.
d. Large dose of medications can be administered by this route.
e. The nurse must closely observe the client for symptoms of adverse reactions.
f. The nurse should double-check the six rights of safe medication.
g. If the medication has an antidote, it must be available during administration.
h. When administering potent medications, the nurse assesses vital signs before, during and after
infusion.
Nursing Interventions in IV Infusion
a. Verify the doctor’s order
b. Know the type, amount, and indication of IV therapy.
c. Practice strict asepsis.
d. Inform the client and explain the purpose of IV therapy to alleviate client’s anxiety.
e. Prime IV tubing to expel air. This will prevent air embolism.

262
 f. Clean the insertion site of IV needle from center to the periphery with alcoholized cotton ball to
prevent infection.
g. Shave the area of needle insertion if hairy.
h. Change the IV tubing every 72 hours. To prevent contamination.
i. Change IV needle insertion site every 72 hours to prevent thrombophlebitis.
j. Regulate IV every 15-20 minutes. To ensure administration of proper volume of IV fluid as
ordered.
k. Observe for potential complications.

TYPES OF IV FLUIDS
Isotonic solution – has the same concentration as the body fluid
a. D5 W
b. Na Cl 0.9%
c. plain Ringer’s lactate
d. Plain Normosol M
Hypotonic – has lower concentration than the body fluids.
a. NaCl 0.3%
Hypertonic – has higher concentration than the body fluids.
a. D10W
b. D50W
c. D5LR
d. D5NM
7. Complication of IV Infusion
1. Infiltration – the needle is out of nein, and fluids accumulate in the subcutaneous tissues.
Assessment:
 Pain, swelling, skin is cold at needle site; pallor of the site, flow rate has decreases or stops.
Nursing Intervention:
 Change the site of needle
 Apply warm compress. This will absorb edema fluids and reduce swelling.
Circulatory Overload -Results from administration of excessive volume of IV fluids.
Assessment:
 Headache
 Flushed skin
 Rapid pulse

263
 Increase BP
 Weight gain
 Syncope and faintness
 Pulmonary edema
 Increase volume pressure
 SOB
 Coughing
 Tachypnea
 shock
Nursing Interventions:
 Slow infusion to KVO
 Place patient in high fowler’s position. To enhance breathing
 Administer diuretic, bronchodilator as ordered

3.Drug Overload – the patient receives an excessive amount of fluid containing drugs.
Assessment:
 Dizziness
 Shock
 Fainting
Nursing Intervention
 Slow infusion to KVO.
 Take vital signs
 Notify physician

4. Superficial Thrombophlebitis – it is due to o0veruse of a vein, irritating solution or drugs, clot

formation, large bore catheters.
Assessment:
 Pain along the course of vein
 Vein may feel hard and cordlike
 Edema and redness at needle insertion site.
 Arm feels warmer than the other arm
Nursing Intervention:
 Change IV sites every 72 hours
264
 Use large veins for irritating fluids.
 Stabilize venipuncture at area of flexion.
 Apply cold compress immediately to relieve pain and inflammation; later with warm compress to
stimulate circulation and promotion absorption.
 “Do not irrigate the IV because this could push clot into the systemic circulation’
5.Air Embolism – Air manages to get into the circulatory system; 5ml of air or more causes air
embolism.
Assessment:
 Chest, shoulder, or backpain
 Hypotension
 Dyspnea
 Cyanosis
 Tachycardia
 Increase venous pressure
 Loss of consciousness
Nursing Intervention
 Do not allow IV bottle to “run dry”
 “Prime” IV tubing before starting infusion.
 Turn patient to left side in the trendelenburg position. To allow air to rise in the right side of the
heart. This prevent pulmonary embolism.
6.Nerve Damage – may result from tying the arm too tightly to the splint.
Assessment
 Numbness of fingers and hands
Nursing Interventions
 Massage the area and move shoulder through its ROM
 Instruct the patient to open and close hand several times each hour.
 Physical therapy may be required
Note: apply splint with the fingers free to move.

7. Speed Shock – may result from administration of IV push medication rapidly.

 To avoid speed shock, and possible cardiac arrest, give most IV push medication over 3 to
4minutes.

265
 BLOOD ADMINISTRATION
AND TRANSFUSION REACTIONS
INTRODUCTION
As many as 15 million blood transfusions are given each year in the United States. A variety of
medical conditions result in the need for a patient to receive a blood and/or blood product transfusion.
Nursing care for these patients is centered on knowledge of the various blood products, thorough pre-
assessment skills, and through the application of accurate infusion parameters. Awareness of the signs and
symptoms of early and late transfusion reactions is also very important.

OVERVIEW OF BLOOD TRANSFUSIONS

Blood transfusions, when used correctly, can improve health and save lives. Appropriate use of
blood and blood products can be directly related to a well organized blood program and the ongoing
education and training of staff involved in the transfusion process. The absence of adequate testing
increases the possibility of transmitting infectious diseases such as HIV, hepatitis viruses, syphilis
and Chagas disease (WHO, n.d.a).
Even in countries where blood is available, the risk of transfusion-transmissible infections (TTIs)
occurs due to poor selection practices, the use of untested blood and poor blood donor recruitment
(WHO, n.d.b)

THE HISTORY OF BLOOD TRANSFUSIONS

Blood transfusions were first recorded in 1492 when Pope Innocent VIII, in Rome, had a stroke
and lapsed into a coma. The Pope’s physician advised a blood transfusion as a therapeutic
measure for the Pope's illness. Sadly and not surprisingly, the Pope did not benefit and died
later that year (bloodbook.com. n. d).

266
 Up until 1901 when an Austrian physician by the name of Karl Landsteiner documented the
first three human blood groups, experimentation with direct human to human and animal to
human transfusions took place with disastrous results.
Once blood grouping was in place, the early 1900’s saw the development of sodium citrate and
citrate-glucose, long-term anticoagulants that allowed preservation of blood. Blood could now
be stored in containers for later transfusion which aided in eliminating vein-to-vein transfusion
(Bloodbook.com. n. d).

THE HISTORY OF BLOOD BANKING

The first United States federal license permitting the processing and manufacture of whole
blood was issued in 1946. Blood banking was experiencing rapid growth due to the return of
physicians from World War II who had experienced the effectiveness of transfusion therapy.
The American Association of Blood Banks (AABB) was formed in 1947, to support and
encourage continued blood research and to develop standards of practice for blood banks. In
1950 the plastic infusion bag for blood collection and storage replaced breakable glass
bottles. Throughout the 1960s and 1970’s more precise standards were developed for blood
administration.
In 1985 the U.S. began screening all donated blood for HIV (CDC, 2006). In the years since,
improved processes for testing and refining blood products has helped to ensure the safety of
the blood supply.

SOURCES OF BLOOD PRODUCTS

There are three basic sources of blood products. These include autologous blood, donor specific
and banked blood. Patients that experience a considerable blood loss during a surgical procedure
may be a candidate for auto transfusion as well.

Autologous Blood

267
 One of the safest and most effective ways to treat blood loss is to give patients their own blood
through the process of preoperative donation. Replacement of lost blood with previously donated
blood eliminates most transfusion-associated risks.
This type of blood source is typically coordinated in the setting of a pre-arranged, elective surgery,
when the physician anticipates a need for a post-operative blood transfusion. To allow for the
adequate time needed for testing and processing, it is important to remember that autologous blood
must be donated at least 3 days prior to the surgical date.
Limitations for autologous donations also include a low hemoglobin level (< 11 g/dL) or certain
cardiac conditions.
Some patients may be the recipient of their own blood that has been collected during a surgical
procedure. Certain criteria apply. This is known as auto transfusion.

Donor Specific Blood

This type of blood source is also called “donor directed” blood. The blood source is from an
individual, designated by a patient or a patient’s family, who is interested in donating blood for the
patient.
The blood donor must meet both the eligibility criteria and have a compatible blood type. Donor
specific blood must be donated at least three days prior to administration. The donated blood will be
tested by the blood collection agency according to the guidelines determined by the American
Association of Blood Banks, American Blood Centers, and the American Red Cross.

BANK BLOOD
Bank blood is a blood product that is donated by the general public. Prior to donating blood the
donor must meet donor eligibility criteria. Donated blood is tested by the blood collection agency
according to national guidelines from the American Association of Blood Banks, American Blood
Centers, and the American Red Cross.

SELECTION OF WHOLE BLOOD

268
 The patient’s healthcare provider will evaluate which blood product is best for treatment of the
underlying medical or surgical condition. It is important for healthcare professionals to be familiar with the
many different types of blood products available for treatment.

Whole Blood
A whole blood transfusion replenishes both the volume and the oxygen-carrying capacity of the
circulatory system. This type of transfusion treats decreased hemoglobin and hematocrit levels, but is
typically used in the setting of hypovolemia such as hemorrhage.
Whole blood contains cellular debris, requiring in-line filtration during administration.
Transfusion of whole blood is not common, but may be ordered when a needed blood component is
unavailable, such as in the setting of the Emergency Department when an acute trauma patient is
hemorrhaging and there is not enough time to wait for the blood type and cross match to be
performed. Whole blood typically contains approximately 500mL of volume.

SELECTION OF PACKED RED BLOOD CELLS

To avoid potential circulatory overload with whole blood transfusions, packed red blood cells
(PRBCs) are given when decreased hemoglobin and hematocrit levels accompany a normal
blood volume.
Transfusion of PRBCs (from which 80% of the plasma has been removed) restores the
oxygen-carrying capacity of the blood with less volume. The normal hemoglobin level is
between 12-18 g/dl. Elderly patient’s values are normally slightly decreased.
If a patient’s hemoglobin level is < 7 g/dl and they are also symptomatic, a transfusion is
generally indicated. It is generally NOT appropriate to transfuse a patient with PRBCs when
the hemoglobin is > 10 g/dl.
Each unit of blood should raise the patient’s hematocrit by approximately 3%. One unit is
approximately 250 ml of volume and is typically infused over 2-4 hours.
Patients who are prone to congestive heart failure (CHF) or circulatory overload may require
a slower rate of infusion, (not to exceed 4 hours) as well as administration of a diuretic per
physician’s orders.
Like whole blood, this product also contains some cellular debris, thereby requiring an in-line
filtration during administration

Washed PRBC's and Leukocyte-poor PRBC's

Washed Packed Red Blood Cells

269
 This type of blood product is used for patients previously sensitized to transfusions. The blood is
rinsed with a special solution that removes white blood cells and plasma proteins, thus decreasing the
chance of a transfusion reaction. This product typically contains approximately 250 ml of volume.

Leukocyte-poor Red Blood Cells

This product is similar to PRBCs combined with the removal of approximately 95- 99% of the
leukocytes. The removal of leukocytes helps to prevent a febrile reaction from leukocyte antibodies.
This product typically contains approximately 200 ml of volume.

Platelets and Fresh Frozen Plasma

Platelets: The transfusion of platelets is given to treat a patient that has a decreased platelet count
(thrombocytopenia) due to either a decreased platelet production or increased platelet destruction.
Platelet transfusions are also given to treat acute leukemia and bone marrow aplasia. A typical
platelet transfusion contains 35-50 ml per unit. Up to 10 units can be transfused at a time.
FRESH FROZEN PLASMA: Fresh frozen plasma (FFP) is a product in which plasma is separated
from RBCs. This plasma is rich in coagulation factors V, VIII and IX and may be given to expand
plasma volume, treat post-operative hemorrhage/shock or to correct an undetermined coagulation
factor deficiency.
FFP is indicated for urgent warfarin reversal and in liver disease with coagulopathy and bleeding.
This product is kept frozen until needed and then thawed in the blood bank. FFP typically contains
200 to 250 ml of volume and can be infused over 30-45 minutes.

Less Common Blood Products

Factor VIII (Cryoprecipitate or Cryo): This product is the insoluble portion of plasma recovered
from FFP. It is typically transfused to treat hemophilia A and to control bleeding associated with
factor VIII and/or fibrinogen deficiency. A normal fibrinogen level is between 200-400 mg/dl or 2.0-
4.0 g/L. If the patient’s fibrinogen level is < 100 mg/dl, a cryoprecipitate transfusion may be
indicated. The amount given depends on the patients underlying disease and the “goal” fibrinogen
level.

Cytomegalovirus (CMV) Negative Blood : This type of blood product does not contain CMV
antibodies. Leuco-reduced products, which are prepared by leukocyte reduction filters, are
considered to be CMV safe products and are equivalent to CMV negative blood. CMV negative

270
 blood may be used for premature infants, intrauterine transfusions, and CMV negative patients with
an immunosuppressed system or at risk for other reasons.

OVERVIEW OF BLOOD PRODUCTS & NURSING CONSIDERATIONS

Blood Product Actions Administration & timing Nursing Considerations

Whole Blood Improves tissue Max hangs time per unit: 4 Requires ABO and Rh
(RBC’s, WBC’s, oxygenation, hours from refrigerator crosshmatching.
Platelets, Plasma expands volume & removal. Recommended Rarely used today, except for
& electrolytes. promotes total infusion time in patients needing rapid, massive
coagulation. otherwise healthy adult: 1.5 replacement of lost volume
to 2 hours. (loss of more than 25% of total
blood volume).
Packed RBC’s Increases the oxygen Max hangs time per unit: 4 Composed of 70 -80%
(PRBCs) carrying capacity of hours from refrigerator hematocrit, so very viscous.
blood in anemic removal. Can split into Require ABO and Rh cross
patients; often used smaller bags. matching.
to replace blood lost
during surgery.
Blood Product Actions Administration & timing Nursing Considerations

Platelets Contain concentrate Max hangs time per unit: 4 Avoid filters to transfuse whole
made from whole hours from refrigerator blood or PRBCs, as red cell
blood (random removal or by expiration dedris accumulated in filter may
donor) or time marked on the unit trap platelets; use new filter
plasmapheresis label (whichever occurs instead.
(single donor); may first). Doesn’t require ABO and Rh
also contain plasma crosshmatching in adults.
and some RBCs and
WBCs.
Fresh Frozen Aids coagulation in Use as soon as possible after Use blood component recipient
Plasma actively bleeding thawing. Maximum hang set, and monitor coagulation
Contains normal patients with clotting time for one unit; 6 hours. studies. Needs ABO

271
components of deficiencies. crosshatching.
blood plasma,
including
fibrinogen.

BLOOD TESTING
Ensuring that the United States (U.S.) blood supply remains safe is the ultimate responsibility of the
nation's more than 3,000 blood establishments, which collect and process 14 million units of donated whole
blood each year. Blood transfusions are protected by layers of overlapping safeguards. Some of these
safeguards include accurate blood typing and cross matching testing. With blood typing, ABO and Rh
antigens can be detected in the blood of prospective blood donors and potential blood recipients. The ABO
system, Rh factors, and blood cross matching are critical factors in blood transfusion.

ABO SYSTEM

Human blood is grouped according to the presence or absence of these specific antigens. The two
major antigens, A and B, form the basis of the ABO system.

272
 It is important that the recipient not have antibodies to the donor’s RBCs. If this were to occur, there
could be a hypersensitivity reaction, which can vary from mild fever to anaphylaxis with severe
intravascular hemolysis.
To prevent an acute hemolytic transfusion reaction (AHTR), blood for transfusion must be of a
compatible ABO blood type. Patients should receive blood that matches their blood type.
Type O – (negative) whole blood or RBCs may be used for any patient in an emergent situation and
is known as the “universal donor."
Persons with Type AB + (positive) can receive blood from any blood type and are considered the
“universal recipient."

Compatible Red Blood Cell Types – DONOR

RECIPIENT Type O Type A Type B Type AB
Type AB X X X X
Type B X X
Type A X X
Type O X
ABO SYSTEM
Human blood is grouped according to the presence or absence of these specific antigens. The two
major antigens, A and B, form the basis of the ABO system.
It is important that the recipient not have antibodies to the donor’s RBCs. If this were to occur, there
could be a hypersensitivity reaction, which can vary from mild fever to anaphylaxis with severe
intravascular hemolysis.
To prevent an acute hemolytic transfusion reaction (AHTR), blood for transfusion must be of a
compatible ABO blood type. Patients should receive blood that matches their blood type.
Type O – (negative) whole blood or RBCs may be used for any patient in an emergent situation and
is known as the “universal donor."
Persons with Type AB + (positive) can receive blood from any blood type and are considered the
“universal recipient."
Rh Factor Testing
The presence or absence of the Rh antigen on the surface of the RBCs determines the
classification of Rh-positive or Rh-negative. Rh factor is the next most important antigen
associated with blood transfusion and ABO compatibility.

273
 If the Rh factor is absent, the patient is considered Rh-negative. If present, the person is
considered Rh-positive. All persons are either Rh positive or negative.
Rh-negative patients may develop antibodies to Rh antigens if exposed to Rh-positive blood
and should always receive Rh- negative blood. Rh-positive patients may receive either Rh-
positive or Rh-negative blood.
The table indicates the most common ABO and Rh factor types in the general population.

BLOOD TYPES
Blood Type % of General
(ABO & Rh) Population
O, + 35%
O, - * 7%
A, + 35%
A, - 7%
B, + 8%
B, - 2%
AB, + ~ 4%
AB, - 2%
*Universal donor ~Universal recipient Compatibility Testing

BLOOD CROSS MATCHING

Although typing for major ABO and Rh antigens is no guarantee that a reaction will not occur, it
does greatly reduce the possibility of such a reaction. Many potential minor antigens are not
routinely detected during blood typing.
If allowed to go unrecognized, these minor antigens also can initiate a blood transfusion reaction.
Therefore, blood is not only typed, but is also crossmatched to identify mismatch of blood caused by
minor antigens. Crossmatching consists of the mixing of the recipient’s serum with the donor’s
RBCs in a saline solution followed by the addition of the Coomb’s serum test.
Only blood products containing RBCs need to be crossmatched. Plasma products DO NOT need
to be crossmatched, but should be ABO compatible because other cells (WBCs and platelets) have
ABO antigens.

ADDITIONAL BLOOD TESTING

274
 There are a few additional tests which donated blood must undergo. Blood is tested for Human T-
Lymphotropic Virus, Types I and II, which can cause infections that can lead to leukemia or a
variety of neurologic diseases.
Donated blood is also tested for both active and previous infections with the bacteria that cause
syphilis.
PREMEDICATION
a) To minimize or prevent transfusion reactions, pharmacological agents may be ordered prior to the
commencement of a blood transfusion, such as acetaminophen (Tylenol) and diphenhydramine
(Benadryl). These agents can minimize fever and histamine release.
b) If there is a higsh risk of fluid overload, a diuretic such as furosemide (Lasix) may also be ordered prior
to the transfusion.
c) Febrile non hemolytic transfusions seem to be linked to certain blood components, such as platelets and
fresh frozen plasma, as opposed to packed red blood cells (Bielefeldt, S, 2009). These reactions are
mediated by donor leucocytes in the plasma, causing sensitization to human leucocyte antigens.
d) Use of blood products that have been leucocyte reduced or irradiated have been linked to reduced
complications stemming from an immunological response (Bielefeldt, S, 2009).
e) In organ transplant recipients, these products reduce the risk of graft rejection as well.

EQUIPMENT NEEDED FOR BLOOD PRODUCT ADMINISTRATION

The nurse will need the following supplies and equipment:
• Blood administration tubing with in-line filter
• IV pole or infusion pump
• Gloves
• Gown
• Face shield
• 250 ml .9% normal saline solution
• Venipuncture equipment (if the patient does not have a central or peripheral line in place)

SAFE BLOOD ADMINISTRATION

The following eight steps outline the appropriate procedure to safely administer blood.
Step 1
Double check the patient has a physician order for the actual transfusion of the product.
Unfortunately transfusion errors have occurred when the physician order reads to “type and cross 2
units of PRBCs” versus an order to “administer 2 units of PRBCs.” The first order is to only prepare

275
 the products (should the transfusion be needed at a future time), and not to actually administer the
product.
The second order is to actually administer the blood product. It is important for the nurse to
differentiate between these two types of orders.
You should also evaluate the patient’s need for a blood product. Question whether the laboratory
results and patient symptoms are consistent with the need for a blood product transfusion. If the
rationale is unclear, call the prescribing physician to clarify.

Step 2
Assess that the patient has a blood bank identification armband and/or barcode. Blood must never be
administered to a patient who has a “no blood” designation. Some hospitals have a “blood
conservation” armband. These patients have elected to not use blood products except in a medical
emergency.
Typically the “No Blood” or “Blood Conservation” armbands will only be removed if a patient has
changed an existing advance directive to indicate that blood products are acceptable. Follow your
hospital’s policy for all specific types of armbands and the process used to alter the armbands.

Step 3
Explain the procedure to the patient. Make sure there is a signed informed consent form (per hospital
policy) before the therapy is initiated. The physician is required (via the Paul Gann Act) to discuss
with patient (or legal representative), the benefits, risks, and possible alternatives to transfusion.
The physician is also required to document this information in the medical record.

Step 4
Obtain the patient’s blood pressure, heart rate, respiratory rate and temperature. Obtaining an
accurate temperature is important since febrile reactions are the most common reaction to blood
transfusions.
An increased temperature may be one of the first signs of impending reaction.
Ideally, it is helpful if the transfusion begins when the patient is afebrile or has an only low-grade
temperature of < 100-101 °s Fahrenheit. Follow your facility’s policies to guide you in regards to blood
transfusions and increasing temperature or fever.
Make sure you know and adhere to the window of time during which the product must be transfused
- starting from when the product arrives from the blood bank to when the infusion should be completed.

276
Failing to adhere to these times increases the risk of complications like bacterial contamination (Bielefeldt,
S., 2009).

Step 5
Do not administer any blood products if there is a patient related discrepancy.

Determine per hospital policy and physician’s order if the blood product is to be given via gravity
flow or through an infusion pump. For gravity infusions, a 20-gauge or larger catheter is
recommended. For transfusions administered via an infusion pump, a 22-gauge catheter may be
adequate (check with infusion pump manufacturer’s recommendations for specific catheter
requirements and your facility policy).
Prime the transfusion tubing using aseptic technique. Only 0.9% intravenous sodium chloride
solution should be used to push the blood tubing or blood bag. Dextrose solutions may lyse RBCs
and decrease RBC survival. The calcium contained in the Lactated Ringers (LR) solution may cause
clotting.

Step 6
Obtain whole blood, packed RBCs, or the blood product from the blood bank and begin
administering the product within 30 minutes of the transfusion start time. If there is an unexpected
delay with the initiation of the transfusion, return the blood to the blood bank approved refrigerator
as soon as possible. Most hospitals have a policy that the blood product will be discarded and
wasted if there is greater than a 30-minute delay in returning the blood.
Blood cannot be stored in the medication refrigerator on your unit. Blood can only be stored in
refrigerators continuously monitored by the hospital’s blood bank department.

Step 7
Perform a visual check of the product. Assess the blood product for any abnormalities in color, RBC
clumping, gas bubbles or extraneous material. Return outdated or abnormal blood to the blood bank.
Step 8

277
 Perform a bedside patient identification and blood product verification by two licensed individuals.
Check your facility’s policy for the definition of “licensed” personnel, but this typically includes
RNs, MDs, LVNs, and Perfusionists.

Compare the name and number on the patient’s wristband or barcode with those on the blood bag label.
Verify the following information:

• Patients full name

• Medical record number or other designated number
• Blood bank armband number
• Unit number
• Blood component type
• ABO/RH type compatibility
• Expiration date
Note: Upon completion of bedside verification, both persons verifying the accuracy of the patient
identification and blood product information will sign the transfusion record.

BLOOD ADMINISTRATION TIPS

It is always a good idea to review your hospital’s blood administration policy before administering
blood products. The following recommendations are generic and typically found in the policies of most
facilities.
• After the blood product has been co-assessed, put on gloves, a gown, and a face shield. Using a Y-type IV
blood tubing set (with built-in filter), close all clamps. Insert the spike of one Y line into the bag of the
.9% NS solution using aseptic technique. Next, open the port on the blood bag and insert the other Y
spike of the line into the blood product. Both Y tubings should be clamped.
• Hang the saline and blood products on an IV pole. Open the clamp on the line of the saline solution and
squeeze drip chamber until at least half full. Prime the tubing with the NS.
• Remember that the blood tubing cannot be piggybacked into an existing IV line. Do not add medications
or IV fluids other than normal saline to blood transfusions. Blood and blood products may be
administered through a needleless device.
 Record the patient’s vital signs per facility policy. Stay alert for signs and symptoms of a reaction, such
as fever, chills, flank pain, nausea, headache, urticaria, dyspnea, and bronchospasm.
• Optimal management of reactions begins with a standardized protocol for monitoring and documenting
vital signs (Bielefeldt, S., 2009).
• After completing the transfusion, put on gloves and remove the blood tubing and bag. Dispose of the IV
tubing and empty blood bag in the biohazardous containers or per your facility policy.
278
Most fatal reactions occur from human error. The most important step in preventing such error is to
follow your facility's policies and procedures for administering blood products

Blood Administration Filters

The standard blood administration set Y blood tubing has a built-in 170-260 micron filter designed
to remove debris and clots. This tubing must be used for administration of all blood and blood
components.
The entire surface of the filter must be filled with the component to improve flow rates. Each
standard blood administration set with built-in filter can be used for the transfusion of up to 2 units
of PRBC or for a maximum of 6 hours of total hang time. It is felt that microbial growth may
increase within the tubing when hanging for > 6 hours.
Leukocyte removal filters are used for leukocyte removal from the RBCs when pre- filtered
products are not available. Filters are generally issued from the blood bank. Each filter can be used
for only one unit of RBCs.
Micro aggregate filters are a 40-micron filter. These filters are used in conjunction with auto-
transfusions.
If a transfusion needs to be given slower than over a 4-hours period (for potential CHF or
hypervolemia), the unit of RBCs should be separated into smaller units in the blood blank. This
separation should be performed by blood bank personnel only
TRANSFUSION REACTIONS
Blood transfusion reactions occur when the recipient's immune system launches a response against a
component of the transfused product.
If the reaction occurs within the first few minutes of the transfusion, it is termed an acute reaction. A
reaction that develops hours to days later is termed a delayed reaction. Late reactions may go
undetected for days, weeks, or even months, and generally occur more than 48 hours after the
transfusion.
If red blood cells are destroyed, the reaction is further classified as hemolytic; all other types of
reactions are non-hemolytic (Bielefeldt, S., 2009). Some reactions result from infectious, chemical,
or physical forces or human error during blood product preparation.

TYPES OF TRANSFUSION REACTIONS

Type of Reaction Signs & Symptoms Nursing Interventions

279
Acute Hemolytic Classic triad of chills, flank pain & Stop transfusion immediately. Hydrate
Reaction blood stained urine with normal saline. Maintain airway,
breathing & circulation.
Delayed Hemolytic Mild fever, jaundice & decreased post As above, plus obtain pre-transfusion
Reaction transfusion hematocrit. bank specimens. If ordered, replace
lost blood with additional transfusion.
Febrile non- Fever, chills, flushing, nausea most Same management as for acute
hemolytic Reaction common type hemolytic reaction.
Anaphylactic Lack of fever, urticaria, dyspnea, chest Same as above, & administer steroids
Reaction tightness & hypotension, decreased & epinephrine as ordered.
oxygen saturation.
Bacterial Infection Fever or hypothermia, chills or rigors, Same as above, plus broad spectrum
abdominal pain, nausea. antibiotics as ordered. Notify blood
bank & lab. Draw cultures for testing.

MANAGEMENT OF TRANSFUSION REACTIONS

As soon as a transfusion reaction is suspected, the transfusion should be immediately stopped. With
new IV tubing, use NS at a rate to keep vein open for future IV access. Do not discard the blood or blood
tubing as the blood bank will require these for testing.
Follow your facility guidelines which likely indicate to:
• Notify the physician.
• Monitor vital signs every 5-15 minutes or as indicated by the severity and type of reaction.
• Compare the labels on all blood containers with corresponding patient identification forms to verify the
transfusion was the correct blood or blood product.
• Notify the blood bank when a possible hemolytic or septic transfusion reaction is suspected. Collect
blood and urine samples as ordered. Immediately send the samples, all transfusion containers (even if
empty), and the blood tubing to the blood bank. The blood bank will re-type and cross the patient with
the new blood specimen. The first voided urine specimen is analyzed for the presence of hemoglobin,
which indicates a hemolytic reaction. Closely monitor intake and output. Note evidence of oliguria or
anuria because hemoglobin deposits in the renal tubules can cause renal damage.
• If prescribed, administer oxygen, epinephrine, or other drugs and apply hypothermia blanket to reduce
fever.
• Make the patient as comfortable as possible and provide reassurance.
• Document the following:

280
• Time of the transfusion reaction.
• Type and amount of infused blood or blood product.
• Clinical signs of the transfusion reaction in order of occurrence.
• Vital signs.
• Specimens sent to the lab.
• Treatments given and patient are response to treatment.
• If required by your facility policy, complete the transfusion reaction form and any quality variance
forms.
RISK OF INFECTION

Transfusion-associated transmission (TAT) of infectious diseases includes HIV, hepatitis, and West Nile
virus (WNV). Blood in the U.S. is tested for:
• Hepatitis B and C viruses (HBV and HCV)
• Human Virus (HIV 1 and 2)
• Human T-Lymphotropic Virus, Types I and II (which can cause infections that can lead to leukemia or a
number of neurologic diseases).
• Syphilis (FDA, 2002)
• West Nile virus
In addition, the FDA has licensed the first nucleic acid test (NAT) system for screening donors of
blood components including red cells, fresh plasma and platelets. The NAT process recognizes the genetic
material of HCV and HIV, and can detect these infections before the appearance of their symptoms.

RISKS ASSOCIATED WITH BLOOD TRANSFUSION:

 Hepatitis: Hepatitis is the most common transfusion-transmitted infection. The tests that detect both
hepatitis B and C can produce false-negative results, and may allow some hepatitis cases to go
undetected. These viruses have a long seronegative period when they cannot be detected by
screening. Thus, donors may test negative for hepatitis, but in fact are infected with the virus. By the
time the hepatitis is detected, the donor blood may already be in use.
 Hepatitis C: accounts for more than 90% of transfusion-transmitted hepatitis cases. Approximately
2% are attributed to hepatitis B. All blood components and most blood products, except albumin, can
transmit hepatitis. High risk factors for hepatitis can be identified through pre-donation screening
questions that make certain patients ineligible to donate, thereby helping decrease the chances of
transmitting hepatitis. The risk of acquiring hepatitis C is approximately 1 in 103,000 transfusions.

281
  HIV: The estimated risk of acquiring human immunodeficiency virus (HIV) from a blood product is
approximately 1 in 493,000 transfusions. Although less than 20 HIV cases per year are transfusion-
related, this virus remains one of the most feared transfusion-transmitted infections for patients.
Identification of high-risk behaviors among potential donors, and the improved use of sensitive lab
assays have decreased the risk of HIV infection from donor blood. When testing for the antibodies to
HIV, the challenge is that these specific antibodies are not detectable until 6 to 12 weeks after
exposure
 CMV: Many blood banks screen blood for cytomegalovirus (CMV). Blood with CMV is especially
dangerous for an immunosuppressed or critically ill patient. An estimated 60% of blood donors carry
the virus. Transfusion of infected blood can cause CMV infection in the recipient. All leukocyte-
containing blood products, including whole blood and RBCs, transmit the virus.
 In critically ill patients, CMV is a major cause of increased morbidity and mortality. Post transfusion
infection with CMV can manifest within 2-4 weeks in immunocompetent patients, but more quickly
in critically ill patients. Symptoms include fever lasting 2 to 3 weeks, varying °s of hepatitis,
splenomegaly, and atypical lymphocytosis resembling that of mononucleosis.

CONCLUSION
Administration of blood and blood products is a common nursing activity, however, it carries with it
certain risks.
Knowledge about blood products and adherence to appropriate procedures for blood administration
is critical. Recognition of reactions and rapid treatment is essential for the safe administration of blood
products.
The nurse is the central healthcare provider who performs the pre-administration assessment, safely
infuses the product, monitors for potential adverse outcomes, and supports the patient through the entire
process.

282
 HAND WASHING
Hand washing is the simplest and most cost effective way of preventing the transmission of infection
and thus reducing the incidence of health-care associated infections

CDC HAND HYGIENE RECOMMENDATIONS:

1. INDICATIONS FOR HANDWASHING AND HAND ANTISEPSIS
 When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with
blood or other body fluids, wash hands with either a non-antimicrobial soap and water or an
antimicrobial soap and water.
 If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all
other clinical situations described in items Alternatively, wash hands with an antimicrobial soap and
water in all clinical situations described in items .Decontaminate hands before having direct contact with
patients.
 Decontaminate hands before donning sterile gloves when inserting a central intravascular catheter.
 Decontaminate hands before inserting indwelling urinary catheters, peripheral vascular catheters, or
other invasive devices that do not require a surgical procedure .Decontaminate hands after contact with a
patient's intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient)
 Decontaminate hands after contact with body fluids or excretions, mucous membranes, non intact skin,
and wound dressings if hands are not visibly soiled.
 Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care
G. Decontaminate hands after contact with inanimate objects (including medical equipment) in the
immediate vicinity of the patient’s. Decontaminate hands after removing gloves.
 Before eating and after using a restroom, wash hands with a non-antimicrobial soap andwater or with an
antimicrobial soap and water.
 Antimicrobial-impregnated wipes (i.e., towelettes) may be considered as an alternative towashing hands
with non-antimicrobial soap and water. Because they are not as effective as alcohol-based hand rubs or

283
 washing hands with an antimicrobial soap and water for reducing bacterial counts on the hands of
HCWs, they are not a substitute for using an alcohol-based hand rub or antimicrobial soap.
 Wash hands with non-antimicrobial soap and water or with antimicrobial soap and water if exposure to
Bacillus anthracis is suspected or proven. The physical action of washing and rinsing hands under such
circumstances is recommended because alcohols, chlorhexidine, iodophors, and other antiseptic agents
have poor activity against spores.
 No recommendation can be made regarding the routine use of non alcohol-based hand rubs for hand
hygiene in health-care settings. Unresolved issue.

2. HAND-HYGIENE TECHNIQUE
 When decontaminating hands with an alcohol-based hand rub, apply product to palm of one-hand and
rub hands together, covering all surfaces of hands and fingers, until hands are dry. Follow the
manufacturers’ recommendations regarding the volume of product to use.
 When washing hands with soap and water, wet hands first with water, apply an amount of product
recommended by the manufacturer to hands, and rub hands togethervigorously for at least 15 seconds,
covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a
disposable towel. Use towel to turn off the faucet. Avoid using hot water, because repeated exposure to
hot water may increase the risk of dermatitis.
 Liquid, bar, leaflet or powdered forms of plain soap are acceptable when washing hands with a non-
antimicrobial soap and water. When bar soap is used, soap racks that facilitate drainage and small bars of
soap should be used.
 Multiple-use cloth towels of the hanging or roll type are not recommended for use in health-care
settings.

3. SURGICAL HAND ANTISEPSIS

 Remove rings, watches, and bracelets before beginning the surgical hand scrub.
 Remove debris from underneath fingernails using a nail cleaner under running water.
 Surgical hand antisepsis using either an antimicrobial soap or an alcohol-based hand rub with persistent
activity is recommended before donning sterile gloves when performing surgical procedures.
 When performing surgical hand antisepsis using an antimicrobial soap, scrub hands and forearms for the
length of time recommended by the manufacturer, usually 2-6 minutes. Long scrub times (e.g., 10
minutes) are not necessary.
 When using an alcohol-based surgical hand-scrub product with persistent activity, follow the
manufacturer's instructions. Before applying the alcohol solution, prewash hands and forearms with a
284
 non-antimicrobial soap and dry hands and forearms completely. After application of the alcohol-based
product as recommended, allow hands and forearms to dry thoroughly before donning sterile gloves.

4. SELECTION OF HAND-HYGIENE AGENTS

 Provide personnel with efficacious hand-hygiene products that have low irritancy potential, particularly
when these products are used multiple times per shift. This recommendation applies to products used for
hand antisepsis before and after patient care in clinical areas and to products used for surgical hand
antisepsis by surgical personnel.
 To maximize acceptance of hand-hygiene products by HCWs, solicit input from these employees
regarding the feel, fragrance, and skin tolerance of any products under consideration. The cost of hand-
hygiene products should not be the primary factor influencing product selection.
 When selecting non-antimicrobial soaps, antimicrobial soaps, or alcohol-based hand rubs, solicit
information from manufacturers regarding any known interactions between products used to clean
hands, skin care products, and the types of gloves used in the institution.
 Before making purchasing decisions, evaluate the dispenser systems of various product manufacturers or
distributors to ensure that dispensers function adequately and deliver an appropriate volume of product.
 Do not add soap to a partially empty soap dispenser. This practice of "topping off" dispensers can lead to
bacterial contamination of soap.

5. SKIN CARE
 Provide HCWs with hand lotions or creams to minimize the occurrence of irritant contact dermatitis
associated with hand antisepsis or hand washing.
 Solicit information from manufacturers regarding any effects that hand lotions, creams, or alcohol-based
hand antiseptics may have on the persistent effects of antimicrobial soaps being used in the institution.

6. OTHER ASPECTS OF HAND HYGIENE

 Do not wear artificial fingernails or extenders when having direct contact with patients at high risk (e.g.,
those in intensive-care units or operating rooms).
 Keep natural nails tips less than 1/4-inch long.
 Wear gloves when contact with blood or other potentially infectious materials, mucous membranes, and
non-intact skin could occur.
 Remove gloves after caring for a patient. Do not wear the same pair of gloves for the care of more than
one patient, and do not wash gloves between uses with different patients.
 Change gloves during patient care if moving from a contaminated body site to a clean body site.
285
 No recommendation can be made regarding wearing rings in health-care settings.

PURPOSE
 Hand washing helps to remove micro-organisms that might cause disease.
 Washing with soap and water kills many transient micro-organisms and allows them to be
mechanically removed by rinsing.
 Washing with antimicrobial products kills or inhibits the growth of micro-organisms in deep layers
of the skin

TYPES OF HAND WASHING

 HAND WASHING Hand washing is usually limited to hands and wrists; the hands are
washed for a minimum of 10 – 15 seconds with soap (plain or
antimicrobial) and water.
 HAND ANTISEPSIS AND Hand antisepsis removes or destroys transient micro-organisms and
DECONTAMINATION confers a prolonged effect. It may be carried out in one of the
following two ways: Wash hands and forearms with antimicrobial
soap and water, for 15-30 seconds (following manufacturer’s
instructions).
Decontaminate hands with a waterless, alcohol-based hand gel or hand
rub for 15-30 seconds. This is appropriate for hands that are not soiled
with protein matter or fat. Immersion of hands in bowls of antiseptics
is not recommended
 SURGICAL HAND Surgical hand antisepsis removes or destroys transient micro-
ANTISEPSIS organisms and confers a prolonged effect. The hands and forearms are
washed thoroughly with an antiseptic soap for a minimum of 2-3
minutes. The hands are dried using a sterile towel. Surgical hand
antisepsis is required before performing invasive procedures.

FACILITIES AND MATERIALS REQUIRED FOR HAND

 WASHING
Running water
Access to clean water is essential. It is preferable to have running water and large washbasins with
hand-free controls, which require little maintenance and have antisplash devices. When no running water is

286
available use either a bucket with a tap, which can be turned on and off, a bucket and pitcher, or 60%-90 %
alcohol hand rub.

Materials used for hand washing/hand antisepsis

1. Soap: Plain or antimicrobial soap depending on the procedure.
2. Plain soap: Used for routine hand washing, available in bar, powder or liquid form.
3. Antimicrobial soap: Used for hand washing as well as hand antisepsis.
4. If bar soaps are used, use small bars and soap racks, which drain.
5. Do not allow bar soap to sit in a pool of water as it encourages the growth of some micro-organisms such
as pseudomonas.
6. Clean dispensers of liquid soap thoroughly every day.
7. When liquid soap containers are empty they must be discarded, not refilled with soap solution.

Specific antiseptics: recommended for hand antisepsis:

1. 2%-4% chlorhexidine,
2. 5%-7.5% povidone iodine,
3. 1% triclosan, or
4. 70% alcoholic hand rubs.
5. Waterless, alcohol-based hand rubs: with antiseptic and emollient gel and
6. Alcohol swabs, which can be applied to clean hands.
7. Dispensers should be placed outside each patient room.
8. Note: Alcohol hand-rubs are appropriate for rapid hand decontamination between patient contacts. They
are not a substitute for hand washing if hands are soiled.
 FACILITIES FOR DRYING HANDS
 Disposable towels, reusable single use towels or roller towels, which are suitably maintained, should be
available. If there is no clean dry towel, it is best to air-dry hands.
 Equipment and products are not equally accessible in all countries, or health care facilities.
 Flexibility in products and procedures, and sensitivity to local needs will improve compliance.
 In all cases, the best procedure possible should be instituted. Common towels must not be used as they
facilitate transmission of infection

STEPS IN HAND WASHING

PREPARING FOR HAND WASHING:
1. Remove jewellery (rings, bracelets) and watches before washing hands,
2. ensure that the nails are clipped short (do not wear artificial nails),
3. Roll the sleeves up to the elbow.

287
4. Wet the hands and wrists, keeping hands and wrists lower than the elbows. (permits the water to flow to
the fingertips, avoiding arm contamination).
5. Apply soap (plain or antimicrobial) and lather thoroughly.
6. Use firm, circular motions to wash the hands and arms up to the wrists, covering all areas including
palms, back of the hands, fingers, between fingers and lateral side of fifth finger, knuckles, and wrists.
Rub for minimum of 10-15 seconds.
7. Repeat the process if the hands are very soiled. Clean under the fingernails.
8. Rinse hands thoroughly, keeping the hands lower than the forearms.
9. If running water is not available, use a bucket and pitcher.
10. Do no dip your hands into a bowl to rinse, as this re contaminates them. Collect used water in a basin
and discard in a sink, drain or toilet.
11. Dry hands thoroughly with disposable paper towel or napkins, clean dry towel, or air-dry them. Discard
the towel if used, in an appropriate container without touching the bin lids with hand. Use a paper towel,
clean towel or your elbow/foot to turn off the faucet to prevent recontamination.

USING ANTISEPTICS, HAND RUBS, GELS OR ALCOHOL SWABS FOR HAND ANTISEPSIS
1. Apply the product to the palm of one hand. The volume needed to apply varies by product
2. Rub hands together, covering all surfaces of hands and fingers, until hands are dry.
3. Do not rinse. When there is visible soiling of hands, they should first be washed with soap and water
before using waterless hand rubs, gels or alcohol swabs.
4. If soap and water are unavailable, hands should first be cleansed with detergent-containing towellettes,
before using the alcohol-based hand rub, gel or swab.
 2-3 minutes hand wash upto elbows before entering NICU.
 15-30 seconds hand wash in between / before handling babies.

288
289
 STERILIZATION AND DISINFECTION
STERILIZATION
It is defined as the process where all the living microorganisms, including bacterial spores are killed.
Sterilization can be achieved by physical, chemical and physiochemical means. Chemicals used as
sterilizing agents are called chemi-sterilants.

DISINFECTION
It is the process of elimination of most pathogenic microorganisms (excluding bacterial spores) on
inanimate objects.
Disinfection can be achieved by physical or chemical methods. Chemicals used in disinfection are
called disinfectants. Different disinfectants have different target ranges, not all disinfectants can kill all
microorganisms. Some methods of disinfection such as filtration do not kill bacteria, they separate them out.
Sterilization is an absolute condition while disinfection is not. The two are not synonymous.

 DECONTAMINATION is the process of removal of contaminating pathogenic microorganisms

from the articles by a process of sterilization or disinfection. It is the use of physical or chemical
means to remove, inactivate, or destroy
 living organisms on a surface so that the organisms are no longer infectious.

 SANITIZATION is the process of chemical or mechanical cleansing, applicable in public health

systems. Usually used by the food industry. It reduces microbes on eating utensils to safe, acceptable
levels for public health.

 ASEPSIS is the employment of techniques (such as usage of gloves, air filters, uv rays etc) to
achieve microbe-free environment.

 ANTISEPSIS is the use of chemicals (antiseptics) to make skin or mucus membranes devoid of
pathogenic microorganisms.

 BACTERIOSTASIS is a condition where the multiplication of the bacteria is inhibited without

killing them.

290
  BACTERICIDAL is that chemical that can kill or inactivate bacteria. Such chemicals may be called
variously depending on the spectrum of activity, such as bactericidal, virucidal, fungicidal,
microbicidal, sporicidal, tuberculocidal or germicidal.

 ANTIBIOTICS are substances produced by one microbe that inhibits or kills another microbe.
Often the term is used more generally to include synthetic and semi-synthetic antimicrobial agents.

METHODS OF STERILIZATION /DISINFECTION

PHYSICAL METHODS OF STERILIZATION:

 SUNLIGHT: The microbicidal activity of sunlight is mainly due to the presence of ultra violet rays in it.
It is responsible for spontaneous sterilization in natural conditions. In tropical countries, the sunlight is
more effective in killing germs due to combination of ultraviolet rays and heat. By killing bacteria
suspended in water, sunlight provides natural method of disinfection of water bodies such as tanks and
lakes. Sunlight is not sporicidal, hence it does not sterilize.

 HEAT: Heat is considered to be most reliable method of sterilization of articles that can withstand heat.
Heat acts by oxidative effects as well as denaturation and coagulation of proteins. Those articles that
cannot withstand high temperatures can still be sterilized at lower temperature by prolonging the
duration of exposure.
FACTORS AFFECTING STERILIZATION BY HEAT ARE:

291
1. Nature of heat: Moist heat is more effective than dry heat
2. Temperature and time: temperature and time are inversely proportional. As temperature increases the
time taken decreases.
3. Number of microorganisms: More the number of microorganisms, higher the temperature or longer the
duration required.
4. Nature of microorganism: Depends on species and strain of microorganism, sensitivity to heat may vary.
5. Spores are highly resistant to heat.
6. Type of material: Articles that are heavily contaminated require higher temperature or prolonged
exposure.
7. Certain heat sensitive articles must be sterilized at lower temperature.
8. Presence of organic material: Organic materials such as protein, sugars, oils and fats increase the time
required.
ACTION OF HEAT
Dry heat acts by protein denaturation, oxidative damage and toxic effects of elevated levels of
electrolytes. The moist heat acts by coagulation and denaturation of proteins.
Moist heat is superior to dry heat in action. Temperature required to kill microbe by dry heat is more
than the moist heat. Thermal death time is the minimum time required to kill a suspension of
organisms at a predetermined temperature in a specified environment.

DRY HEAT:
Articles such as bacteriological loops, straight wires, tips of forceps and searing spatulas are
sterilized by holding them in Bunsen flame till they become red hot. This is a simple method for
effective sterilization of such articles, but is limited to those articles that can be heated to redness in
flame.

FLAMING:
This is a method of passing the article over a Bunsen flame, but not heating it to redness. Articles
such as scalpels, mouth of test tubes, flasks, glass slides and cover slips are passed through the flame
a few times.
Even though most vegetative cells are killed, there is no guarantee that spores too would die on such
short exposure.This method too is limited to those articles that can be exposed to flame. Cracking of
the glassware may occur.

INCINERATION:

292
 This is a method of destroying contaminated material by burning them in incinerator. Articles such
as soiled dressings; animal carcasses, pathological material and bedding etc should be subjected to
incineration. This technique results in the loss of the article, hence is suitable only for those articles
that have to be disposed. Burning of polystyrene materials emits dense smoke, and hence they should
not be incinerated.

HOT AIR OVEN:

This method was introduced by Louis Pasteur. Articles to be sterilized are exposed to high
temperature (160° C) for duration of one hour in an electrically heated oven. Since air is poor
conductor of heat, even distribution of heat throughout the chamber is achieved by a fan.
The heat is transferred to the article by radiation, conduction and convection. The oven should be
fitted with a thermostat control, temperature indicator, meshed shelves and must have adequate
insulation.

ARTICLES STERILIZED:
Metallic instruments (like forceps, scalpels, and scissors), glassware’s (such as Petri-dishes, pipettes,
flasks, all-glass syringes), swabs, oils, grease, petroleum jelly and some pharmaceutical products.
Sterilization process: Articles to be sterilized must be perfectly dry before placing them inside to
avoid breakage.
Articles must be placed at sufficient distance so as to allow free circulation of air in between. Mouths
of flasks, test tubes and both ends of pipettes must be plugged with cotton wool. Articles such as
petri dishes and pipettes may be arranged inside metal canisters and then placed. Individual glass
articles must be wrapped in Kraft paper or aluminum foils.

STERILIZATION CYCLE:
This takes into consideration the time taken for the articles to reach the sterilizing temperature,
maintenance of the sterilizing temperature for a defined period (holding time) and the time taken for
the articles to cool down.
Different temperature-time relations for holding time are 60 minutes at 160°C, 40 minutes at 170°C
and 20 minutes at 180oC. Increasing temperature by 10 °s shortens the sterilizing time by 50 percent.
The hot air oven must not be opened until the temperature inside has fallen below 60°C to prevent
breakage of glassware’s. Sterilization control: Three methods exist to check the efficacy of
sterilization process, namely physical, chemical and biological. Physical: Temperature chart recorder
and thermocouple.

293
 Chemical: Browne’s tube No.3 (green spot, color changes from red to green)
 Biological: 106 spores of Bacillus subtilis var niger or Clostridium tetani on paper strips are placed
inside envelopes and then placed inside the hot air oven. Upon completion of sterilization cycle, the
strips are removed and inoculated into thioglycollate broth or cooked meat medium and incubated at
37°C for 3-5 days. Proper sterilization should kill the spores and there should not be any growth.
ADVANTAGES
1. It is an effective method of sterilization of heat stable articles.
2. The articles remain dry after sterilization.
3. This is the only method of sterilizing oils and powders.
DISADVANTAGES
1. Since air is poor conductor of heat, hot air has poor penetration.
2. Cotton wool and paper may get slightly charred.
3. Glasses may become smoky.
4. Takes longer time compared to autoclave.

INFRA RED RAYS:

Infrared rays bring about sterilization by generation of heat. Articles to be sterilized are placed in a
moving conveyer belt and passed through a tunnel that is heated by infrared radiators to a
temperature of 180°C.The articles are exposed to that temperature for a period of 7.5 minutes.
Articles sterilized included metallic instruments and glassware. It is mainly used in central sterile
supply department. It requires special equipments,hence is not applicable in diagnostic laboratory.
Efficiency can be checked using Browne’s tube No.4 (blue spot).

MOIST HEAT:
Moist heat acts by coagulation and denaturation of proteins.
At temperature below 100°C:
PASTEURIZATION:
This process was originally employed by Louis Pasteur. Currently this procedure is employed in
food and dairy industry. There are two methods of pasteurization, the holder method (heated at 63°C
for 30 minutes) and flash method (heated at 72°C for 15 seconds) followed by quickly cooling to
13°C.Other pasteurization methods include Ultra-High Temperature (UHT), 140°C for 15 sec and
149°C for 0.5 sec.

294
 This method is suitable to destroy most milk borne pathogens like Salmonella, Mycobacteria,
Streptococci, Staphylococci and Brucella, however Coxiella may survive pasteurization. Efficacy is
tested by phosphatase test and methylene blue test.
VACCINE BATH
The contaminating bacteria in a vaccine preparation can be inactivated by heating in a water bath at
60°C for one hour. Only vegetative bacteria are killed and spores survive.

SERUM BATH
The contaminating bacteria in a serum preparation can be inactivated by heating in a water bath at
56°C for one hour on several successive days. Proteins in the serum will coagulate at higher
temperature. Only vegetative bacteria are killed and spores survive.

INSPISSATIONS
This is a technique to solidify as well as disinfect egg and serum containing media. The medium
containing serum or egg are placed in the slopes of an inspissator and heated at 80-85°C for 30
minutes on three successive days.
On the first day, the vegetative bacteria would die and those spores that germinate by next day are
then killed the following day. The process depends on germination of spores in between
inspissations. If the spores fail to germinate then this technique cannot be considered sterilization.

AT TEMPERATURE 100°C:
Boiling
Boiling water (100°C) kills most vegetative bacteria and viruses immediately. Certain bacterial
toxins such as Staphylococcal enterotoxins are also heat resistant. Some bacterial spores are resistant
to boiling and survive; hence this is not a substitute for sterilization.
The killing activity can be enhanced by addition of 2% sodium bicarbonate. When absolute sterility
is not required, certain metal articles and glassware’s can be disinfected by placing them in boiling
water for 10-20 minutes. The lid of the boiler must not be opened during the period.

Steam at 100°C
Instead of keeping the articles in boiling water, they are subjected to free steam at
100oC.Traditionally Arnold’s and Koch’s steamers were used. An autoclave (with discharge tap
open) can also serve the same purpose.

295
 A steamer is a metal cabinet with perforated trays to hold the articles and a conical lid. The bottom of
steamer is filled with water and heated. The steam that is generated sterilizes the articles when
exposed for a period of 90 minutes. Media such as TCBS, DCA and selenite broth are sterilized by
steaming. Sugar and gelatin in medium may get decomposed on autoclaving; hence they are exposed
to free steaming for 20 minutes for three successive days.
This process is known as tyndallisation (after John Tyndall) or fractional sterilization or intermittent
sterilization. The vegetative bacteria are killed in the first exposure and the spores that germinate by
next day are killed in subsequent days. The success of process depends on the germination of spores.

AT TEMPERATURE ABOVE 100°C:

Autoclave
Sterilization can be effectively achieved at a temperature above 100°C using an autoclave. Water
boils at 100°C at atmospheric pressure, but if pressure is raised, the temperature at which the water
boils also increases.
In an autoclave the water is boiled in a closed chamber. As the pressure rises, the boiling point of
water also raises. At a pressure of 15 lbs inside the autoclave, the temperature is said to be 121°C.
Exposure of articles to this temperature for 15 minutes sterilizes them.
To destroy the infective agents associated with spongiform encephalopathy’s (prions), higher
temperatures or longer times are used; 135°C or 121°C for at least one hour are recommended.

Advantages of steam:
It has more penetrative power than dry air, it moistens the spores (moisture is essential for
coagulation of proteins), condensation of steam on cooler surface releases latent heat, condensation
of steam draws in fresh steam. Different types of autoclave: Simple “pressure-cooker type”
laboratory autoclave, Steam jacketed downward displacement laboratory autoclave and high pressure
pre-vacuum autoclave

Construction and operation of autoclave

A simple autoclave has vertical or horizontal cylindrical body with a heating element, a perforated
try to keep the articles, a lid that can be fastened by screw clamps, a pressure gauge, a safety valve
and a discharge tap. The articles to be sterilized must not be tightly packed.

296
 The screw caps and cotton plugs must be loosely fitted. The lid is closed but the discharge tap is kept
open and the water is heated. As the water starts boiling, the steam drives air out of the discharge tap.
When all the air is displaced and steam start appearing through the discharge tap, the tap is closed.
The pressure inside is allowed to rise upto 15 lbs per square inch. At this pressure the articles are
held for 15 minutes, after which the heating is stopped and the autoclave is allowed to cool. Once the
pressure gauge shows the pressure equal to atmospheric pressure, the discharge tap is opened to let
the air in. The lid is then opened and articles removed.

ARTICLES STERILIZED:
Culture media, dressings, certain equipment, linen etc.
Precautions
Articles should not be tightly packed, the autoclave must not be overloaded, air discharge must be
complete and there should not be any residual air trapped inside, caps of bottles and flasks should not
be tight, autoclave must not be opened until the pressure has fallen or else the contents will boil over,
articles must be wrapped in paper to prevent drenching, bottles must not be overfilled.
Advantage
Very effective way of sterilization, quicker than hot air oven.
Disadvantages
Drenching and wetting or articles may occur, trapped air may reduce the efficacy, takes long time to
Cool.

Sterilization control

297
 Physical method includes automatic process control, thermocouple and temperature chart recorder.
Chemical method includes Browne’s tube No.1 (black spot) and succinic acid (whose melting point
is 121oC) and Bowie Dick tape.
Bowie Dick tape is applied to articles being autoclaved. If the process has been satisfactory, dark
brown stripes will appear across the tape. Biological method includes a paper strip containing 106
spores of Geobacillus stearothermophilus.

RADIATION
Non-ionizing rays are low energy rays with poor penetrative power while ionizing rays are high-
energy rays with good penetrative power.
Since radiation does not generate heat, it is termed "cold sterilization". In some parts of Europe,
fruits and vegetables are irradiated to increase their shelf life up to 500 percent.
Two types of radiation are used, ionizing and non-ionizing.

Non-ionizing rays
Rays of wavelength longer than the visible light are non-ionizing. Microbicidal wavelength of UV
rays lie in the range of 200-280 nm, with 260 nm being most effective. UV rays are generated using
a high-pressure mercury vapor lamp.
It is at this wavelength that the absorption by the microorganisms is at its maximum, which results in
the germicidal effect. UV rays induce formation of thymine-thymine dimmers, which ultimately
inhibits DNA replication. UV readily induces mutations in cells, Eradicated with a non-lethal dose.
Microorganisms such as bacteria, viruses, yeast, etc. that are exposed to the effective UV radiation
are inactivated within seconds. Since UV rays don’t kill spores, they are considered to be of use in
surface disinfection.
UV rays are employed to disinfect hospital wards, operation theatres, virus laboratories, corridors,
etc. Disadvantages of using UV rays include low penetrative power, limited life of the UV bulb,
some bacteria have DNA repair enzymes that can overcome damage caused by UV rays, organic
matter and dust prevents its reach, rays are harmful to skin and eyes. It doesn't penetrate glass, paper
or plastic.

Ionizing rays
Ionizing rays are of two types, particulate and electromagnetic rays. Electron beams are particulate in
nature while gamma rays are electromagnetic in nature. High speed electrons are produced by a
linear accelerator from a heated cathode.

298
 Electron beams are employed to sterilize articles like syringes, gloves, dressing packs, foods and
pharmaceuticals. Sterilization is accomplished in few seconds. Unlike electromagnetic rays, the
instruments can be switched off. Disadvantage includes poor penetrative power and requirement of
sophisticated equipment.

Electromagnetic rays
Some gamma rays emanate from nuclear disintegration of certain radioactive isotopes (Co 60,
Cs137). They have more penetrative power than electron beam but require longer time of exposure.
These high-energy radiations damage the nucleic acid of the microorganism.
A dosage of 2.5 megarads kills all bacteria, fungi, viruses and spores. It is used commercially to
sterilize disposable Petri dishes, plastic syringes, antibiotics, vitamins, hormones, glassware’s and
fabrics.
Disadvantages include; unlike electron beams, they can’t be switched off, glassware’s tend to become
brownish, loss of tensile strength in fabric. Gamma irradiation impairs the flavor of certain foods. Bacillus
pumilus E601 is used to evaluate sterilization process.

FILTRATION:
Filtration does not kill microbes, it separates them out. Membrane filters with pore sizes between
0.2-0.45 μm are commonly used to remove particles from solutions that can't be autoclaved.
It is used to remove microbes from heat labile liquids such as serum, antibiotic solutions, sugar
solutions, urea solution. Various applications of filtration include removing bacteria from ingredients
of culture media, preparing suspensions of viruses and phages free of bacteria, measuring sizes of
viruses, separating toxins from culture filtrates, counting bacteria, clarifying fluids and purifying
hydatid fluid.
Filtration is aided by using either positive or negative pressure using vacuum pumps. The older
filters made of earthenware or asbestos are called depth filters.
DIFFERENT TYPES OF FILTERS ARE:
1. Earthenware filters: These filters are made up of diatomaceous earth or porcelain. They are usually
baked into the shape of candle. Different types of earthenware filters are:
a. Pasteur-Chamberland filter: These candle filters are from France and are made up of porcelain (sand
and kaolin). Similar filter from Britain is Doulton. Chamberland filters are made with various porosities,
which are graded as L1, L1a, L2, L3, L5, L7, L9 and L11. Doulton filters are P2, P5 andP11.
b. Berkefeld filter: These are made of Kieselguhr, a fossilized diatomaceous earth found in Germany.
They are available in three grades depending on their porosity (pore size); they are V (veil), N (normal)

299
 and W (wenig). Quality of V grade filter is checked using culture suspension of Serrtia marcescens (0.75
μm).
c. Mandler filter: This filter from America is made of kieselguhr, asbestos and plaster of Paris.
2. Asbestos filters: These filters are made from chrysotile type of asbestos, chemically composed of
magnesium silicate. They are pressed to form disc, which are to be used only once. The disc is held
inside a metal mount, which is sterilized by autoclaving. They are available in following grades;
HP/PYR (for removal of pyrogens), HP/EKS (for absolute sterility) and HP/EK (for clarifying).
3. Sintered glass filters: These are made from finely ground glass that is fused sufficiently to make small
particles adhere to each other. They are usually available in the form of disc fused into a glass funnel.
Filters of Grade 5 have average pore diameter of 1-1.5 μm. They are washed in running water in reverse
direction and cleaned with warm concentrated H2SO4 and sterilized by autoclaving
4. Membrane filters: These filters are made from a variety of polymeric materials such as cellulose nitrate,
cellulose diacetate, polycarbonate and polyester. The older type of membrane, called gradocol
(gradedcolloidion) membrane was composed of cellulose nitrate. Gradocol membranes have average
pore diameter of 3-10 μm. The newer ones are composed of cellulose diacetate. These membranes have
a pore diameter ranging from 0.015 μm to 12 μm. These filters are sterilized by autoclaving. Membrane
filters are made in two ways, the capillary pore membranes have pores produced by radiation while the
labyrinthine pore membranes are produced by forced evaporation of solvents from cellulose esters. The
disadvantages of depth filters are migration of filter material into the filtrate, absorption or retention of
certain volume of liquid by the filters, pore sizes are not definite and viruses and mycoplasma could pass
through. The advantages of membrane filters are known porosity, no retention of fluids, and reusable
after autoclaving and compatible with many chemicals. However, membrane filters have little loading
capacity and are fragile.
5. Air Filters: Air can be filtered using HEPA (High Efficiency Particle Air) filters. They are usually used
in biological safety cabinets. HEPA filters are at least 99.97% efficient for removing particles >0.3 μm
in diameter. Examples of areas where HEPA filters are used include rooms housing severely neutropenic
patients and those operating rooms designated for orthopedic implant procedures. HEPA filter efficiency
is monitored with the dioctylphthalate (DOP) particle test using particles that are 0.3 μm in diameter.

 SONIC AND ULTRASONIC VIBRATIONS

Sound waves of frequency >20,000 cycle/second kills bacteria and some viruses on exposing for one
hour. Microwaves are not particularly antimicrobial in themselves, rather the killing effect of
microwaves are largely due to the heat that they generate. High frequency sound waves disrupt cells.

300
 They are used to clean and disinfect instruments as well as to reduce microbial load. This method is not
reliable since many viruses and phages are not affected by these waves.

CHEMICAL METHODS OF DISINFECTION

Disinfectants are those chemicals that destroy pathogenic bacteria from inanimate surfaces. Some
chemical have very narrow spectrum of activity and some have very wide. Those chemicals that can sterilize
are called chemisterilants. Those chemicals that can be safely applied over skin and mucus membranes are
called antiseptics.
An ideal antiseptic or disinfectant should have following properties:
 Should have wide spectrum of activity
 Should be able to destroy microbes within practical period of time
 Should be active in the presence of organic matter
 Should make effective contact and be wettable
 Should be active in any pH
 Should be stable
 Should have long shelf life
 Should be speedy
 Should have high penetrating power
 Should be non-toxic, non-allergenic, non-irritative or non-corrosive
 Should not have bad odors
 Should not leave non-volatile residue or stain
 Efficacy should not be lost on reasonable dilution
 Should not be expensive and must be available easily
Such an ideal disinfectant is not yet available. The level of disinfection achieved depends on contact
time, temperature, type and concentration of the active ingredient, the presence of organic matter, the
type and quantum of microbial load. The chemical disinfectants at working concentrations rapidly lose
their strength on standing.

CLASSIFICATION OF DISINFECTANTS
CLASSIFICATION
1. Based on consistency 2. Based on spectrum of 3. Based on mechanism of action
a. Liquid (E.g., Alcohols, activity a. Action on membrane

301
Phenols) a. High level (E.g., Alcohol, detergent)
b. Gaseous (Formaldehyde b. Intermediate level b. Denaturation of cellular proteins
vapor, Ethylene oxide) c. Low level (E.g., Alcohol, Phenol)
c. Oxidation of essential sulphydryl groups
of enzymes
(E.g., H2O2, Halogens)
d. Alkylation of amino-, carboxyl- and
hydroxyl group (E.g., Ethylene Oxide,
Formaldehyde)
e. Damage to nucleic acids (Ethylene
Oxide, Formaldehyde)

ALCOHOLS:
Mode of action: Alcohols dehydrate cells, disrupt membranes and cause coagulation of protein.
Examples: Ethyl alcohol, isopropyl alcohol and methyl alcohol
Application: A 70% aqueous solution is more effective at killing microbes than absolute alcohols.
70% ethyl alcohol (spirit) is used as antiseptic on skin. Isopropyl alcohol is preferred to ethanol. It
can also be used to disinfect surfaces. It is used to disinfect clinical thermometers. Methyl alcohol
kills fungal spores, hence is useful in disinfecting inoculation hoods.
Disadvantages: Skin irritant, volatile (evaporates rapidly), inflammable

ALDEHYDES:
Mode of action: Acts through alkylation of amino-, carboxyl- or hydroxyl group, and probably
damages nucleic acids. It kills all microorganisms, including spores.
Examples: Formaldehyde, Gluteraldehyde
Application: 40% Formaldehyde (formalin) is used for surface disinfection and fumigation of
rooms, chambers, operation theatres, biological safety cabinets, wards, sick rooms etc. Fumigation is
achieved by boiling formalin, heating paraformaldehyde or treating formalin with potassium
permanganate. It also sterilizes bedding, furniture and books. 10% formalin with 0.5% tetraborate
sterilizes clean metal instruments. 2% gluteraldehyde is used to sterilize thermometers, cystoscopes,
bronchoscopes, centrifuges, anesthetic equipments etc. An exposure of at least 3 hours at alkaline pH
is required for action by gluteraldehyde. 2% formaldehyde at 40oC for 20 minutes is used to
disinfect wool and 0.25% at 60oC for six hours to disinfect animal hair and bristles.

302
 Disadvantages: Vapors are irritating (must be neutralized by ammonia), has poor penetration, leaves
non-volatile residue, activity is reduced in the presence of protein. Gluteraldehyde requires alkaline
pH and only those articles that are wet table can be sterilized.

PHENOL:
Mode of action: Act by disruption of membranes, precipitation of proteins and inactivation of
enzymes.
Examples: 5% phenol, 1-5% Cresol, 5% Lysol (a saponified cresol), hexachlorophene,
chlorhexidine, chloroxylenol (Dettol)
Applications:
 Joseph Lister used it to prevent infection of surgical wounds. Phenols are coal-tar derivatives.
They act as disinfectants at high concentration and as antiseptics at low concentrations. They
are bactericidal, fungicidal, mycobactericidal but are inactive against spores and most viruses.
They are not readily inactivated by organic matter.
 The corrosive phenolics are used for disinfection of ward floors, in discarding jars in
laboratories and disinfection of bedpans. Chlorhexidine can be used in an isopropanol
solution for skin disinfection, or as an aqueous solution for wound irrigation.
 It is often used as an antiseptic hand wash. 20% Chlorhexidine gluconate solution is used for
pre-operative hand and skin preparation and for general skin disinfection.
 Chlorhexidine gluconate is also mixed with quaternary ammonium compounds such as
cetrimide to get stronger and broader antimicrobial effects (eg. Savlon).
 Chloroxylenols are less irritant and can be used for topical purposes and are more effective
against gram positive bacteria than gram negative bacteria. Hexachlorophene is chlorinated
diphenyl and is much less irritant. It has marked effect over gram positive bacteria but poor
effect over gram negative bacteria, mycobacteria, fungi and viruses. Triclosan is organic
phenyl ether with good activity against gram
positive bacteria and effective to some extent against many gram negative bacteria including
Pseudomonas. It also has fair activity on fungi and viruses
Disadvantages: It is toxic, corrosive and skin irritant. Chlorhexidine is inactivated by anionic soaps.
Chloroxylenol is inactivated by hard water.

 HALOGENS:
Mode of action: They are oxidizing agents and cause damage by oxidation of essential sulfydryl
groups of enzymes. Chlorine reacts with water to form hypochlorous acid, which is microbicidal.

303
 Examples: Chlorine compounds (chlorine, bleach, hypochlorite) and iodine compounds (tincture
iodine, iodophores)
Applications: Tincture of iodine (2% iodine in 70% alcohol) is an antiseptic. Iodine can be
combined with neutral carrier polymers such as polyvinylpyrrolidone to prepare iodophores such as
povidone-iodine. Iodophores permit slow release and reduce the irritation of the antiseptic. For hand
washing iodophores are diluted in 50% alcohol. 10% Povidone Iodine is used undiluted in pre and
postoperative skin disinfection. Chlorine gas is used to bleach water. Household bleach can be used
to disinfect floors. Household bleach used in a stock dilution of 1:10. In higher concentrations
chlorine is used to disinfect swimming pools. 0.5% sodium hypochlorite is used in serology and
virology. Used at a dilution of 1:10 in decontamination of spillage of infectious material. Mercuric
chloride is used as a disinfectant.
Disadvantages: They are rapidly inactivated in the presence of organic matter. Iodine is corrosive
and staining.
Bleach solution is corrosive and will corrode stainless steel surfaces.

 HEAVY METALS:
Mode of action: Act by precipitation of proteins and oxidation of sulfydryl groups. They are
bacteriostatic.
Examples: Mercuric chloride, silver nitrate, copper sulfate, organic mercury salts (e.g.,
mercurochrome,
merthiolate)
Applications: 1% silver nitrate solution can be applied on eyes as treatment for opthalmia
neonatorum (Crede’s method). This procedure is no longer followed. Silver sulphadiazine is used
topically to help to prevent colonization and infection of burn tissues. Mercurials are active against
viruses at dilution of 1:500 to 1:1000. Merthiolate at a concentration of 1:10000 is used in
preservation of serum. Copper salts are used as a fungicide.
Disadvantages: Mercuric chloride is highly toxic, are readily inactivated by organic matter.

 SURFACE ACTIVE AGENTS

Mode of actions: They have the property of concentrating at interfaces between lipid containing
membrane of bacterial cell and surrounding aqueous medium. These compounds have long chain
hydrocarbons that are fat soluble and charged ions that are water-soluble. Since they contain both of
these, they concentrate on the surface of membranes. They disrupt membrane resulting in leakage of
cell constituents.

304
 Examples: These are soaps or detergents. Detergents can be anionic or cationic. Detergents
containing negatively charged long chain hydrocarbon are called anionic detergents. These include
soaps and bile salts. If the fat-soluble part is made to have a positive charge by combining with a
quaternary nitrogen atom, it is called cationic detergents. Cationic detergents are known as
quaternary ammonium compounds (or quat). Cetrimide and benzalkonium chloride act as cationic
detergents.
Application: They are active against vegetative cells, Mycobacteria and enveloped viruses. They are
widely used as disinfectants at dilution of 1-2% for domestic use and in hospitals.
Disadvantages: Their activity is reduced by hard water, anionic detergents and organic matter.
Pseudomonas can metabolise cetrimide, using them as a carbon, nitrogen and energy source.

 DYES:
Mode of action: Acridine dyes are bactericidal because of their interaction with bacterial nucleic
acids.
Examples: Aniline dyes such as crystal violet, malachite green and brilliant green. Acridine dyes
such as acriflavin and aminacrine. Acriflavine is a mixture of proflavine and euflavine. Only
euflavine has effective antimicrobial properties. A related dye, ethidium bromide, is also germicidal.
It intercalates between base pairs in DNA. They are more effective against gram positive bacteria
than gram negative bacteria and are more bacteriostatic in action.
Applications: They may be used topically as antiseptics to treat mild burns. They are used as paint
on the skin to treat bacterial skin infections. The dyes are used as selective agents in certain selective
media.

 HYDROGEN PEROXIDE:
Mode of action: It acts on the microorganisms through its release of nascent oxygen. Hydrogen
peroxide produces hydroxyl-free radical that damages proteins and DNA.
Application: It is used at 6% concentration to decontaminate the instruments, equipments such as
ventilators. 3% Hydrogen Peroxide Solution is used for skin disinfection and deodorizing wounds
and ulcers. Strong solutions are Sporicidal
Disadvantages: Decomposes in light, broken down by catalase, proteinaceous organic matter
drastically reduces its activity.

 ETHYLENE OXIDE (EO):

305
 Mode of action: It is an alkylating agent. It acts by alkylating sulfydryl-, amino-, carboxyl- and
hydroxyl- groups.
Properties: It is a cyclic molecule, which is a colorless liquid at room temperature. It has a sweet
ethereal odor, readily polymerizes and is flammable.
Application: It is a highly effective chemisterilant, capable of killing spores rapidly. Since it is
highly flammable, it is usually combined with CO2 (10% CO2+ 90% EO) or
dichlorodifluoromethane. It requires presence of humidity. It has good penetration and is well
absorbed by porous material. It is used to sterilize heat labile articles such as bedding,textiles, rubber,
plastics, syringes, disposable petri dishes, complex apparatus like heart-lung machine, respiratory
and dental equipments. Efficiency testing is done using Bacillus subtilis var niger.
Disadvantages: It is highly toxic, irritating to eyes, skin, highly flammable, mutagenic and
carcinogenic.

 BETA-PROPIOLACTONE (BPL):
Mode of action: It is an alkylating agent and acts through alkylation of carboxyl- and hydroxyl-
groups.
Properties: It is a colorless liquid with pungent to slightly sweetish smell. It is a condensation
product of ketane with formaldehyde.
Application: It is an effective sporicidal agent, and has broad-spectrum activity. 0.2% is used to
sterilize biological products. It is more efficient in fumigation that formaldehyde. It is used to
sterilize vaccines, tissue grafts, surgical instruments and enzymes
Disadvantages: It has poor penetrating power and is a carcinogen.

 PHYSIO-CHEMICAL METHOD:
Mode of action: A physio-chemical method adopts both physical and chemical method. Use of
steam formaldehyde is a physio-chemical method of sterilization, which takes into account action of
steam as well as that of formaldehyde. Saturated steam at a pressure of 263 mm has a temperature of
70oC. The air is removed from the autoclave chamber and saturated steam at sub-atmospheric
pressure is flushed in. Formaldehyde is then injected with steam in a series of pulses, each of 5-10
minutes. The articles are held at this holding temperature for one hour. Formaldehyde is then flushed
by inflow of steam.
Disadvantages: Condensation of formaldehyde occurs and induction of large volume of
formaldehyde wets the steam resulting in loss of latent heat.
Sterilization control: using paper strips containing 106 spores of G.stearothermophilus.

306
 SURVEILLANCE

SURVEILLANCE
It is the monitoring of infections in the unit by conducting periodic surveys in order to identify unusual
pattern of flora and infections
It also includes monitoring of antibiotic use and resistance, whereby positive cultures are reviewed every 4-6
months based on which antibiotic policy of the unit is revised, if necessary

HOW FREQUENTLY SHOULD SURVEILLANCE BE CARRIED OUT? WHAT

ALL SHOULD BE CULTURED?
 Room air - weekly
 Surfaces (viz. laminar flow, warmer, incubator, trolleys) - weekly
 Equipment (viz. laryngoscopes, AMBU bags, mask, stethoscopes, oxygen hoods, B.P. cuffs) - weekly
 Liquids (viz. water in humidifier bottles) - twice weekly
Babies
 Blood / CSF culture whenever indicated
 Pus cultures whenever present
 Personnel: hands, nasal / throat swabs as required Terminal Disinfection
 Terminal disinfection is done after transferring out, discharge or death of a baby. Preferably all items of
the baby to be kept in the incubator and fumigated with 40% formalin (grossly infected baby). Otherwise
one can just do routine cleaning thoroughly.

SURVEILLANCE OF OPERATION THEATRE

 Examination of Air
 Estimations are done for detection of bacteria carrying particles in Air.
 Factors influence
 Number of persons present.
 Body movements,
 Disturbances of clothing

FUMIGATION

307
 Fumigation is a process of gaseous sterilization which is used for killing of micro-organisms and
prevention of microbial growth in air, on surface of wall or floor. It is generally used in the
pharmaceuticals, operation theatres, hospitals, hotels and offices and wherever required. Generally
for fumigation, chemicals like formaldehyde an potassium permanganate is used. It is also helpful for
removing lizards, cockroaches, cobwebs, rodents, files and insects from the area.

PRINCIPLE
Formaldehyde (Chemically H – CHO) in its pure form is a gas at room temperature, with a boiling
point of -19°C but readily polymerises at temperature below 80°C to form white solid.
The important polymers are paraformaldehyde, a colorless substance which rapidly yields
formaldehyde on heating. Formaldehyde is also marketed in aqueous solution as formalin which
contains 37 to 40 per cent formaldehyde.
The vapors can be generated from solid polymes such as paraformaldehyde or from a solution of 37
per cent formaldehyde in water (formalin). Formalin usually contains 37 per cent methanol to
prevent polymerisation.
Its bactericidal powders are superior to ethylene oxide but it has weak penetrating power and it is
only a surface disinfectant. Absorbed gas is very difficult to remove and long airing times are
required. One of the disadvantages of this process is limited ability of formaldehyde vapors to
penetrate covered surface. Formalin and paraformaldehyde are two principle sources of
formaldehyde. It is used for sterilization of gases.

MODE OF ACTION
It’s mechanism of action is thought to involve the production of intermolecular cross link between
protein together with interaction with RNA and DNA. Its acts as mutagenic and alkylating agent
reacting with carbonyl, Thiol and hydroxyl groups.
In order to be effective, the gas has to dissolve in the film of moisture surrounding the bacteria and
for these reason relative humidifies in the order of 75% RH are required (limit humidity 60 – 80 per
cent and temperature 22°C).

METHOD AND CONCENTRATION

Steam can be used to increase humidity the temperature in room up to required limit. Aerosol
generator can be used to a generate fumes. Following are two different concentrations of fumigation:
1. 500ml formaldehyde and one liter distilled water for 28 cubic meter of area for four hours or
overnight.
308
 2. 170gm. Potassium permanganate and 500 ml formaldehyde for 28 cubic meter for four hours or
overnight.

PRECAUTIONS
 Raw material finished goods, intermediates or in process goods should not be present in area of
fumigation. If unavoidable over it with thick polythene.
 Formaldehyde fumes are irritating and toxic to human eye, nose and throat. Therefore use of nose mask
and goggles while doing fumigation is advisable.
 Windows, doors should be closed. AC and AHU should be switched off before starting fumigation.
 Area under fumigation, do not enter status label should be displayed on either side of the entrance.
 Intimation of fumigation and for additional rounds should be given to security.
 Before entry into fumigated area, half an hour exhaust should be given. Now-a-days this method is not
recommended, because of its disadvantages and Hydrogen peroxide can be used using fogger for
fumigation in pharmaceuticals.

PROCEDURE OF FUMIGATION
1. Seal the room with adhesive tape.
2. Sealing the edges around the doors is important,
3. Measure the volume of your operation theatre
4. For each 1000 cu ft use 500 ml of formaldehyde.
5. Mix with water @ 1000 ml for 500 ml of Formaldehyde needed.
6. Seal the Room for 24 hours,
7. Open the Door / Avoid the formalin gas with mask
8. Neutralize Residual formalin gas with Ammonia by exposing 250 ml of Ammonia per liter of
Formaldehyde used.

URINE COLLECTION
DESCRIPTION
 Allows screening for urinary tract infection and renal disorders, evaluation of treatment, and detection
of systemic and metabolic disorders.
 Provides a simple, effective alternative by offering minimal risk of specimen contamination without
resorting to catheterization or suprapubic aspiration.
 Contraindicated in a patient with extremely sensitive or excoriated perineal skin, due to collection bag
being secured with adhesive flaps.
309
  Alternative methods of collecting urine from small children: use of an inside-out disposable diaper or a
test tube.

EQUIPMENT
 Pediatric urine collection bag
 Urine specimen container
 Label
 Laboratory request form
 Two disposable diapers of appropriate size
 Scissors
 Gloves
 Washcloth
 Soap
 Water
 Towel
 Bowl
 Linen saver pad/ Mackintosh
ESSENTIAL STEPS
 Explain the procedure to the child and his/her parents
 Provide privacy, especially if the patient is beyond infancy
 Confirm the child’s identity using two patient identifiers according to facility policy.

COLLECTING A RANDOM SPECIMEN

 Wash your hands.
310
 Place the child on a linen-saver pad/ Mackintosh.
 Clean the perineal area with soap, water and a wash cloth, working from the urinary meatus outward to
prevent contamination of the urine specimen. Wipe gently to prevent tissue trauma and stimulation of
urination.
 Separate the labia of the female patient and retract the foreskin of the uncircumcised male patient to
expose the urinary meatus.
 Thoroughly rinse the area with clear water and dry with a towel. Don’t use powders, lotions, or cream
because these counteract the adhesive.
 Place the patient in the frog position, with his legs separated and knees flexed. If necessary, have the
child’s parent hold him while you apply the collection bag.
 Remove the protective coverings from the collection bag’s adhesive flaps.

 For the female patient, first separate the labia and gently press the bag’s lower rim to the perineum.
Then, working upward toward the pubis, attach the rest of the adhesive rim inside the labia majora.
 For the male patient, place the bag over the penis and scrotum, and press the adhesive rim to the skin.
 After the bag is attached, gently pull it through the slit in the diaper to prevent compression of the bag
by the diaper and to allow observation of the specimen immediately after the patient voids. Then fasten
the diaper on the patient.
 When urine appears in the bag, put on gloves and gently remove the diaper and the bag. Hold the bag’s
bottom port over the collection container, remove the tab from the port, and let the urine flow into the
container.

311
  Measure the output if necessary.
 Label the specimen and attach the laboratory request form to the container. Send it directly to the
laboratory.
 Remove and discard gloves.
 Put the second diaper on the child, and make sure he’s comfortable.

NURSING CONSIDERATIONS
 Avoid forcing fluids to prevent dilution of the specimen, which can alter test results.
 Obtain a first-voided morning specimen if possible.
 To collect a urine specimen from an infant or a young child with extremely sensitive or excoriated
perineal skin, use the inside-out disposable diaper method. Place cotton balls in the perineal area of
the diaper to absorb urine. After he has voided, remove the diaper and squeeze urine from the cotton
balls into a specimen cup. Alternatively, tape a test tube to a male patient’s penis to collect urine.

312
 URINE COLLECTION: INDWELLING CATHETER

CLINICAL GUIDELINES
 Urine collection for diagnostic analysis is ordered by a healthcare prescriber.
 A registered nurse (RN) or licensed practical nurse (LPN) may collect the specimen from the
indwelling catheter.
 A urine specimen is collected from an indwelling catheter when a urinary tract infection is suspected
and a sterile urine specimen is needed for a urine culture and sensitivity test.
EQUIPMENT
 Clamp
 Gloves
 Sterile alcohol swabs
 Sterile 3 to 10 ml syringe
 Sterile 21 to 25G needle or sterile needleless syringe adaptor
 Clean towel
 Specimen container and label (if the specimen obtained is to be sent to the laboratory for culture and
sensitivity, the container for container must be sterile)
 Biohazard bag for transporting the specimen to the laboratory.

CHILD AND FAMILY ASSESSMENT AND PREPARATION

 Assess the cognitive level, readiness, and ability to process information of the child and family. The
readiness to learn and process information may be impaired as a result of age, stress, or anxiety.
 Reinforce the need for the urine specimen collection, as appropriate, to both the child and the family.
 Provide the opportunity to ask questions and alleviate fears.
 Assess the color and clarity of urine in the catheter drainage tubing.

INDWELLING CATHETER URINE COLLECTION

STEPS RATIONALE/POINTS OF EMPHASIS
1. Perform hand hygiene. Gather the Reduces transmission of microorganisms. Promotes
necessary supplies. efficient time management and provides an organized
approach to the procedure.
2. Close the door to the child’s room and Provides privacy during the procedure.

313
 draw the curtains around the bed to provide
privacy, as appropriate.
3. Clamp the indwelling catheter just below Allows urine to collect in the drainage tube. Amount of
the aspiration site. Clamps need to remain time necessary for urine to collect may vary from child to
in place long enough for urine to collect in child.
the drainage tubing.
4. Establish a clean working area, using a Establishes a space from which to gather equipment and
clean towel spread open. proceed with collection without contamination.
5. Using sterile technique, open the sterile Facilitates ease of access to the equipment.
alcohol swabs, sterile 3 or 5 ml syringe,
sterile 21 to 25G needle, and sterile
specimen container and place them on the
towel in their packages to maintain the
sterility of the supplies.
6. Don gloves Reduces transmission of microorganisms.
7. Wipe the aspiration site of the catheter with Prevents contamination of the aspiration site and
friction using sterile specimen container specimen by microorganisms and prevents introduction
and place them on the towel in their of organisms into the closed catheter system.
packages to maintain the sterility of the
supplies.
8. Withdraw fresh urine from the aspiration Allows for specimen to be obtained. Urine should not be
site using a needleless adaptor with syringe collected from the urine collection bag because that urine
(preferred) or a 23 or 25G needles. is contaminated and the components of the urine change
when the urine has been sitting at room temperature.
9. Withdraw the needleless adaptor or needle Draining the urine directly into the specimen container
and syringe and inject the urine directly decreases the possibility of contaminating the specimen.
into the sterile specimen container.
10. Put the lid on the container, label the Standard precautions.
specimen, and place it in a biohazard bag.
11. Unclamp the indwelling catheter tubing. Allows urine to flow into the drainage bag. Stasis of
urine in the bladder can cause urinary tract infections.
12. Send the specimen to the laboratory Results of the test may be altered if urine is allowed to sit
immediately. for any length of time.
13. Dispose of used equipment and waste in Standard precautions. Reduces transmission of

314
 appropriate receptacle. Perform hand microorganisms.
hygiene.

CHILD AND FAMILY EVALUATION AND DOCUMENTATION

- Evaluate the child for presence or absence of signs and symptoms of urinary tract or bladder
infection, including fever, feeling of fullness, bladder spasms, foul-smelling urine, redness or
irritation of urethral opening, urethral discharge, and crying without consolation or discomfort.

- Document the following:

 Amount, color, clarity, and odor of the urine and the presence of any sediment.
 Child’s response to the specimen collection.
 Presence or absence of signs and symptoms of a distended bladder or residual urine, for which
bladder emptying would be required.
COMMUNITY CARE
If the procedure is done at the child’s home, instruct the family to
 Transport the specimen in a cooler from the home to the laboratory to keep it as fresh as possible.
 Dispose of used needles and syringes in biohazard sharps container.
 Dispose of used equipment in a sealed plastic bag.Instruct the family to contact the healthcare
provider if
 Catheter becomes dislodged and the child and family do not know how to reinsert the catheter.
 Urine is cloudy or dark.
 Blood is present in the urine or a change in smell of the urine occurs.
 Child has nausea or vomiting.
 Child has chills or fever.
 Child has flank pain
 Child is lethargic
 Child has painful voiding or frequent urgency to void
 Swelling or redness occurs around the urethral opening.

315
 URINE COLLECTION: 24 HOUR SPECIMEN
CLINICAL GUIDELINES
 Urine collection for diagnostic analysis is ordered by a healthcare prescriber.
 A registered nurse (RN), licensed practical nurse (LPN), or unlicensed assistive personnel (UAP)
may collect urine for diagnostic analysis.
 Urine is collected over a 24 hour period to determine the excretion rate of certain hormones, proteins,
and electrolytes. The laboratory supplies the container and any necessary preservatives.
 If urine is discarded accidentally after the urine collection has begun, the healthcare prescriber
should be notified, and the test should be started again. Any loss of urine invalidates the results of the
test.

EQUIPMENT
 Large capped collection container (containing preservative, if necessary).
 Clean bedpan or toilet specimen container, adhesive urine collection bag, or clean urinal, if an
indwelling catheter is not in place.
 Large basin with ice (freshened with new ice, when the ice melts).
 Adhesive label or marker
 Signs: “24 hour Urine Collection in Progress”
 Gloves.

CHILD AND FAMILY ASSESSMENT AND PREPARATION

 Assess the cognitive level, readiness, and ability to process information by the child and family.
 Reinforce the need for the urine specimen collection, as appropriate, to both the child and the family.
 Instruct the child and the family in saving voided urine and notifying nursing personnel of each void.

24 HOUR URINE SPECIMEN COLLECTION

STEPS RATIONALE/POINTS OF EMPHASIS
1. Obtain a collection container from the Urine must be kept and stored together in the same
laboratory to be kept at the bedside. If the collection container over a 24 hour period.
child will be voiding using a bedpan or
toilet specimen container, instruct the
child to place the container toward the

316
 perineum or the front of the toilet so that
if the child has the urge to defecate, the
feces will not mix with the urine in the
collection container.
2. Post signs on the door to the child’s Reminds all nursing personnel and family members
room, above the child’s bed, and in the to save the child’s urine. A 24 hr collection of urine
bathroom saying that a 24 hour urine test is needed; if any urine is discarded, test results will
is in progress. be invalid. The total volume of urine collected
during the 24 hr period is a factor used to calculate
the excretion rate of the substance. Feces and toilet
tissue may alter the test results.
3. Don gloves Standard precautions to reduce transmission of
microorganisms.
4. If the child is able, have him or her void Because the 24 hour urine is a timed quantitative
to empty the bladder and discard the determination, it is essential to start the test with an
voided urine. If an indwelling catheter is empty bladder.
in place, discard any urine already in the
drainage bag.
5. Note the time that the first urine was This time is the beginning of the 24 hour collection
discarded. period.
6. Pour urine from each void into the Ice is used for preservation and to control bacterial
collection container and keep the growth. Results may be altered by urine that is not
container on ice. If indwelling catheter or properly stored.
urine collection bag is in place, empty
and add to collection container on ice at
least every 2 hours. It is not necessary to
measure the volume of a voiding unless
specifically ordered.
7. Before the end of the 24 hour collection This is necessary for all urine excreted during the
period, ask the child to void one last 24-hr time period to be collected. The last specimen
specimen. Pour this final specimen into should be obtained as closely as possible to the
the collection container. stated end time of the test.
8. Label the collection container and send it Allows urine to flow into the drainage bag. Stasis of
to the laboratory immediately after the 24 urine in the bladder can cause urinary tract

317
 hour period. infections.
9. Remove gloves and perform hand Reduces transmission of microorganisms.
hygiene after each contact with the urine
specimen.

CHILD AND FAMILY EVALUATION AND DOCUMENTATION

 Assess the color and clarity of the urine, presence of any sediment, and any unusual odor of the
urine.
 Document the following:
 Time and collection began and time completed.
 Color and clarity of the urine, presence of any sediment, and any unusual odor of the urine.
 Child’s response to the specimen collection process.
COMMUNITY CARE
 If the collection is to be done at the child’s home, write specific instructions for the child and family
to follow. Ensure family has a collection container with an appropriate preservative.
 If the specimen is to be kept cool, make sure that the family has ice or refrigeration available.
 Make specific arrangements to return for the specimen and transport the specimen in a cooler.
 Instruct the family to contact the healthcare provider if
 The 24 hour collection is interrupted for some reason.
 Urine is cloudy or dark.
 Blood is present in the urine or a change in smell of the urine occurs.
 Child has nausea or vomiting.
 Child has chills or fever.
 Child has flank pain
 Child is lethargic
 Child has painful voiding or frequent urgency to void
 Swelling or redness occurs around the urethral opening.

318
 URINE COLLECTION: SUPRAPUBIC ASPIRATION
CLINICAL GUIDELINES
 To confirm the diagnosis of a urinary tract infection, suprapubic aspiration or transurethral bladder
catheterization may be obtained if a child with unexplained fever is assessed as being sufficiently ill
to warrant immediate antimicrobial therapy.
 Suprapubic aspiration is typically performed on children younger than 2 years of age and on
premature infants. Small bladder capacity, anterior wall infection, and bleeding disorders are
considered contraindications for performing this procedure.

EQUIPMENT
 Sterile gloves sized for person performing procedure.
 Non-sterile gloves for assistant.
 Antiseptic solution
 Sterile 20 to 23G needle with syringe.
 Sterile gauze pad
 Bandage or occlusive dressing
 Urine collection container with labels
 Plastic biohazard transmittal bag

CHILD AND FAMILY ASSESSMENT AND PREPARATION

 Explain procedure to parents and child in appropriate developmental terms, using instructional props
as necessary.
 Allow parents to stay at bedside to comfort child.
 Obtain consent as required by institution.
 Assess the child for signs and symptoms of urinary tract or bladder infection, including fever,
inability to void, burning on urination, feeling of fullness, bladder spasms, foul-smelling urine,
redness or irritation of urethral opening, urethral discharge, crying without consolation, and
discomfort.
 Assess time of last voiding by wetness of diaper or by palpating bladder above symphysis. Bedside
USG of the bladder may be performed before the procedure to establish certainty of the presence or
amount of urine in the bladder.

319
  Coordinate timing of procedure with healthcare prescriber to ensure that adequate amount of urine is
present in bladder and that grouping of activities can aid in decreasing the stress and anxiety of child
and family.

SUPRAPUBIC ASPIRATION URINE SPECIMEN COLLECTION

STEPS RATIONALE/POINTS OF EMPHASIS
1. Perform hand hygiene. Reduces transmission of microorganisms.
2. Gather the necessary supplies and set up Promotes efficient time management and provides
supplies for procedure, maintaining sterility. organized approach to the procedure.
Ensure specimen collection containers are easily
accessible.
3. Transport infant/child to treatment area. Child’s bedside should be viewed as a safe
environment where painful procedures do not
occur.
4. Perform hand hygiene and don gloves Standard precautions to reduce transmission of
microorganisms.
5. Stand at head of child. Position infant/child on Controls child’s movement to decrease inadvertent
back with legs extended or flexed, as injury.
practitioner prefers. Restrain as necessary.
6. Assist practitioner performing procedure as Bio-behavioral measures can aid in calming infant
required. Offer comfort measures such as and in minimizing movements.
pacifier or quiet soothing tones during
procedure.
7. After procedure, apply pressure to site as Minimizes bleeding, which is usually minimal;
directed by practitioner. Ease infant/child from little pressure is needed after the procedure.
restrained position.
8. Apply a bandage to the site. Protects site.
9. Allow infant/child to be held and comforted by Calms child and reduces stress.
parent.
10. Label specimen with child’s name, medical Ensures that correct tests are performed on
record number, and date and time specimen was specimen. Prompt testing reduces changes in
obtained and by whom; place in plastic specimen (e.g. bacterial growth).
biohazard transmittal bag following standard
precautions. Send to laboratory as soon as
320
 possible.
11. Perform hand hygiene. Reduces transmission of microorganisms.

CHILD AND FAMILY EVALUATION AND DOCUMENTATION

 Address questions and concerns of child and parents regarding procedure after it is completed.
 Evaluate puncture site for bleeding.
 Document the following:
 Time of procedure
 Practitioner who performed the task
 Appearance of the aspiration site
 Amount and appearance of urine collected
 Test the sample was sent for
 Child’s tolerance of procedure
 Family teaching provided.

COMMUNITY CARE
 Instruct family to contact the healthcare provider if
 Oozing is present at needle insertion site
 Child does not void.

321
BLOOD DRAWING FROM PERIPHERAL SITES: HEEL STICK
AND FINGER STICK
EQUIPMENT
 Mechanical (automated) lancing device or lancet
 Antiseptic wipes (75% isopropanol)
 2 x 2 sterile wipes
 Gloves
 Specimen container or capillary tube
 Warming supplies (i.e. chemical warmer, cloth)

CHILD AND FAMILY ASSESSMENT AND PREPARATION

 Assess child for signs of poor perfusion, local edema, infection at the site, and impaired blood
coagulation. The presence of these findings can lead to inadequate sampling, blood specimen
contamination, increased pain, and infection. Avoid edematous areas because the presence of fluids
can contaminate the blood specimen. The presence of ecchymosis or hemolysed samples can give
false results (e.g. elevated bilirubin or potassium levels). Rotate the sites of puncture to decrease
these complications.
 Apply topical anesthetic (e.g. lidocaine, prilocaine) for finger stick before procedure, as time allows,
and based on child’s preference. The research is conflicting, but most studies indicate that topical
anesthetics are not effective for the pain of heel stick. Because a risk for methemoglobinemia exists,
do not use lidocaine and prilocaine. If the child is receiving methemoglobin inducing agents (e.g.
sulfonamides, acetaminophen).
 Question parents about the existence of coagulation, disorders in their family history and previous
signs of a blood dyscrasia (e.g. the presence of unexpected ecchymotic spots or prolonged bleeding
after blood testing or injury).
 Administer Vitamin K per newborn routine before heel stick to increase clotting and prevent
prolonged bleeding.
 Verify physician’s order for laboratory tests.
 Explain procedure to child, as appropriate, and parents.
 Prepare the child, as appropriate to cognitive and developmental level. Provide therapeutic play as
indicated, or involve a child life specialist, to allow the child to work through fears, help with the
procedure (e.g. hold Band-Aid), and master control of the situation.
322
  Encourage parents to remain with the child during the procedure. Discuss with parents comfort
measures (e.g. swaddling, use of sucrose pacifiers) and distraction techniques that they can use with
their child.

PERFORMING HEEL AND FINGER STICKS

STEPS RATIONALE/POINTS OF EMPHASIS
1. Gather the necessary supplies, including Provides efficient time management and provides
puncture device. An automated device is an organized approach to the procedure.
recommended; refer to manufacturer’s Mechanical device either puncture or incise the
recommendations for use. skin and may be less painful than lancets. A
shallow incision may facilitate bleeding, healing,
and reduce pain. There is an increased chance of
bone penetration resulting in injury and infection
(e.g. perichondritis, osteomyelitis) with puncture
devices of longer length. Research on preterm
infants indicates that the use of an automatic
incision device for collecting repeated skin
puncture samples is less traumatic than use of a
conventional manual lancet, causing less bruising
and inflammation of the heel.
2. Apply warming device to area for 5 to 10 Increases blood flow and reduces hemolysis and
minutes before puncture. The following bruising. Hematocrit and capillary blood gas
methods are acceptable: samples collected from nonwarmed heels are
 Commercially prepared chemical warmer inaccurate. Do not use microwave-warmed
 Warm cloth (< 109 °F or 42.8°C) products because uneven heating occurs and
presents a burn risk. Research on heel warming
before capillary blood sampling on preterm and
term infants indicates that this may be an
unnecessary technique. Volume of blood, collection
time, crying time and repeat procedures have not
indicated they were enhanced by prewarming the
site. More research is needed.
3. Perform hand hygiene and don gloves. Standard precaution to reduce transmission of
microorganism.
323
4. Remove warming device. Leaving a warming device in contact with the skin
cools by conduction.
5. Select and identify puncture site: Using appropriate site minimizes the risk of injury
i. Heel, outer aspects (infants younger than 18 (e.g. striking artery, bone, or nerve).
months)
 Lateral to an imaginary line drawn from
between the fourth and fifth toes and running
parallel to the lateral aspect of heel
 Medial to an imaginary line drawn from the
middle of the great toe and running parallel to
the medial aspect of the heel. Never puncture
the back of an infant’s heel because the
calcaneus is closest to the surface in that
location.
ii. Finger (older than 18 months of age)
 The side of the third or fourth finger, near the
tip.
6. a. Cleanse puncture site with antiseptic (75% Provides disinfection. Wiping prevents alcohol
isopropanol) and allow to dry for 30 seconds. contamination of blood sample, which may cause
Then dry with sterile gauze. hemolysis and errors in glucose values.
b. If topical anesthetic cream has been used,
remove before cleansing. Residual alcohol may cause hemolysis. Prevents
inadvertent movement by child; controls position of
site for puncture.
7. Place extremity in a dependent position. Grasp Facilitates blood flow to area. Prevents inadvertent
extremity firmly; dorsiflex infant’s foot for heel movement by child; controls position of site for
stick. puncture.
8. Briskly puncture skin with selected lancing Eliminates tissue fluids or residual alcohol
device and wipe off first drop of blood with potentially present in initial drop of blood, which
sterile gauze. can alter test values.
9. a. Continue to hold puncture site Harshly squeezing the area may produce hemolysed
in dependent position while samples and bruising and may contaminate sample
gently applying intermittent with tissue fluid.
pressure to surrounding area;

324
 collect blood in appropriate
container.
b. When using capillary tubes or Holding tube horizontal and applying intermittent
micropipettes, hold pressure facilitates blood flow. Covering the tube
horizontally to fill them by prevents blood loss. (Do not pipette orally or scrape
capillary action and fill two blood into tubing. Oral pipette greatly increases the
thirds to three fourths full. chance of contact with potentially contaminated
Cover the end with your finger body fluids and scraping causes hemolysis).
when transferring the
specimen to bedside test
strip, sealing clay, or other
material.
10. a. Elevate extremity above level of heart. Facilitates hemostasis.
Gently press dry sterile guaze to puncture site
until bleeding stops.

b. Do not use bandages. Bandages can lead to skin maceration and pose an
aspiration hazard.
11. Properly dispose of contaminated equipment. Prevents needle-stick injury and transmission of
Place lancing device in sharps container and blood-borne pathogens.
blood-soaking gauze in a biohazard bag.
12. Remove gloves and perform hand hygiene. Reduces transmission of microorganisms. Standard
precautions.
13. Perform bedside laboratory testing or label Ensures that correct specimen is tested for the right
specimen with child’s name, medical record patient.
number and unit, date and time of collection,
and collector’s initials.
14. a. Place specimen in biohazard Standard precautions.
bag and transport specimen to
laboratory, if necessary.
b. Provide appropriate Reduces degradation of specimen before analysis.
environment for transport
(e.g. ice, refrigeration).

325
CHILD AND FAMILY EVALUATION AND DOCUMENTATION
 Evaluate puncture site for evidence of continued bleeding; keep wound clean and dry.
 Monitor child for signs of pain and involve parents in providing comfort measures (e.g. rocking,
cuddling, swaddling, talking in a quiet and soothing voice, providing pacifier, praise, presenting a
small reward).
 Document the following:
 Date and time
 Site of puncture
 Specimens obtained
 Amount of blood loss
 Child’s response to procedure
 Maintain running total of blood loss in neonates or when multiple samples are being obtained.

COMMUNITY CARE
 Educate parents, and child if appropriate, on proper technique for home blood sampling (i.e. device
use, site selection, sharps disposal, when to obtain samples, and complication recognition); give
written instructions and observe return demonstration.
 A single-use mechanical device is the option of choice for home sampling. Coordinate to ensure that
proper equipment is available for home use.
 Instruct the family to contact healthcare provider if
 The child has signs of infection
 The child has excessive bleeding or pain
 Laboratory values are outside of normal parameters.

326
 BLOOD DRAWING FROM PERIPHERAL SITES:
VENIPUNCTURE
EQUIPMENT
 70% alcohol pads or chlorhexidine 2 mg/mL, solution or swabs.
 Dry sterile guaze pads
 Tourniquet
 Small adhesive bandage
 Appropriate specimen tubes for tests ordered.
 Venous access device:
 Vacuum container needle and vacuum holder with needle protection system, or
 A 1-inch butterfly needle with attached tubing and Luer adapter for children younger than 12
years of age, 23 gauge for children younger than 12 years of age, and 21 gauge for children
older than 12 years of age.
 Patient labels for specimen tubes
 Appropriate laboratory requisitions
 Gloves
 Cold pack for specimens that need to be transported cold (i.e. coagulation studies)
 Biohazard bag

CHILD AND FAMILY ASSESSMENT AND PREPARATION

 Assess severity of child’s illness and determine whether there is time for use of topical pain relief
and amount of time that can be devoted to explanation of procedure.
 Determine whether fasting or timing of medication administration is a consideration for the test
being performed.
 Assess child for previous puncture experiences and reactions to latex. Use this information in
preparing child.
 Assess child’s total blood volume and associated pathology that affects oxygen-carrying capacity of
blood (e.g. anemia, ongoing blood loss, shock) to determine necessity of blood previously taken for
specimen analysis and ° of total blood deficit in child. Calculate minimal amount of blood necessary
to perform microanalysis of specimens; compare necessity of test versus amount of blood needed.

327
 Check with laboratory to determine the minimum amount of blood needed, particularly for a preterm
infant, many tests can be run on 0.5 ml or less of blood.
 Prepare child and family for procedure as developmentally appropriate. In emergent situations,
explain actions as they are implemented. Use simple clear explanations. Explain that the child needs
to stay still but can yell or cry if so desired. Teach the child simple distraction techniques to assist in
pain management.
 Encourage parents to remain with the child during the procedure. Discuss with parents distraction
techniques and other pain management techniques they can use with their child.

 When not emergent, apply a topical anesthetic to two sites. Therefore if the initial puncture is
unsuccessful, a second site is already prepared. When using a eutectic mixture (e.g. EMLA), it
should remain on the skin for at least 60 minutes before puncture. When using a stimulated
ionotophoresis method, it should remain on the skin for 5 to 15 minutes before puncture.
PERFORMING VENIPUNCTURE
STEPS RATIONALE/POINTS OF EMPHASIS
1. Verify orders, laboratory requisitions and Prevents unneeded punctures. Allows the gathering of
patient labels. correct materials for tests ordered.
2. Identify the child using two different patient Ensures correct patient for specimen collection.
identifiers.
3. Perform hand hygiene. Reduces transmission of microorganisms. Antibiotic-
resistant gram-negative organisms frequently
contaminate the hands of healthcare personnel, in
addition to the usual skin flora.
4. Gather the necessary supplies based on size Promotes efficient time management and provides an
of child, method of collection, and tests organized approach to the procedure.
required. Too large a needle may damage valves in the vein.

328
 Butterfly wings provide more control and thus fewer
traumas to vessels.
Use of a syringe and straight needle to draw blood is
not recommended because the amount of pressure
exerted cannot be controlled, the vein collapses, and
damage may occur.
5. Select puncture site, using the distal veins The median antecubital vein may not always be visible,
first. Veins most commonly used are the but it is usually large and palpable. It is well supported
antecubital fossa. by subcutaneous tissue and least likely to roll.
6. Place the site in dependent position. Facilitates blood flow to the area. (Older children may
cooperate better if they can sit up with the arm well
supported on a pillow, if they are given detailed
explanations, and if they are involved in decisions as
appropriate [e.g. site selection]. If child is younger than
school age, have child lie down. A second person to
assist in stabilizing the site may be helpful).
7. Don gloves. Standard precaution to reduce transmission of
microorganisms.
8. If child is able to follow commands, ask the Assists in vein distention for older children.
child to make a fist.
9. Apply tourniquet around child’s extremity Obstructs venous blood flow and causes vein distention
above the site. so that the vein is easier to see and palpate.

10. Cleanse the site with alcohol or Moves microorganisms away from the proposed
chlorhexidine using a circular motion from puncture site, thus decreasing the transfer of
site outward. When using alcohol, scrub the microorganisms. Alcohol is less effective than
site for 20 seconds. If using chlorhexidine, chlorhexidine in decreasing bacterial colonization and
allow to dry for at least 30 seconds. Always causes the greatest amount of permanent tissue damage
use chlorhexidine when obtaining blood in animal studies.
cultures. Do not touch the cleansed area
again with your finger or any other unsterile
object. (In infants younger than 2 months of
age, remove cleansing solution, after it
dries, with sterile water. Use of

329
 chlorhexidine may be associated with
contact dermatitis in LBW infants).
11. Remove needle shield. Anchor the child’s Prevents rolling of vein.
vein with thumb of your non-dominant
hand.
12. Hold the needle bevel up, positioned at a Allows placement of needle parallel to the vein.
45° angle over the vein. Puncture the site. If
unsuccessful after two attempts, have
another practitioner perform procedure.
13. a. Obtain blood using a vacuum container. If the needle is in the vein, the tube will begin to fill
Stabilize the vacuum holder and push in with blood.
on the specimen tube to puncture the
stopper; when first specimen tube is full,
remove it from the vacuum holder while
stabilizing
the holder, being careful not to jar the needle;
stabilizing the holder, insert succeeding tubes
in holder, making sure that the stoppers are
punctured on each tube to initiate blood flow;
gently invert tubes containing additives 8 to 10
times.
b. Obtain blood using butterfly: When a
blood backflow is seen, insert Luer Once the specimen tube is full, vacuum stops the flow
adapter into the microtainer or of blood. Inserting succeeding tubes quickly and evenly
Vacutainer, or gently withdraw blood allows obtaining several specimens from one puncture
with a 1- or 3-mL syringe if blood for site. Inverting tubes ensures mixture of additives.
several tests is needed.
14. Release the tourniquet. Prevents blood from entering surrounding tissue.
15. Note the total amount of blood withdrawn. Provides a gauge of how much blood has been taken
and when replacement may be needed.
16. Remove tourniquet. Allows venous blood flow to resume.
17. Apply dry sterile gauze and withdraw Stops the bleeding. Elevation promotes negative
needle. Apply pressure to puncture site until pressure in vein and promotes clotting.
bleeding stops. Keeping the arm straight,

330
 elevate the extremity above the level of the
heart.
18. a. Place specimen in appropriate tube. Ensures adequate preparation and stabilization of
b. Invert all tubes containing additives 8 to specimen for accurate analysis.
10 times before specimen collection in Ensures mixture of additives.
next time.
19. Dispose of sharps immediately: Prevents accidental needle-stick injuries with
 If using a needle-protection device, contaminated sharps.
withdraw the needle back into the
container until a click is heard.
 When not using a needle-protection
device, place the needle in the needle-
protection box immediately without
reshielding it.
20. Apply small bandage, as appropriate. Prevents further bleeding. Reassures children,
particularly preschool-aged children that all their blood
will leak out.
21. Label all specimen tubes with the following: Ensures that correct specimens are tested for correct
 Child’s name child.
 Time and date of collection
 Initials of person collecting
 Medical record number
22. Place in biohazard bag and transport to the Protects against blood contact.
laboratory.
23. Dispose of equipment and waste in Standard precautions. Reduces transmission of
appropriate receptacle. Remove gloves and microorganisms.
perform hand hygiene.
24. Recheck puncture site. Detects further bleeding.

CHILD AND FAMILY EVALUATION AND DOCUMENTATION

 Evaluate child and family understanding of procedure.
 Evaluate effectiveness of child and family coping during procedure. Determine whether a better
coping mechanism could be used during future blood sampling. If so, teach to child and family.
 Document the following:
331
 - Date and time
- Site of puncture
- Specimens obtained
- Amount of blood loss
- Child’s response to procedure
 Maintain running total of blood loss in neonates or when multiple samples are being obtained.
COMMUNITY CARE
 Assure parents that although the equipment used in the home may differ from that used in the
hospital, it works with the same effectiveness.
 Ensure that there is a sealed needle container in the child’s home. Upon completion of the procedure,
dispose of the used needle in the container and make sure that it is out of reach of children in the
home.
 Teach parents to monitor for signs of bleeding or infection at puncture site.
 Transport blood specimens in a cool dark container as quickly as possible to the laboratory.
 Instruct the family to contact the healthcare provider if
- The child has signs of infection
- The child has excessive bleeding or pain
- Laboratory values are outside of normal parameters

332
 BLOOD GAS SAMPLING AND MONITORING
INTRODUCTION
 Children who are physiologically compromised and/or those who need adjunctive oxygen therapy
may require blood gas analysis and/or monitoring.
 Blood gas analysis provides a direct method to assess oxygenation, acid-base balance, adequacy of
ventilation, hypoxic states, and evaluation of the child’s response to therapy via blood sample
collection.
 Blood gas samples may be obtained from arterial lines or puncture (arterial blood gas [ABG]),
capillary puncture (CBG), or, if necessary, venous blood draws (VBG). Capillary sampling is a
useful alternative to arterial sampling even in the presence of hypothermia and hypo-perfusion,
provided that hypertension is not present. CBG and VBG are not recommended for determining PO2
of arterial blood.
 A basic understanding of normal arterial blood gas values is essential for accurate interpretation of
blood gas results.
pH = 7.32 to 7.45
PaCO2 = 5 to 45 mm Hg
PaO2 = 80 to 100 mm Hg
SaCO2 = 94% to 98%
Base excess = 12 to 22
HCO3 = 22 to 26 mEq/L

EQUIPMENT
For Capillary Blood gas sampling
 Warm, moist cloth or commercially prepared warming pad.
 Non-sterile gloves.
 Skin antiseptic
 Pre-heparinized glass capillary tube
 Clay or wax sealant or cap
 Sterile lancet (1.5 mm in depth)
 Adhesive bandages
 Patient specimen label
 Ice (sample must be on ice if analysis delayed > 10 minutes).
 Gauze or cotton balls
333
  Sharps and biohazard disposal container
 Biohazard bag for transporting the specimen to the laboratory.
For Arterial blood gas sampling by Arterial Puncture
 Pre-heparinized 1 ml syringe with cap
 25 G needle or 25 G butterfly needle
 Non-sterile gloves
 Skin antiseptic
 Gauze or cotton balls
 Patient specimen label
 Ice (sample must be on ice if analysis delayed >10 minutes).
 Adhesive bandage
 Patient specimen label
 Biohazard bag for transporting the specimen
 Sharps and biohazard disposal container
 Anesthetic for non-emergent sampling:
 Topical agents
 Local anesthetic (injectable buffered lidocaine, 1% without epinephrine).
 Ice pack for puncture site (if needed)

For Blood Gas Sampling by Indwelling Heparinized Arterial or Deep Venous Catheter
 3 ml syringe (heparinized if discard blood will be reinfused).
 1 ml syringe heparinized
 3 mL heparinized normal saline flush syringe
 Non-sterile gloves
 Alcohol wipes
 Patient specimen label
 Ice (sample must be on ice if analysis delayed > 10 minutes).
 Biohazard bag for transporting the specimen
 Sharps and biohazard disposal container.

For Transcutaneous Blood Gas Monitoring

 Transcutaneous monitor
 Adhesive electrode rings

334
  Transcutaneous sensor contact gel.
 Calibration gases and calibrator

CHILD AND FAMILY ASSESSMENT AND PREPARATION

 Assess child and child’s medical record for:
- History of circulatory impairment (i.e. presence of cardiac or vascular grafts). Puncture of
vessels or grafts may cause hematoma and decreased circulation.
- Prolonged clotting times or bleeding disorders that may affect clotting times.
- Impaired gas exchange related to underlying disease processes or for impaired breathing and
note oxygen therapy and whether child requires continuous ventilatory assistance.
- Factors that may influence blood gas measurements (i.e. anxiety, suctioning, child’s position,
temperature, oxygen therapy, metabolic rate)
- Allergies to local anesthetics (e.g. lidocaine) or latex; implement latex precautions if necessary.
 Explain the procedure, as appropriate, to both the child and the family. Provide the opportunity to
ask questions and alleviate fears.
 Explain to the child and family that a lancet or needle will be used to puncture the child’s skin and
gain access to the blood that is needed for this procedure. A topical anesthetic may be administered
with arterial punctures before the procedure to minimize the pain of this needle stick. Explain that
the blood withdrawn will be used to look at the amount of oxygen in the child’s blood. After the
procedure, a Band-Aid or small dressing will be placed on the site.
 Reinforce the need for blood gas collection, as appropriate, to both the child and the family.

CAPILLARY BLOOD GAS SAMPLING

STEPS RATIONALE/POINTS OF EMPHASIS
Gather the necessary supplies. Promotes efficient time management and
provides an organized approach to the procedure.

335
 Perform hand hygiene. Reduces transmission of microorganisms.
Raise the bed to a comfortable working height, Promotes good body mechanics and reduces back
or stand on a step stool at crib side. strain.
Select capillary puncture site. Facilitates visualization and ease of access.
Wrap the selected foot or hand with a warmed Warming the site arterializes the patient sample
moist cloth or commercially prepared warming and allows for vasodilation. Inadequate warming
pad; leave on for 5 to 10 mints. of the site before puncture may result in capillary
values that poorly correlate with arterial pH and
PCO2.
Don gloves Standard precaution to reduce transmission of
microorganisms.
Removing the warming cloth or pad. Scrub the Reduces transmission of microorganisms.
selected site with antiseptic wipe and allow
drying.
Ensure that end caps, lancet, capillary tube, Allows for procedure to continue quickly and
cotton or gauze, and adhesive bandage are efficiently. Facilitates ease of access to the
within easy reach. equipment.
Puncture capillary site with sterile lancet; Provides for specimen sample.
advance lancet at an angle so as to cut more
capillary beds and generate greater blood flow.
As indicated with nondominant hand: Grasp the Allows for control of blood flow.
foot firmly with the thumb and index finger
wrapped around heel, or grasp the finger or great
toe firmly with thumb and index finger wrapped
around the finger or toe.
Gently apply pressure to heel, finger, or toe in an Provides for adequate specimen sample. Undue
upward direction to drive maximum blood to the squeezing of the puncture site may result in
puncture site. venous and lymphatic contamination of the
sample.

 Release pressure periodically to allow blood to Controls blood flow, so as not to stave off blood
continue to build and flow. flow.
 Remove the first drop of blood from puncture Usually, the first drop of blood contains tissue
site with gauze or cotton using dominant hand. fluid and thereby contaminates the blood gas

336
 sample.
 Holding the capillary tube horizontally with the Holding the tube horizontally prevents air
dominant hand, introduce blood into the tube. entrapment.
 Fill the entire tube with blood and cap the ends. Maintains blood within the tube.

 Cleanse the puncture site with gauze or cotton Reduces transmission of microorganisms.
and apply adhesive bandage over area; do not Alcohol stings and prolongs bleeding.
use alcohol.
 Place the sample in a laboratory specimen bag, Allows for blood gas analysis and ensures that
label properly, and transport for analysis as soon results are reported on correct patient.
as possible.
 Return the child’s bed to the lowest position or Reduces potential injury from falls.
to a level that is age appropriate.
 Dispose of used equipment and waste in Standard precautions. Reduces transmission of
appropriate receptacle. Remove gloves and microorganisms.
perform hand hygiene.

ARTERIAL BLOOD GAS SAMPLING USING ARTERIAL PUNCTURE

STEPS RATIONALE
1. Gather the necessary supplies. Promotes efficient time management and provides an
organized approach to the procedure.
2. Perform hand hygiene. Reduces transmission of microorganisms.
3. Raise the bed to a comfortable working Promotes good body mechanics and reduces back strain.
height, or stand on a step stool at crib
side.
4. Select arterial puncture site. Perform a Facilitates visualization and ease of access. Ensures
collateral circulation test for occlusion adequate blood supply to the extremity. If the test is
of the radial or ulnar and radial arteries negative (no collateral circulation), then select another
until blanching of the hand is seen. site.
Upon removal of pressure from one of
the arteries, the redness of the hand is
observed. The radial artery is small and easily stabilized as it passes

337
 a. Use the radial artery as first choice. over a bony groove located at the wrist.
b. Use the brachial artery as the second Studies have shown the brachial artery to be technically
choice except in case of poor easier to access and more comfortable for the child.
pulsation due to shock, obesity, or The femoral artery is easily palpated and punctured;
sclerotic vessel. however, complications surrounding femoral artery
c. Use the femoral artery in the case of puncture limit its usefulness. Also, there is greater risk for
altered perfusion to the upper contamination from venous blood in the nearby femoral
extremity arteries or vein as well as infection because of the close proximity of
cardiopulmonary arrest. the pubic area.
5. Don gloves Standard precaution to reduce transmission of
microorganisms.
6. Position the child; have another staff Facilitates visualization and ease of access. Limit child’s
member assist in holding the child. movements and promotes safer performance of procedure.
7. Scrub the selected site with antiseptic; Reduces transmission of microorganisms.
wipe in a circular motion, moving
outward. Allow to dry.
8. In non-emergent situation, use topical Minimizes discomfort.
anesthesia (e.g. cream or vapocoolant)
and locally anesthetize the site with
lidocaine.
9. Ensure that pre-heparinised 1 ml syringe Allows for procedure to continue quickly and efficiently.
with cap, 25G needle or 25G butterfly Facilitates ease of access to the equipment.
needle, gauze or cotton balls, patient
specimen label, adhesive bandage, and
biohazard bag for transporting the
specimen are within reach.
10. Perform percutaneous puncture of the Allows for control of blood flow.
selected artery by pulling the skin taut
around the position with the
nondominant hand and puncturing the
skin slowly with the dominant hand
using the 25G needle and heparinised 1
ml syringe, bevel up, in a 45 to 60 °
angle to the artery. Keep index finger on

338
 the artery to determine which direction
to advance the needle.
Advance the needle until the artery is
punctured. Blood will appear in the needle hub when the artery is
Do not move the needle around as if punctured. Excessive movement of the needle and
“hunting” for the vessel. reinsertion may cause nerve and/or artery damage and is
very painful for the child.
11. Slowly and evenly withdraw required Prevents inadvertent aspiration of air during withdrawal.
amount of blood for sample.
12. Remove needle while stabilizing the Hematomas and hemorrhage can occur if pressure is not
barrel of the syringe and have assistant applied quickly and correctly. If bleeding persists, place
quickly apply firm continuous pressure an ice pack over site and continue with firm pressure.
to the puncture site with cotton or gauze
for 5 mints or until bleeding stops.
13. Once bleeding stops apply adhesive Prevents further bleeding and reduces transmission of
bandage firmly and stretched tautly over microorganisms.
puncture site.
14. Hold blood sample syringe upright and Air bubbles may alter test results.
express any air bubbles rapidly.
15. Seal tip of syringe immediately with cap Keep airtight to prevent alterations in results.
or stopper. Roll syringe gently to mix
blood with heparin to prevent clot
formation.
16. Place the sample in a laboratory Allows for blood gas analysis and ensures that results are
specimen bag, label properly, and reported on correct patient. Ice slows oxygen metabolism.
transport for analysis as soon as
possible. Place the sample on ice if
analysis will be delayed longer than 10
mints.
17. Return the child’s bed to the lowest Reduces potential injury from falls.
position or to a level that is age
appropriate.
18. Dispose of used equipment and waste in Standard precautions. Reduces transmission of
appropriate receptacle. Remove gloves microorganisms.

339
 and perform hand hygiene.

BLOOD GAS SAMPLING USING AN INDWELLING HEPARINIZED ARTERIAL

OR DEEP VENOUS CATHETER
STEPS RATIONALE
1. Gather the necessary supplies. Promotes efficient time management and provides
an organized approach to the procedure.
2. Perform hand hygiene. Reduces transmission of microorganisms.
3. Raise the bed to a comfortable working height, Promotes good body mechanics and reduces back
or stand on a step stool at crib side. strain.
4. Vigorously cleanse the aspiration stopcock or Reduces transmission of microorganisms.
part of the indwelling catheter with an alcohol
wipe.
5. Apply 3 ml syringe to aspiration port and Opens the system from the child to the syringe.
stopcock of indwelling catheter and turn the
stopcock off to the infusing fluid (or as
appropriate to line setup).
6. Withdraw twice the dead space of the syringe Removes any clot material and intravenous fluid
(approximately 1.5 – 2.0 ml) of discard blood. from within the catheter; accesses blood.
7. Turn the stopcock to a position midway Facilitates removal of blood gas sample.
between the infusing fluid and syringe
connection and replace the 3 mL discard
syringe with a heparinized 1 mL syringe.
If blood discard is to be re-infused into the child
(follow institutional guidelines), maintain Blood discard may be re-infused in neonates and
sterility. children at risk for anemia to minimize blood
volume depletion.
8. Turn the stopcock off to the infusing fluid and Prevents inadvertent aspiration of air during
slowly and evenly withdraw required amount of withdrawal. Decreases arterial spasm if done
blood for sample into 1 mL syringe. slowly. Accurate tests can be done with as little as
0.2 ml of sample.
9. Turn the stopcock off to the syringe; remove This will be used for the blood gas sample.

340
 and cap the 1 mL syringe and momentarily set
aside.
10. If blood is to be re-infused, visually examine Reinfusion of discard reduces blood loss with
discard syringe for clots; if none, apply syringe sampling and helps maintain child’s blood volume.
with discard fluid to stopcock, turn stopcock off Examination of discard avoids infusing clotted
to infusing fluid, and infuse contents slowly. blood. Rapid infusion may precipitate
Turn the stopcock off to the syringe. If discard arteriospasm.
will not be used, omit this step.
11. Apply 3 ml heparinised NS flush syringe to Maintains patency of indwelling catheter.
stopcock, turn off to infusing fluid, and flush
catheter through of blood until line is again
clear (or flush as appropriate for line setup).
12. Hold blood sample syringe upright and express Air bubbles may alter test results.
any air bubbles rapidly.
13. Place the sample in a laboratory specimen bag, Allows for blood gas analysis and ensures that
label properly, and transport for analysis as results are reported on correct patient. Ice slows
soon as possible. Place the sample on ice if oxygen metabolism.
analysis will be delayed longer than 10 mints.
14. Return the child’s bed to the lowest position or Reduces potential injury from falls.
to a level that is age appropriate.
15. Dispose of used equipment and waste in Standard precautions. Reduces transmission of
appropriate receptacle. Remove gloves and microorganisms.
perform hand hygiene.

TRANSCUTANEOUS BLOOD GAS MONITORING

STEPS RATIONALE/POINTS OF EMPHASIS

1. Gather the necessary supplies. Promotes efficient time management and provides an
organized approach to the procedure.
2. Perform hand hygiene. Reduces transmission of microorganisms.
3. Raise the bed to a comfortable working Promotes good body mechanics and reduces back
height, or stand on a step stool at crib side. strain.
4. Attach the appropriate sensor to the front Allows for correct monitoring of patient.

341
 of the machine following manufacturer’s
instructions.
5. Turn the machine on and double-click for Ensures power to the machine.
battery operations.
6. Calibrate the machine according to Ensures correct calibration.
manufacturer’s instructions.
7. Set alarm limits. Ensures safety of the device, especially from
overheating and the possibility of a skin burn.
8. Attach the ring to the sensor face and, A clean sealed application allows for accurate
with a drop of sensor gel, apply to the monitoring. Avoid bubbles, and check for a damaged
patient. membrane, which could limit the precision of the
device.
9. Dispose of equipment and waste in Standard precautions. Reduces transmission of
appropriate receptacle. Perform hand microorganisms.
hygiene.

CHILD AND FAMILY EVALUATION AND DOCUMENTATION

 Evaluate the neurovascular status of the extremity used. Check the site for delayed hematoma
formation and for impaired circulation to the distal extremity. Children with frequent blood gas
draws from arterial puncture can be at increased risk for thrombosis (especially in the femoral
artery).
 Monitor for large or small arterial occlusions, which can present as cold extremities, absent pulses, or
petechiae.
 Evaluate for local edema, which can be caused by internal hemorrhage.
 Assess the child’s tolerance and response to the procedure, the ease or difficulty of obtaining sample,
and the presence of complications or adverse reactions.
 Determine whether the child and family have other areas of concern to discuss.
 Continue to assess and document the condition of the site, per institutional policy (at least once per
shift or more often, as indicated by child’s condition), until wound is healed; if child is discharged
before healing, give discharge instructions for monitoring site. Evaluate child for signs and
symptoms of infection, including fever, tachycardia, redness, swelling, or inflammation at the
puncture site.
 For indwelling arterial lines, check and document circulation of extremity and integrity of line at
minimum with vital sign checks or per institutional policy.
342
  Document the following in child’s medical record for blood gas sampling:
- Date and time procedure performed.
- Topical or local anesthetic used.
- Catheter size used or removed.
- Ease or difficulty of obtaining sample.
- Amount of blood aspirated and re-infused.
- Presence of complications or adverse reactions.
- Child’s response to and tolerance of the procedure.
- Child’s temperature at the time the blood gas was obtained, position or level of activity,
clinical appearance, and any adjunctive therapies such as chest tubes.
- Blood gas results. Note the amount of oxygen the child is receiving, the oxygen
administration device or ventilator settings, and any noninvasive respiratory monitoring
values (e.g. respiratory rate, pulse oximetry, transcutaneous values, and end-tidal CO2
values).
 Document the following in child’s medical record for transcutaneous monitoring:
- Date and time of measurement
- Transcutaneous reading
- Child’s position
- Respiratory rate
- Child’s activity level
- Inspired oxygen concentration or supplemental oxygen flow (specify type of oxygen delivery
device).
- Mode of ventilatory support, ventilator, or continuous positive airway pressure settings.
- Electrode placement site, electrode temperature, and time of placement.
- Clinical appearance of the child including perfusion, pallor, and skin temperature.
- Results of simultaneously obtained PaO2, PaCO2, and pH when available.
COMMUNITY CARE
 Instruct family on the care and dressing of the wound puncture site at home and how to monitor for
signs of respiratory distress and local and systemic infection.
 If the procedure will be completed in a physician’s office or clinic, encourage family to discuss the
procedure with the child on the trip to the office or clinic.
 Instruct the family to notify the healthcare provider if:
- Child demonstrates signs of respiratory distress.
- Infection at puncture site or systemically.

343
 BONE MARROW ASPIRATION
INTRODUCTION
 Bone marrow aspiration is completed by a healthcare prescriber according to scope of practice.
 A healthcare prescriber, registered nurse (RN), or licensed practical nurse (LPN) assists with the
procedure and participates in sedation procedures as ordered.
 If the child is receiving medication for sedation, nursing personnel remain present during the
procedure to monitor the child, and sedation guidelines are used.

EQUIPMENT
 Bone marrow tray, which includes
- Three sterile cotton balls or gauze
- Sterile forceps
- Sterile bowl
- Sterile drape
- Gauze pads of various sizes
- Two 10 mL syringes
- Adhesive bandage or pressure dressing
- Chlorhexidine solution
- Sterile gloves (for practitioner performing procedure)
- Bone marrow aspirate needle (may use a spinal needle), sized according to the child.
- Specimen containers/slides with labels, depending on diagnostic tests being completed
- Tape
 Nonsterile gloves (for assistive personnel)
 Small sheet, rolled.
344
  Anesthetic cream
 1% lidocaine with syringe, if being used
 Pain/Sedation medications as ordered
 Stethoscope
 Blood pressure monitoring equipment (as needed)
 Pulse oximeter (if child is sedated)
 Age – appropriate resuscitation equipment
 Age – appropriate diversional activities (music, guided imagery, hand-holding)

CHILD AND FAMILY ASSESSMENT AND PREPARATION

 Assess child and family’s readiness to learn.
 Explain to child and parents the use of the anesthetic cream, sedation medications, and NPO status,
as needed.
 Explain the procedure to the child and the family. Reassure them that the procedure may be
somewhat uncomfortable and that there will be some soreness for 1 to 2 days after the procedure
that may be relieved with acetaminophen. No activity restrictions are required.
 Hydrate the child before the procedure whenever possible to facilitate bone marrow withdrawal.
Providing twice the amount of maintenance intravenous fluid is preferable when physiologically
possible.
 Assess the child’s coagulation status to anticipate bleeding complications.
 Show the child and family the procedure/treatment room.
 Assess the child for previously used comfort methods and diversional strategies. Reinforce these
strategies or teach new methods (e.g. breathing techniques, music therapy).
 Verify that a legal consent form for the procedure has been obtained and signed by the parents or
guardians.
 Assess the child for medication allergies if using anesthetic cream, lidocaine, or sedation/pain
medication during the procedure.
 If using sedation, follow institution’s policy regarding NPO status before the procedure and for
monitoring the child’s status before and after the procedure.
 Explain to the parents that their role during the procedure is to offer physical and verbal support to
their child. Discuss with the parents ways they can provide diversionary activities for the child.

345
ASPIRATING BONE MARROW
STEPS RATIONALE/POINTS OF EMPHASIS
1. Apply anesthetic cream to site of aspiration Anesthetic cream will help to decrease pain at the
at least 1 hour before procedure. injection site.
2. Gather the necessary supplies. Promotes efficient time management and provides an
organized approach to the procedure.
Preparation before the child is in the room can help to
decrease the child’s anxiety by limiting the length of
time the child is in the treatment room.
3. Perform hand hygiene. Reduces transmission of microorganisms.
4. Set up sterile bone marrow tray. Maintains sterility while setting up the supplies.
5. Bring the child and family member (if Painful procedures are never completed in the child’s
available and willing to accompany child) own room; that area should remain a “safe haven”.
into the treatment room. Place the infant or The child should not be left unattended on the
young child on the procedure table, procedure table because there is the potential to roll
keeping one hand on the child at all times off or fall off the table.
to ensure safety. Permit the older child to Family presence during invasive procedures has been
climb on to the procedure table with demonstrated to be beneficial to the child and the
minimal assistance (if not sedated). participating family members. Families perceive
Show the family member where he or she themselves as active participants, caring for the child
can stand to be of most support and benefit with the staff. Families generally view their presence
to the child during the procedure. as a right, an obligation, and a natural event. Family
presence is optimal and their choice in this matter
should be respected.
6. Assess the child’s vital signs and comfort Provides baseline for monitoring changes during and
level. after the procedure.
7. Perform hand hygiene, and don gloves. Standard precautions to reduce transmission of
microorganisms. Note: The healthcare prescriber
performing the procedure will be wearing sterile
gloves. The nurse assisting in the procedure does not
need sterile gloves unless their activities enter the
346
 sterile field.
8. Administer pain management/ sedation Bone marrow aspiration is a painful procedure.
medications as ordered. Pulse and oxygen saturation monitoring should be
If ordered, administer sedation. Monitor used to assess the child’s status because of the
the child according to sedation guidelines. potential for decreased responsiveness and altered
respiratory status during sedation.
9. Position the child according to the Assists the healthcare prescriber in locating the correct
aspiration site selected by the healthcare landmark for the aspiration procedure.
prescriber: Decreases risk of complication by misplacement of
 Posterior iliac crest: prone with a small needle.
roll under the child’s hips.
 Sternum or anterior iliac crest: supine.
 Vertebral: on one side, with knees and
head tucked tightly together.
 Tibia: supine with knee bent and
supported by pillow or towel roll.
10. Wipe the site with a clean cloth or gauze to Removes white cream for clear visualization of
remove the anesthetic cream. landmarks.
11. The healthcare prescriber will perform the The initial aspirate on a newly diagnosed leukemic
aspiration procedure using sterile child may be difficult to withdraw because the bone
technique. Several sites and attempts may marrow is very hypercellular and packed with
be necessary to gather the needed amount leukemic cells
of specimen.
The healthcare prescriber will drape the Cleaning the site reduces transmission of bacteria.
selected area with sterile towels and
cleanse the site with a chlorhexidine Surface analgesia aids in pain relief during the
solution. procedure.
A surface anesthetic is injected at this time.
12. Hold the child in place during the Decrease in movement allows for the procedure to be
procedure. completed with ease and prevents misplacement of the
needle. Older children may be able to hold still with
little need for physical restraint to maintain correct
positioning during the procedure.
13. During the procedure, use age-appropriate May help distract and reduce child’s perception of

347
 diversion and breathing techniques to pain and help enhance the child’s coping skills.
distract the child. For instance, the older
child may prefer to listen to music on
headphones during the procedure.
14. After the procedure is completed, remove Decreases the risk for skin irritation from the
the drapes and cleanse the chlorhexidine chlorhexidine.
from the area.
15. Assess the bone marrow aspirate site for Detects complication properly.
signs of bleeding and apply a dressing Reduces risk of bleeding.
(using a gauze pad secured with tape) or an
adhesive bandage.
16. Label the specimens and send to the Decreases the risk for error and loss.
appropriate laboratory for examination.
17. Dispose of equipment and waste in Standard precautions. Reduces transmission of
appropriate receptacle. Remove gloves and microorganisms.
perform hand hygiene.
18. Assist the child to return to a comfortable Promotes comfort and reduction of anxiety.
position and maintain diversion.
19. If sedation was used, assess the child until Ensures early detection of cardiorespiratory
he/she is fully awake (which can take about compromise.
60 mints from the time the medication was Monitoring must be maintained until child reaches
administered), because duration of baseline premedicated cognitive state to ensure child’s
medications administered for sedation may anxiety.
extend beyond length of time needed to
complete the procedure.
20. Assess the child for discomfort and The child may have pain at the injection site for 1to 2
medicate as ordered. days after the procedure.
21. Return the child to his or her room or Moving the child to a more comfortable and safe
discharge child home when stable. location will help alleviate the child’s anxiety.

CHILD AND FAMILY EVALUATION AND DOCUMENTATION

 Monitor the bone marrow aspiration site for signs and symptoms of bleeding and infection.
 Continue ongoing assessment of the child’s pain and implement pharmacologic interventions as needed.
 Document the following:
348
  Location of bone marrow aspirate
 Condition of the site at the end of the procedure
 Type of dressing applied to site, and time dressing was applied
 Child’s status before, during, and after the procedure, including vital signs, oxygen saturation.
 Child’s response to medications
 Diversional activities provided during procedure and effectiveness of these interventions.
 Post-procedural instructions provided to the child and family.

COMMUNITY CARE
 For pain relief, the child may use acetaminophen or ibuprofen. Aspirin should not be used because it
may interfere with platelet aggregation.
 No restrictions on the child’s activities are required after the procedure.
 Instruct the child and parent to remove the original dressing no earlier than 8 hours and no later than 24
hours after the procedure to prevent bleeding. Leaving the bandage in place for longer periods of time
may predispose the immunocompromised child to infection.
 If the child is reluctant to have the bandage removed, suggest taking the bandage off during the child’s
bath because a wet bandage is easier to remove.
 Instruct the family to contact the healthcare provider if
 The child develops a fever
 The aspiration site becomes reddened or irritated or oozes any fluid or blood.
 The child complains of unmanageable pain.

349
 LUMBAR PUNCTURE

CLINICAL GUIDELINES
 A physician, nurse practitioner (NP), or physician’s assistant (PA) performs this procedure.
 A registered nurse (RN) or licensed practical nurse (LPN) is present during this procedure to assist in
positioning the child and in assessing the child’s status.
 The procedure is performed in a treatment room, unless the child is in an emergency room or ICU
and should not be moved from the bed because of his or her condition.
 Informed consent must be obtained before the procedure.
 The procedure is carried out under aseptic technique.

EQUIPMENT
 Sterile disposable pediatric lumbar puncture tray to include
- Sterile drapes
- A 3 ml syringe with 25 G needle
- Three way stopcock
- Adhesive bandage
- Three to five fluid collection tubes
- Povidone- iodine swabs
- Spinal fluid pressure monometer (optional)
 Two lumbar puncture needles
 Ampoule of 1% lidocaine
 Sterile gloves
 Labels with child’s name for specimen tubes
 Anesthetic cream (optional)

CHILD AND FAMILY ASSESSMENT AND PREPARATION

 Assess the pertinent history and physical findings for signs of increased intracranial pressure.
 Assess the age, developmental level, and coping strategies of the child.
 Discuss with the child and parents distraction techniques that may be useful during the procedure
(e.g. imagery, focused breathing).

350
  Assess the child’s and parent’s knowledge of the reasons for the procedure, expected outcomes, and
potential adverse reactions.
 Discuss role of the parent to provide support to the child if the parent will be present during the
procedure.
 Ensure that written consent has been obtained to perform the procedure.
 Apply topical anesthetic to lumbar puncture site if using agent that requires advanced time for
complete activation.

ASSISTING WITH LUMBAR PUNCTURE

STEPS RATIONALE
1. Perform hand hygiene. Reduces transmission of microorganisms.
2. Set up equipment using aseptic technique. Maintains sterile integrity of environment, promotes
efficient time management, and provides an organized
approach to the procedure.
3. Airborne and/or contact isolation Meningococcal meningitis is highly contagious and is
precautions may be needed. Don gown, an airborne contaminant. Unprotected staff exposed to
gloves, and mask as needed if the procedure this organism by the child will have to undergo
is being performed on a child with a prophylactic treatment measures.
potential infection.
4. Verify child’s identity and transport child to Helps ensure correct patient, correct procedure. Painful
treatment room (unless procedure is to be procedures should not be performed at the child’s
done at the bedside). If not already bedside unless absolutely necessary because of the
completed, apply anesthetic cream to site; child’s critical condition. The child’s hospital room
transport child to treatment room after the should remain a safe haven where intrusive procedures
agent has been applied for the period of time are not completed. By applying anesthetic cream at this
recommended by manufacturer. point, the site will be desensitized by the time procedure
is performed.
5. Position child on the treatment table in one
of the following ways:
a. Knee-chest position – with back rounded Best position for infant. Maximizes separation of the
and parallel to side of treatment table, place vertebral bodies. The L3 – L4 interspace is the preferred
child on side with lumbar area exposed. site for a lumbar puncture, but the L2 – L3 and L4 – L5
Hold small infant in position by placing one interspaces can also be used.

351
 hand over his/her neck and the other hand
over the buttocks. Bend the child’s back to
the desired position.
b. Recumbent position – Hold older infant or Best position for older infant or young child to
child in position by placing one hand behind maximize separation of vertebral bodies.
child’s neck or one arm around neck and
grasping child’s legs behind the knees. Place
the other arm around child’s buttocks and
grasp his or her hands. Put pressure on neck
and legs to bend child’s body as necessary.
c. Sitting position – Support the child in
position by having the child sit at edge of This may be a comfortable position for the older child
the table with shoulders and head bent who is able to cooperate without restraint. An assistant
forward. Elbows should be placed on the must hold infants placed in this position in the sitting
knees and the back arched. position.

6. When the child is in position, the sterile Aseptic technique is used to decrease exposure to
drapes are placed over the back to expose microorganisms during this invasive procedure.
the puncture area only. Research supports that parental presence decreases child
The child is instructed to stay as still as fear and anxiety and that parents can use a variety of
possible while the assistant continues to comforting and distracting strategies to support their
hold the child securely in position. The child during the painful procedure.
assistant or parent present in the room
initiates distraction measures.
7. Follow institution policy and procedure for Implements Universal Protocol for Preventing Wrong
ensuring preoperative verification process is Site, Wrong Procedure, Wrong Person Surgery and
completed, appropriate operative site is follows the Joint Commission on Accreditation of
marked, and “time out” is completed before Healthcare Organizations (JCAHO) National Patient
start of procedure. The healthcare provider Safety Goals 2004: 1).Improve the accuracy of patient

352
 performing the procedure identifies the identification; and 4). Eliminate wrong site, wrong
puncture area and scrubs the area with patient, and wrong procedure surgery. Decreases
povidone-iodine. Tell the child he or she microorganisms at site. Telling the child what sensations
will feel a cold sensation on the back during they will feel may help them cope.
the cleansing.
8. The healthcare provider performing the Provides local anesthesia to the site.
procedure instills lidocaine (Xylocaine)
intradermally around the area of the
puncture site.
9. The healthcare provider performing the When CSF fills the monometer, CSF pressure can be
procedure inserts needle and stylet into the monitored. Normal pressure in the relaxed patient is 50
subarachnoid space. When the needle is in – 80 mm in children. Each heartbeat creates a
position, a free drip of CSF is established, fluctuation of 2 – 5 mm and each respiration a
and spinal pressure may be assessed using fluctuation 4 – 10 mm. Increased CSF pressure may be
the spinal pressure monometer. The present with meningitis and other neurologic conditions
monometer is attached to the spinal needle that cause increased intracranial pressure.
by means of a three-way stopcock. Normal CSF is clear. Red fluid can indicate intracranial
When the measurement is completed, the hemorrhage or a traumatic tap. Cloudy turbid fluid
stopcock is turned to allow the CSF to be indicates infection. Yellow fluid indicates
collected in three to five sterile specimen hyperbilirubinemia or hemolysed red blood cells.
tubes. CSF color and turbidity are noted at Assists in appropriate collection of results.
this time.
Before removing the needle, the healthcare
provider performing the procedure may
choose to use the monometer closing CSF
pressure.
10. Throughout the procedure, the assistant Brainstem herniation is a potential complication.
monitors for complications such as: Children with increased intracranial pressure are at
 Decreased responsiveness greatest risk. Other complications include penetration of
 Tachycardia or bradycardia a nerve and breakage of the needle (in an uncooperative
 Sluggish or unequal pupil reaction moving child).

 Abnormal breathing due to positioning.

 Complaints of severe pain
11. Spinal needle is withdrawn, the child’s back Protects the puncture site.

353
 is wiped clean of wet fluids, and an adhesive
bandage is placed over the puncture site.
12. Dispose of equipment and waste in Standard precautions. Reduces transmission of
appropriate receptacle. Perform hand microorganisms.
hygiene.
13. Return the child to his or her own bed, Despite a lower incidence than is seen in the adult
making child comfortable lying flat in the population, postdural puncture headaches do occur in
bed. The child should remain lying flat for children. The headaches usually start within 48 hours
at least 1 hour after the procedure. after the procedure and resolve within 5 to 7 days
without therapy. Lying flat and providing the child with
good hydration can minimize the risk for headaches.
14. Continue to monitor the child for the Postprocedural complications may become evident and
complications noted in step 10. need to be treated.
15. Ensure that specimens are correctly labeled Prompt distribution of the specimens will assist in early
and sent to the laboratory immediately. diagnosis of the child’s condition.

CHILD AND FAMILY EVALUATION AND DOCUMENTATION

 Document the following:
- Time and duration of procedure
- Name of healthcare provider performing procedure
- Color and character of fluid withdrawn
- Date and time that specimens were sent to the laboratory for analysis
 Evaluate response of the child during and after the procedure. Document findings in the medical
record. Document findings in the medical record.

COMMUNITY CARE
 Encourage the child to drink plenty of fluids.
 Explain to child and parent the need to have child remain on bed rest for 1 hour after the procedure to
decrease incidence of headaches. Although less frequently seen in the pediatric population,
headaches are generally noted to start within 48 hours of the procedure, usually resolving within 5 to
7 days without therapy.
 Instruct the family to contact the healthcare provider if
- Child has a severe headache.

354
- Child exhibits changes in neurologic status, such as changes in level of consciousness, irritability,
onset of high-pitched cry (infants), and bulging fontanel (infants).
- Child has bleeding or leaking of fluid from the puncture site.
- Redness or irritation develops at puncture site.
- Child develops a fever.
- Child complains of numbness in the legs.

355
 STOOL COLLECTION AND ANALYSIS
CLINICAL GUIDELINES
 A healthcare prescriber’s order is required to obtain a stool specimen for bedside testing or
laboratory analysis.
 The child should be isolated if an acute infectious gastroenteritis is suspected, although children with
similar symptoms may be cohorted, if necessary.

EQUIPMENT
If obtaining a laboratory stool specimen:
 Tongue blade
 Non-sterile gloves
 Bedpan or commode specimen container, as appropriate
 Urine bag, if needed.
 Specimen container with lid or swab and culture tube for laboratory specimens
 Adhesive label
 Laboratory request form
 Self-sealing plastic biohazard bag.
 If obtaining a rectal swab, additional equipments:
 Normal saline or broth medium
 Soap, water, and washcloth
 Rectal swab If obtaining a stool sample by enema, additional equipment:
 Saline solution or tap-water enema If obtaining a stool specimen for bedside testing:
 Tongue blade or other wood instrument
 Non-sterile gloves
 Diaper (for infants and children who do not have bowel and bladder control)
 Bedpan or commode specimen container (for children who have bowel and bladder control)
 Urine bag, if needed (for children who are diapered)If testing for fecal occult blood, additional
equipment:
 Hematest reagent tablet test kit or Hemoccult fecal blood test kitIf testing stool pH, additional
equipment:
 pH paper and color chartIf testing stool for reducing substances, additional equipment:
Test tube

356
 Clinitest tablets and color chart

CHILD AND FAMILY ASSESSMENT AND PREPARATION

 Assess pertinent history to include
- Length of illness
- Clinical symptoms
- Contacts with other ill persons, particularly at home, school, or child care
- Recent travel
- Recent diet
- Current medications
- Normal and current bowel patterns
- Recent gastrointestinal tests
 Assess the child’s (when appropriate for developmental level) and family’s knowledge regarding the
reason for testing, method used to collect the specimen, and when to expect test results.
 Determine what terms the child and family use to describe relevant body parts and bodily functions.
 Explain the stool collection procedure to the child and family, using terms they can understand. This
helps to relieve anxiety, gains patient and family cooperation with the collection procedure, and
helps to avoid in advertent disposal of stool specimen.
 Provide privacy for the child, regardless of age, during procedure and handle specimen discretely.

OBTAINING A VOIDED STOOL SPECIMEN

STEPS RATIONALE/POINTS OF EMPHASIS
1. Gather the necessary supplies and Promotes efficient time management and provides an
perform hand hygiene. organized approach to the procedure. Reduces
transmission of microorganisms.
2. Pre-label specimen container with the Ensures that correct test is done on the correct patient.
following information: patient’s name,
date of birth, room or patient ID number,
date and time of collection, and initials of
person collecting sample.
3. Complete a laboratory requisition slip Providing relevant patient history notifies the
indicating the desired tests; include any laboratory of events or circumstances that could
relevant patient history. influence or explain test results.

357
4. If stool is to be collected from a diaper, Ensures collection of a fresh specimen, which will not
check frequently for defecation while be distorted by time.
wearing gloves.
Remove soiled diaper, clean perineal Cleaning the perineal area prevents skin irritation from
area, and apply a clean diaper. the stool.
5. Instruct the child with bowel and bladder Ensures collection of a fresh specimen, which will not
control to notify you when having the be distorted by time.
urge to defecate and then have the child
defecate in a clean dry bedpan or
commode specimen container.
Have child wipe perineal area with toilet
paper and wash rectal area and hands Cleaning the perineal area prevents skin irritation from
thoroughly. the stool, washing prevents patient contamination.
6. While wearing gloves and before Observed abnormalities may give insight into possible
transferring stool to specimen container, pathology.
assess color, consistency, and odor. Also
observe for foreign material, such as
blood, mucus or pus.
7. Transfer the most representative stool Begins preparation of the specimen for safe transport
specimen from the diaper, bedpan, or to the laboratory.
commode container to the appropriate
specimen container using tongue blade
and then tightly secure the cap, being
careful not to contaminate the outside of
the container.
8. Wrap tongue blade in paper towel and Standard precautions. Reduces transmission of
dispose of waste in appropriate microorganisms.
receptacle. Remove gloves and perform
hand hygiene.
9. Place specimen container in a self-sealing Delays in stool specimen processing can adversely
biohazard bag and send, with laboratory affect test results.
slip, immediately to the laboratory.
10. Perform hand hygiene. Reduces transmission of microorganisms.

358
OBTAINING A SPECIMEN BY RECTAL SWAB
STEPS RATIONALE/POINTS OF EMPHASIS
1. Gather the necessary supplies and perform hand Promotes efficient time management and
hygiene. provides an organized approach to the
procedure. Reduces transmission of
microorganisms.
2. Pre-label specimen container with the following Ensures that correct test is done on the correct
information: patient’s name, date of birth, room patient.
or patient ID number, date and time of
collection, and initials of person collecting
sample.
3. Complete a laboratory requisition slip indicating Providing relevant patient history notifies the
the desired tests; include any relevant patient laboratory of events or circumstances that could
history. influence or explain test results.
4. Clean area around child’s anus using a Removes any organisms or residue that could
washcloth and water. interfere with sample collection.
5. Insert swab, moistened with normal saline or Allows for safe specimen collection.
broth medium, through the anus and advance
anywhere from 1 cm in infants to 4 cm in larger
adolescents.
6. Move swab side to side and keep in rectum for Allows for absorption of organisms.
30 seconds.
7. While withdrawing swab, gently rotate against Provides a sample of a large area of the rectal
the walls of the lower rectum. mucosa.
8. Place swab in culture tube and secure the lid. Begins preparation of the specimen for safe
Crush the base to release holding media, if transport to the laboratory.
applicable.
9. Dispose of equipment and waste in appropriate Standard precautions. Reduces transmission of
receptacle. Remove gloves and perform hand microorganisms.
hygiene.
10. Place specimen container in a self-sealing Delays in stool specimen processing can
biohazard bag and send, with laboratory slip, adversely affect test results.
immediately to the laboratory.
11. Perform hand hygiene. Reduces transmission of microorganisms.
359
SPECIMEN COLLECTION FOR FREQUENTLY USED LABORATORY TESTS
STEPS RATIONALE/POINTS OF EMPHASIS
Follow the steps in the previous procedures for
specimen collection, with the following test-
specific modifications:
1. Cultures –
a. Collect 1-2 g of stool using a sterile tongue
blade into a sterile container, or use a Decreases the likelihood of contaminating the
sterile swab and place in a sterile culturette specimen.
for transport.
b. Pay particular attention to history of recent
travel or antimicrobial therapy. Some diseases are endemic to particular geographic
c. Use a transport medium or transport the areas; recent antimicrobial therapy may decrease
specimen to laboratory promptly. bacterial growth in a specimen.
Failure to handle specimen properly may result in
loss of enteric pathogens or overgrowth of
nonpathogenic organisms.

2. Rotavirus:
a. Collect 1 g of stool in a preservative-free Ensures an adequate sample without interfering
sterile tube or vial. If a swab is used, it factors.
must be heavily stained with stool.
b. Specimen may be refrigerated for up to 24
hours, if necessary. Preserves the specimen without damage to the
organisms.
3. Ova and parasites:
a. Collect two or three specimens 1-2 days Some organisms may only be passed intermittently
apart. because of cyclic shedding.

360
b. Send the entire stool, whenever possible, or This increases the likelihood that organisms will be
30-50 mL of liquid stool. If a specially discovered, when present.
prepared kit is used, fill each container to
the specified mark and follow package
directions carefully.
c. Note whether any of the foll. Were used
within the past 7-10 days: barium, castor or These agents can destroy organisms or otherwise
mineral oil, magnesium, bismuth, antacids, interfere with laboratory results.
antidiarrheal agents or antibiotics. Keep
stool from coming in contact with urine or
toilet paper.
d. Pay particular attention to recent dietary Certain parasites are common to certain countries.
and travel history as well as use of
antiparasitic drugs within 2 wks of test.
e. Liquid or soft stool specimen must be kept Some organisms can degrade beyond recognition in
warm and transported to the laboratory as little as 30 mints. Excessive heat or cold can
within 30 mins. Formed stool may be destroy parasites.
placed in preservative and kept at a neutral
temp if immediate transport is not possible.
f. Oral laxatives may be used to assist in
producing a stool specimen. Collection by
enema or rectal swab is not appropriate. Parasites rarely locate in the distal colon.
4. Pinworms:
a. Collect specimen early in the morning, Female pinworm usually deposits ova at night.
before patient bathes or defecates,
whenever possible. Pinworm ova rarely appear in the feces because the
b. Use manufacturer-made specimen kit, or female migrates to the anus and deposits ova there.
place a piece of cellophane tape, sticky side
out, on the end of a tongue blade and press
it firmly on the anal area. Transfer tape,
sticky side down, to a slide.
5. Fecal fat:
a. Expect child to be a high-fat diet 1-3 days A diet of 100 g of fat per day is recommended to
before and throughout testing. make excretion of fecal lipids (steatorrhea) evident,

361
 b. Pay particular attention to recent drug if present.
history. Certain drugs can interfere with test results.
c. Requires collection of all stools for a 72- Consider the first stool passed by the child as the
hour period. start of the collection period.
d. Do not collect stool in a waxed container. Wax may become incorporated into the stool and
e. Send each sample, as obtained, or interfere with test results.
refrigerate or freeze stool in collection Preserves the specimen without damage to the fecal
container and send entire specimen to the lipids.
laboratory at the end of the collection
period.
6. Gram stain (for white cells):
a. Collect a stool specimen or rectal swab and Ensures a proper sample for testing.
send immediately to the laboratory.
b. Pay particular attention to recent history of
gastrointestinal tests. Barium may interfere with test results.
7. α1- Antitrypsin:
a. Send 5 g of stool promptly to the Ensures a sufficient quantity of stool for testing.
laboratory after collection. For this test, cold temperatures do not adversely
b. Specimen may be refrigerated or affect stool contents.
frozen, if necessary.
8. Clostridium difficile toxin assay:
a. Send 1-2 g of stool promptly to the Ensures an adequate sample for testing.
laboratory.
9. Group B streptococcus screen:
a. Obtain a rectal swab and transport to Provides the laboratory with an appropriate
the laboratory in a culturette. specimen.
10. Miscellaneous laboratory stool tests:
a. Consult the laboratory to obtain Ensures that an adequate sample is obtained and
information regarding stool sample size, handled properly.
handling requirements, and any special
considerations.

BEDSIDE STOOL TESTING

STEPS RATIONALE/POINTS OF EMPHASIS
362
Begin with steps 1 through 6 from the first
procedure for specimen collection and then:
2. Occult blood (general):
a. Expect child to be on a meatless high-
residue diet, with no turnips or vitamin C Ensures testing accuracy by allowing for the
supplements for 2-3 days before test. Pay possibility of test updates or manufacturer
particular attention to recent drug and variations. Red meat, iron, iodine, turnips,
dietary history. horseradish, melons, radishes, chlorophyll, and
various drugs (such as aspirin or anti-
inflammatory drugs) and dyes can cause false-
positive reactions. Vitamin C, charcoal, antacids,
and some foods can cause false-negative results.
b. Perform test immediately on freshly Increases test accuracy because hemoglobin is not
excreted stool. stable in stool.
c. Test samples from several different Blood from the upper gastrointestinal (GI) tract
portions of the same specimen. may not be evenly disbursed throughout a formed
stool. Lower GI bleeding may appear primarily on
the outer surface of the stool.
d. To confirm positive test results, repeat A single positive test does not necessarily confirm
the test at least three times while child is GI bleeding.
on a proper diet and drug regimen.
3. Hematest reagent tablet test:
a. After collecting stool sample and while Prepares the specimen for testing.
wearing gloves, smear a bit of stool on
the kit’s filter paper with a tongue blade
or swab.
b. Place one reagent tablet in the center of
the stool smear. Remember to close the To remain effective, reagent tablets must be
cap tightly on the reagent tablet bottle protected from moisture, heat, and light.
immediately after use.
c. Add one drop of water to the tablet and
allow it to soak in for 5-10 secs. Add a
second drug, allowing it to run from the Allows the reagent to react to the presence of
tablet onto the stool specimen and filter occult blood.

363
 paper.
d. After 2 mins, the filter paper will turn Will react positively to blood loss of greater than 5
blue if the test is positive for occult mL in 24 hours. Do not read the color that appears
blood. on the tablet or filter paper after the 2-minute
e. Wrap the tongue blade and filter paper in period.
a paper towel and discard. Flush Standard precautions. Reduces transmission of
remaining stool sample in commode. microorganisms.
Remove and discard gloves. Perform
hand hygiene.
4. Stool pH:
a. Dip one end of a strip of pH paper into Allows paper to react to stool pH.
freshly excreted liquid stool.
b. Immediately compare the resulting color Alkaline stool may reflect a high-protein intake.
change on the pH paper with the Acidic stool (pH 6.0) may reflect a high-
accompanying color chart. carbohydrate diet or may be an indicator of mal-
c. Wrap used pH paper in a paper towel and absorption.
discard. Flush stool sample in commode. Standard precautions. Reduces transmission of
Remove and discard gloves. Perform microorganisms.
hand hygiene.
5. Reducing substances:
a. Mix 5 drops of freshly excreted liquid Prepares the sample for testing.
stool with 10 drops of tap water in a test
tube.
b. Add one Clinitest tablet and wait for Allows the testing agent to react to the stool
boiling to stop completely. Do not shake contents.
tube.
c. Once boiling action has stopped, shake The reaction to the stool’s sugar content happens
the test tube and, within the next 15 sec, with the liquid, and the visible color becomes
compare the color of the liquid with the inaccurate after 15 sec. Greater than 0.5%
Clinitest color chart. Ignore the color of reducing substances indicates mal-absorption of
the resulting sediment. sugars.
d. Flush stool sample and material in test
tube in commode. Remove and discard Reduces transmission of microorganisms.
gloves. Perform hand hygiene.

364
CHILD AND FAMILY EVALUATION AND DOCUMENTATION
Document the following:
 Stool color, odor, amount, consistency, and any unusual characteristics.
 For laboratory specimen:
- Record time and method of sample collection
- Required storage (if applicable)
- Time of transport to the laboratory
- Type of tests requested
 For bedside testing:
- Record time and method of sample collection and test results.
- Note condition of skin in perineal area and document any treatment.
- Document child’s tolerance of the procedure.
- Notify healthcare prescriber of any significant abnormalities found during assessment or testing.
- Resume pretest diet and medications, as appropriate.

COMMUNITY CARE
 Reinforce information given by healthcare prescriber regarding test results.
 Explain any monitoring, follow-up appointments, or repeat tests that may be needed.
 Instruct child (as appropriate) and family regarding appropriate perineal skincare based on child’s
age and skin condition.
 For specimen collection at home, instruct child (as appropriate) and family regarding proper
collection method, handling, and transport to the laboratory.
 A piece of plastic wrap can be placed under the commode seat over the commode opening to collect
stool after it is being voided.
 The specimen is to be stored in the refrigerator, instruct the family to keep specimen container in a
paper or plastic jar, stored away from food.
 Instruct the family to contact the healthcare provider if
- Child’s condition worsens
- Child has not received results of tests after time frame needed to complete specific test.

365
 CARDIAC MONITOR
DEFINITION
The cardiac monitor is a device that shows the electrical and pressure waveforms of the
cardiovascular system for measurement and treatment. Parameters specific to respiratory function can also
be measured. Because electrical connections are made between the cardiac monitor and the patient, it is kept
at the patient's bedside.

PURPOSE
 The cardiac monitor continuously displays the cardiac electrocardiogram (EKG) tracing.
 Additional monitoring components allow cardiovascular pressures and cardiac output to be monitored
and displayed as required for patient diagnosis and treatment.
 Oxygen saturation of the arterial blood can also be monitored continuously.
 Most commonly used in emergency rooms and critical care areas, bedside monitors can be
interconnected to allow for continual observation of several patients from a central display.
 Continuous cardiovascular and pulmonary monitoring allows for prompt identification and initiation of
treatment.
DESCRIPTION
The monitor provides a visual display of many patient parameters. It can be set to sound an alarm if
any parameter changes outside of an expected range determined by the physician. Parameters to be
monitored may include, but are not limited to, electrocardiogram, noninvasive blood pressure, intravascular
pressures, cardiac output, arterial blood oxygen saturation, and blood temperature.
Equipment required for continuous cardiac monitoring includes the cardiac monitor, cables, and
disposable supplies such as electrode patches, pressure transducers, a pulmonary artery catheter (Swan-Ganz
catheter), and an arterial blood saturation probe.

366
PREPARATION
As the cardiac monitor is most commonly used to monitor electrical activity of the heart, the patient can
expect the following preparations.
 The sites selected for electrode placement on the skin will be shaved and cleaned causing surface
abrasion for better contact between the skin and electrode.
 The electrode will have a layer of gel protected by a film, which is removed prior to placing the
electrode to the skin.
 Electrode patches will be placed near or on the right arm, right leg, left arm, left leg, and the center left
side of the chest.
 The cable will be connected to the electrode patches for the measurement of a five-lead
electrocardiogram. Additional configurations are referred to as three-lead and 12-lead
electrocardiograms.
 If noninvasive blood pressure is being measured, a blood pressure cuff will be placed around the
patient's arm or leg. The blood pressure cuff will be set to inflate manually or automatically.
 If manual inflation is chosen, the cuff will only inflate at the prompting of the health care provider, after
which a blood pressure will be displayed. During automatic operation, the blood pressure cuff will
inflate at timed intervals and the display will update at the end of each measurement.
 Disposable pressure transducers require a reference to atmosphere, called zeroing, which is completed
before monitoring patient pressures. This measurement will occur once the patient is comfortably
positioned since the transducer must be level with the measurement point.
 The pressure transducer will then be connected to the indwelling catheter. It may be necessary for as
many as four or five pressure transducers to be connected to the patient.
 The arterial blood saturation probe will be placed on the finger, toe, ear, or nasal septum of the patient,
providing as little discomfort as possible, while achieving a satisfactory measurement.

367
 Cardiac monitors display such vital signs as heart rate, pulse, and blood pressure for patients in
the intensive care unit.

AFTER CARE
 After connecting all equipment, the health care provider will observe the monitor and evaluate the
quality of the tracings, while making size and position adjustments as needed.
 The provider will confirm that the monitor is detecting each heartbeat by taking an apical pulse and
comparing the pulse to the digital display.
 The upper and lower alarm limits should be set according to physician orders, and the alarm activated.
 A printout may be recorded for the medical record, and labeled with patient name, room number, date,
time, and interpretation of the strip.
 Maintenance and replacement of the disposable components may be necessary as frequently as every
eight hours, or as required to maintain proper operation. The arterial saturation probe can be repositioned
to suit patient comfort and to obtain a tracing.
 All connections will be treated in a gentle manner to avoid disruption of the signal and to avoid injury to
the patient.

NORMAL RESULTS
 The monitor will provide waveforms and/or numeric values associated with the patient status. These
may include, but are not limited to, heart rate, arterial blood pressure, central venous pressure, and
pulmonary artery pressure, pulmonary capillary wedge pressure, left atrial pressure, cardiac output,
arterial blood saturation, and blood temperature.
 Furthermore, these values can be used to calculate other values, or parameters, or used to diagnose and
treat the patient's condition.
 Patient movement may cause measurement errors; the patient will be requested to remain motionless.
Depending on the mobility of the patient, assistance should be provided by the health care provider prior
to changing from a laying down position to sitting or standing.
 As the patient's condition improves, the amount of monitoring equipment may be decreased. However,
the electrocardiogram and arterial blood saturation probe should be expected to remain attached until
discharge is imminent.

368
 MECHANICAL VENTILATOR
INTRODUCTION
The advent of modern ventilator therapy in the 1980s has been a prominent milestone in the history
of advanced pediatric care. Ventilation should be undertaken in centers with adequate manpower, skill and
technology. Available ventilators for pediatric use have a wide range of capabilities, versatility and clinical
application. Some are more suitable for use with infants, others with older children. Nurses must be well
acquainted with the characteristics of the particular machine being used and the meaning of the setting and
alarms on the machine.

DEFINITION
Mechanical ventilation refers to the use of life-support technology to perform the work of breathing for
patients who are unable to do so, on their own.

OBJECTIVES
The fundamental objectives for ventilatory support in acutely ill patients may be viewed
physiologically and clinically:

PHYSIOLOGICAL OBJECTIVES
 To support or manipulate pulmonary gas exchange
 To normalize alveolar ventilation (PaO2, PaCO2 and pH)
 To achieve and maintain PaO2 >60 mm Hg and peripheral Sat O2 > 90%.
 To increase lung volume and maintain adequate functional residual capacity (FRC)
 To obtain lung expansion and to prevent or treat atelectasis.
 To improve oxygenation and lung compliance.
 To reduce the work of breathing in presence of high airway resistance and/or reduced
compliance, when spontaneous breathing becomes ineffective.

CLINICAL OBJECTIVES
 In presence of pathologic lung- Lung pathology may be connected with difficult gas diffusion,
particularly concerning alveolar oxygen levels (principally paO2), or with ineffective inhaling and/or
exhaling condition, which affect the elimination of CO2 particularly, as well as the acquisition of O2.

Objectives:
369
  Improve lung pathology
 Reverse hypoxemia, hypercarbia and acute respiratory acidosis
 Decrease systemic or myocardial oxygen consumption
 Relieve respiratory distress and reverse ventilatory muscle fatigue
 Stabilize chest wall in case of rib instability and/or loss of integrity

 In healthy lung
Objectives:
 Provide adequate gas exchange
 Permit sedation and/or neuromuscular blockage (e.g. to control seizures or provide general
anesthesia)
 Prevent complications connected with ventilatory support
 Avoid appearance of atelectasis and ventilation/perfusion (V/Q) mismatch.

ADVANTAGES:
 Correct ventilation of both lungs and progressive improvement of lung pathology
 Improvement of oxygenation and reduction of hypercapnia.
 Reduction of respiratory fatigue and oxygen consumption.
 Protection of airways and efficacious broncho-suctioning if tracheal intubation is performed.

ABSOLUTE INDICATION FOR INTUBATION AND MECHANICAL

VENTILATION ARE:
 emergency
 apnea and severe irregularity of spontaneous breathing
 severe respiratory failure
 ineffectiveness of oxygen therapy by mask, CPAP or non- invasive ventilation

BASIC PRINCLIPLE OF A VENTILATOR

To understand the basic principle of a ventilator, we have to conceptualize the AYRES- T-piece
principle. If you completely occlude one end, you produce inspiration by diverting gas flow to the
baby.
If the occlusion is released completely, gas flows through a path of least resistance and produce
expiration. If the occlusion is released partially, pressure builds up at the end of expiration due to
incomplete gas emptying. This is called positive end expiratory pressure (PEEP).
370
 Mechanical ventilators incorporate a time cycling mechanism to occlude the expiratory limb of the
patient circuit (inspiratory time), which may be pneumatic electronic such as Bear Cub, Sechrist or
microprocessor controlled such as Infant Star.

TYPES OF VENTILATION STRATEGIES

Mechanical ventilation can be applied both invasively and non-invasively in the following
ways:
5. Assisted spontaneous breathing: Continuous Positive Airway Pressure (CPAP)
6. Supported spontaneous breathing: Pressure or volume support in spontaneous breathing: Pressure
Support Ventilation and Volume Support Ventilation
7. Mixed respiratory support: Intermittent Mandatory Ventilation and Synchronized Intermittent
Mandatory Ventilation
8. Controlled mechanical ventilation: Pressure controlled Ventilation, Volume Controlled Ventilation,
Pressure Regulated Volume Controlled Ventilation, High Frequency Ventilation
1. ASSISTED SPONTANEOUS BREATHING
1.2 Continuous Positive Airway Pressure (CPAP):
CPAP is a mode of ventilation, which enables the elevation of end-expiratory pressure to levels
above atmospheric pressure to increase total lung volume, and functional residual capacity, thus favoring
improved oxygenation
This method presents several advantages because of:
 increased lung volume and FRC and improve in ventilation/perfusion ratio
 Preventing and resolving atelectasis.
 reduced work of breathing and prevention of muscle fatigue
 Reduced sternum and chest deformities and normalization of respiratory frequency
CPAP is indicated in:
 recurrent apnea, not from CNS origin, connected with exhaustion and muscle fatigue
 Moderate Idiopathic Respiratory Distress Syndrome of premature baby (RDS), transient tachypnea,
pulmonary edema and not severe pneumonia and bronchopneumonia
 Weaning from the ventilator and when reduction of intubation is desired.
CPAP is not advisable in:
 high risk patients
 apnea prolonged over 20 sec or recurrent, complicated by bradycardia
 insufficient spontaneous breathing from different origins
 severe respiratory effort to maintain ventilation

371
 hypercapnia (PaCO2 > 50 mm Hg).
2. SUPPORTED SPONTANEOUS BREATHING
Assisted modes of ventilation are those in which part of the breathing pattern is contributed
or initiated by the child. The work of breathing performed by the child is never abolished.

2.1 Pressure Support Ventilation (PSV):

Pressure support ventilation (PSV) is designed to support spontaneous breaths during inspiratory
phase. It is primarily designed to assist spontaneous breathing and therefore the patient should have
an intact respiratory drive.
The patient triggers each breath by opening the demand valve of the ventilator. A supplementary gas
flow is delivered to the inspiratory circuit to produce positive inspiratory pressure at a pre-set value.
Cycles are pressure limited and there is no pre-set tidal volume. The patient triggers assisted
breathing and regulates respiratory rate, inspiratory and expiratory time and tidal volume.
Advantages:
 minimizes work of breathing
 reduces respiratory muscle fatigue and oxygen consumption
 hemodynamic stability favored as breathing is triggered spontaneously
 Can be used to compensate for extra work produced by endotracheal tube and demand valve.
Disadvantages
Tidal volume is uncontrolled and variable and depends on respiratory mechanics, cycling frequency and
synchrony between patient and ventilator.
 If pressure support is high, the patient tends to reduce his respiratory rate and tidal volume. The risk of
baro and volutrauma is increased and ventilated gases may not be adequately warmed and humidified.
 If pressure support is low, patient tends to increase respiratory frequency and reduce tidal volume.
In such case oxygen consumption and work of breathing are increased.
 In cases of inhomogeneous lung pathology, PSV tends to favor ventilation of better-aerated
areas without affecting collapsed or atelectatic areas.
PSV needs continuous and careful adaptation of respiratory support to avoid the aforementioned
undesirable effects (increased support from health workers).
INDICATIONS:
Intensive care
 Weaning from ventilation after improvement in lung pathology
 Weaning from long term ventilation
 Weaning of patients with chronic obstructive pulmonary disease e.g. infants with severe BPD

372
  To promote respiratory muscle training
 To compensate for high resistance of endotracheal tubes during CPAP.
Postoperative care
3. To preserve or reactivate spontaneous breathing
4. 2. To resolve atelectasis after surgery.
CONTRAINDICATIONS:
6. Deep sedation and muscle paralysis
7. Severe neurological disorders
8. Hypoventilation syndromes
9. Patients who may be unable to activate trigger demand valve.

2.2 VOLUME SUPPORT VENTILATION (VSV):

VSV is a new means of assisting spontaneous breathing which avoids the disadvantages deriving
from pressure support ventilation which needs frequent adaptation by medical staff.
The ventilator, breath by breath, adapts inspiratory pressure support to changes in the mechanical
properties of the lung and the thorax in order to ensure that the lowest possible pressure is used to
deliver pre-set tidal and minute volume that remain constant. Inspiratory pressure is constant and
flow is decelerated.
When the patient is able to ventilate pre-set tidal volume, the ventilator does not support the breath.
At this stage, extubation may be performed with safety. In cases of apnea the ventilator automatically
switches to PRVC.
The initial values for expected tidal and minute volume should be set as should all parameters to be
used in PRVC in the presence of apnea ventilation. Indications and contraindications are similar to
PSV. The main advantages of VSV vs. PSV is the possibility of maintaining stable tidal volume,
being protected should apnea occur and being able to recognize when the patient no longer requires
pressure support to ventilate pre-set tidal volumes (extubation can safely be performed).

3. SYNCHRONIZED INTERMITTENT MANDATORY VENTILATION – SIMV

SIMV combines a pre-set number of ventilator-delivered mandatory breaths of predetermined tidal
volume with the facility for intermittent patient-generated spontaneous breaths. The ventilators on
the market offer the possibility of delivering pressure-or volume-targeted breaths during mandatory
cycles.

373
 Child with SIMV can activate mandatory breaths but if child trigger is not efficacious, ventilator can
deliver a mandatory breath. Pressure or Volume Support can be applied during non-mandatory
support.
Advantages:
 possibility to maintain spontaneous breathing and avoid muscle atrophy, especially in
neuromuscular patients who rapidly lose ability to breath spontaneously
 Progressive reduction of controlled breaths can favor return to complete spontaneous breathing.
 The method is difficult to apply in cases of acute and severe lung pathology, in compromised clinical
status and in cases of neurological disorders than can interfere with ventilation drive. In these cases
children could adapt completely to control breathing furnished from ventilator that could be insufficient
to maintain adequate gas exchange.

4. CONTROLLED MECHANICAL VENTILATION – CMV

This mode of ventilation controls the patient's respiratory activity completely. Introduction of gases
into the lung, inspiration, is obtained using positive pressure, which pushes gases into the lung .
This method is completely different from spontaneous breathing in which introduction of gases into
the lung occurs as a result of negative pressure inside the lung. As a consequence, venous return and
cardiac output can be reduced.
The expiratory phase is passive and is regulated by the opening of expiratory valve at end of
inspiration. This valve is opened when a prefixed pressure or tidal volume is achieved in the lung.

5.1. Constant Pressure Generators (Pressure Controlled Ventilators):

The pressure ventilator delivers a volume of gas at constant pressure to the lung during set
inspiratory time. Volume received by patient is determined by set inspiratory pressure, respiratory
rate and inspiratory time. Pressure remains constant during inspiration, while flow decelerates.

Advantages:
 flow rate is geared to reach Peak Inspiratory Pressure (PIP) as quickly as possible and flow will exceed
patient's demand, improving patient ventilator synchrony and decreasing work of breathing;
 Using decelerating flow pattern and square-wave pressure pattern; distribution of gas within the lung can
be improved.
Disadvantages:-
 pressure remains constant while tidal volume will vary, according to changes in compliance and airway
resistance

374
 Any thorax and diaphragmatic compression reduces tidal volume, which can be insufficient to maintain
adequate gas exchange.
This mode of ventilation has been proposed to protect the lung from barotraumas but instability of tidal
volume and PEEP can create in homogeneity of lung. Hypoventilation or hyperventilation may occur:
e.g. in infants with RDS, with low compliance and normal airway resistance, pressure ventilation may
lead to insufficient tidal volume and hypoventilation.

4.2. Constant Flow Generators (Preset Volume Controlled Ventilators): The generator delivers the same
preset tidal volume with each breath. During inspiratory time pressure will be slowly increased while flow
pattern produces a square wave.
Advantages of volume controlled ventilation:
 supply of constant minute volume
 Maintenance of preset tidal volume with variation of compliance and/or pulmonary resistance.
Disadvantages:
 Atelectatic areas are not re-ventilated, as they require higher pressure in order to be reopened
 Less damaged areas tend to be hyperventilated
 Using uncuffed tubes, a large part of preset tidal volume can be lost leading to inadequate ventilation.
 This ventilatory mode, using small tidal volume and high respiratory frequency to maintain stable
minute volume, has been demonstrated to be effective in reducing Ventilation Associated Lung Injury
(VALI), morbidity and mortality in ARDS.
 The best results have been obtained when PEEP levels have been maintained over inferior flex point
and lung expansion under superior inflection point of volume/pressure curve.

4.3 Pressure Regulated Volume Controlled Ventilation -PRVC:

PRVC ventilation delivers controlled tidal and minute volume in a pressure-limited manner using
lowest possible pressure, kept constant during inspiratory phase.
Gas flow is decelerated and pressure and flow constantly vary, breath by breath, in order to achieve
pre-set tidal volume at minimum peak inspiratory pressure. The ventilator tests the first breath at 5
cm H2O above PEEP and calculates pressure-volume ratio.
Inspiratory pressure changes breath by breath until preset tidal volume is reached at a maximum of 5
cmH2O below set upper pressure limit. At this stage measured tidal volume corresponds to preset
value and pressure remains constant.
If measured tidal volume increases above preset level, inspiratory pressure is reduced until set tidal
volume is reached.

375
Advantages of PRVC ventilation
 improvement of respiratory mechanics and gas exchange
 reduction of barotrauma connected with Peak Inspiratory Pressure (PIP)
 reduction of oxygen toxicity due to possibility of using reduced FiO2 to maintain adequate gas
exchange as compared with conventional mechanical ventilation
 opening of closed areas of lung connected with use of decelerated and laminar flow
 Immediate reduction of PIP in presence of a rapid change of compliance and resistance
as surfactant, bronchodilators, nitric oxide, etc. are used.
Indications:
 when lung compliance and resistance vary rapidly
 If there is an initial requirement of high flow in order to re-open closed pulmonary areas
(e.g. atelectasis, etc.)
 To reduce high ventilatory peak pressure (e.g. in premature infants, interstitial emphysema, etc.)
 To control ventilatory pressures from the moment non-ventilated alveoli and bronchioles are re-
opened (e.g. surfactant, theophylline or nitric oxide administration, etc.)
 In presence of broncho- and bronchiole-spasms (e.g. asthma, bronchiolitis, etc.)
 In all patients in whom PEEP levels must be reduced in order to avoid hemodynamic complications.
Clinical controlled trials are required to evaluate real benefits of PRVC ventilation in acute phase of
lung pathology (need of peak pressure to reopen non ventilating areas), in ventilation of healthy lungs (i.e.,
neurosurgical patients) and during weaning from ventilator.

10. NON-INVASIVE POSITIVE PRESSURE VENTILATION - NIPPV:

The feasibility of applying a ventilatory mode capable of avoiding airway invasion has been
evaluated and tested over time. Two modes using different methodologies to attain respiration have had
large consensus:
1) Negative Pressure Ventilation by means of either iron lung or chest cuirass , and
2) Positive Pressure Ventilation in spontaneous breathing, with CPAP, or Non-invasive Positive
Pressure Ventilation with mask .

COMPLICATIONS:
 Reduction of venous return and cardiac output as a consequence of politicization of inhalatory phase.
This can be seen mainly in cases of hypovolemia
 Lung volume and FRC reduction
 Lung in homogeneity due to over-expansion of better ventilated areas
376
 Small airway closure connected with impossibility to expel secretions and their migration to more
declivous and dependent areas
 Secretion stiffening, loss of ciliary activity and mucus alteration if not well-warmed and humidified
gases are used
 Lung trauma connected with high peak pressure (barotrauma), large volumes (volutrauma) and
biological factors (biotrauma) e.g. inflammation
 Development of infection due to incorrect nursing, insufficient secretion clearance, atelectasis
development, etc.
 Vocal chords and tracheal lesions which can evolve into stenosis if traumatic tracheal intubation is
applied - hypoventilation and hypoxia due to technical problems

EQUIPMENT
17. Gloves
18. Manual resuscitation bag and face mask
19. Suction equipment and catheters
20. Positive end-expiratory valve (PEEP) valve
21. Two sources of oxygen delivery
22. Air source
23. Constant electrical source
24. Sterile water
25. Mechanical ventilator with heated, filtered humidifier,
and in-line thermometer
26. Oxygen analyzer
27. Stethoscope
28. Intubation equipment
29. Cardiopulmonary monitor and equipment
30. Pulse oximetry equipment
31. Intravascular therapy equipment
32. Sedation, pain medication

CHILD AND FAMILY ASSESSEMNT AND PREPARATION

d) Inform the child and the parents of the need for mechanical ventilation or positive-pressure
ventilation.

377
 e) Prepare the family to provide interaction with the child, including touch, talking with, and
providing other comfort measures, even while the child may be sedated.
f) Determine the child’s baseline weight. This will help in determining how much tidal volume or
pressure is required for mechanical ventilation.

MANAGING THE CHILD DURING SYSTEM SETUP

SSTEPS RATIONAL/POINTS OF EMPHASIS

20) Notify respiratory care therapist of In most institution, the respiratory care
need for mechanical ventilator. If the therapist conducts the initiation and setup of
child is not intubated, the respiratory ventilator management.
therapist should be prepared to assist
in intubation procedures.
21) Place appropriately sized manual For the child on a ventilator, emergency
resuscitation bag, oxygen reservoir, respiratory equipment must be maintained at
tubing, flowmeter and appropriately the bedside at all time in case the child
sized face mask at the bed side. Place becomes extubated and requires manual
suction catheters and suction ventilation.
equipment at the bedside.
22) Verify that the child has a patent IV IV access is needed if the child experiences
line for administration of sedatives, cardiac arrest during intubation. Emergency
paralytics, and emergency drugs. medication can also be delivered.
Initiate IV access if none is in place
and if IV access will be needed.
23) Perform hand hygiene and wear Reduces transmission of microorganism.
gloves.

378
24) Initiate bag and mask ventilation or Manual ventilation may be needed if the child’s
manual ventilation though respiratory status is declining rapidly.
endotracheal or tracheostomy tube
until mechanical ventilator is ready to
be connected to the child.
25) If not already completed, connect the Provide for ongoing assessment of the
child to cardiopulmonary monitor and infant/child for any changes in heart rate,
pulse oximeter monitor for the child’s respiratory rate or function, oxygen saturation,
heart rate, respiratory status, and and level of consciousness.
oxygenation status throughout the
procedure.
26) Assess the child for signs of These signs indicate respiratory distress and a
inadequate ventilation. Observe the need for mechanical ventilation.
child for increased work of breathing.
27) Obtain and assess child’s blood gases Determine presence of acute respiratory
(as indicated) acidosis, hypoxemia, or hypercapnia, which
would confirm the need for mechanical
ventilation.
28) Suction the child’s airway as needed. Removes secretions and any potential airway
blockage that may impede successful
ventilation and intubation of child.
29) Administer pain medications, The infant/child should be kept quiet and still
sedatives, or paralytics as ordered during the procedure to prevent additional
immediately before the intubation, inquiries
30) Atropine may also be given Mechanical stimulation of the airway or
pretreatment to reduce the incidence hypoxemia may induce brady-arrhythmias in
of reflex bradyarrhythmias. the infant and young child
31) Assist in intubation procedure. A properly placed and secure tracheal tube is
the most effective and reliable method of
assisted ventilation.
32) Once the child is intubated and the Provides for mechanical ventilation to be
respiratory therapist has set up the instituted to the child.
ventilator, attach airway circuitry
adapter from ventilator to artificial

379
 airway alarms are on and functioning.
33) Confirm that the ventilator setting and Ensures that ventilator setting have been
parameters are as prescribed and that established in the manner prescribed by the
alarms are on and functioning. physician.
34) Ensure that the circuitry tubing is free Provides child-ready ventilation with assurance
of water and is not kinked, all that it is working in the prescribed manner with
connections are secure. emergency equipment at the bedside.
35) Visually assess child’s chest for Monitors efficacy of ventilator and alerts
symmetry of movements auscultate parents to potential problems.
child’s breath sounds with stethoscope
to ensure that there is equal inflation
in all lung fields, without adventitious
sounds.
36) Dispose of equipment and waste in Standard precautions.
appropriate receptacles.
37) Ensure that child is placed in Ensures child’s safety and comfort.
comfortable safe position and is free
from pain
38) Perform hand hygiene. Reduces transmission of microorganisms

MAINTENANCE PROCEDURES
Protective maintenance
A program of cleaning, operational preventive maintenance is important for the proper function and
life of the ventilator. Using the quick checkout procedure on a routine basis will help identify potential
problems.
Routine cleaning and checkout between patients should include:
5. Check out procedure as prescribed for the particular ventilator.
6. Water trap filter check.
7. Cleaning the exhalation block, diaphragm and patient circuit (if reusable), wiping the exterior of the
ventilator.
8. Check air temperature of humidifier (37°C) and adjust control dials accordingly.
Monthly operational checks
6. Battery condition, LED display
7. Air and oxygen pressure gauge accuracy test
380
 8. FiO2 check
9. Proximal airway pressure gauge accuracy test
10. Driving pressure check
Yearly preventive maintenance
The machine’s maintenance should be done every two yearly or after every 10,000 hours of use.
CLEANING AND STERILIZATION
h) Follow instructor’s manual for the equipment.
i) Clean the exterior with mild detergent or a damp cloth. Do not let water enter the ventilator.
j) Do not use strong solvents to clean the panels.
k) The ventilator may be covered with cloth or plastic cover in case it is not in use.
l) It is ideal to use disposable patient circuits compatible with the ventilator. Reusable circuits should be
immersed in gluteraldehyde solution for at least 6 hours and then rinsed in running water. Some
tubing’s which are autoclavable can be autoclaved.
m) Gas sterilization for 4 hrs 140°F with ethylene oxide and CO2 or Freon is ideal for a ventilator.
n) The filters of compressors should be cleaned with water daily. Bacterial filters should only be
autoclaved. However, to extend its use, a culture of the bacterial filter can be taken after running on a
test set up for half an hour. If the results are good, the filter is put to use. It is advisable to repeat the
procedure monthly after 25 autoclaves.

381
 OXYGEN ANALYSER
INTRODUCTION
The equipment oxygen analyzer measures the concentration of oxygen in the inspired air. It employs
a galvanic cell with a long life sensor which has a quick response time. This portable, small and light weight
equipment has alarm function which enables setting of high and low alarm limits. The oxygen sensor
incorporates a thermostat for temperature compensation. The instrument runs on 6 V batteries and it has an
accuracy of ± 2% with response time varying between 5-20 seconds.
Oxygen is the most commonly used pharmacological agent in the neonate. The aim of oxygen therapy is to
ensure adequate supply of oxygen to the tissues which is dependent on
I. The level of arterial oxygen tension
II. The ability of hemoglobin to take up and release oxygen.
III. The state of circulation.
IV. The oxygen carrying capacity of the blood.
V. Ventilation and perfusion of lungs.
Inappropriate oxygen therapy affects the outcome of neonates. Too little oxygen (hypoxia) results in
higher neonatal mortality and long-term neurological sequelae, whereas too much oxygen (hyperoxia) is
associated with pulmonary oxygen toxicity and retinopathy of prematurity.

CALIBRATION
With the power switch on and the oxygen sensor exposed to room air, check that the oxygen
concentration display indicates 21%. If it does not, rotate the calibration control so that it reads 21%.

MEASUREMENT
After calibration is complete, place the oxygen sensor in the gas mixture whose oxygen
concentration is to be measured. After the indication on the display is established, read the displayed
value. This is the concentration of oxygen in the gas measured.

PRECAUTIONS
1. Do not pull or bend the sensor connecting cable.
2. Always perform calibration before measurement.
3. Do not leave oxygen monitor stored with the power switch on.
4. The oxygen sensor contains a special electrolyte which will freeze at low temperature and ignite at
high temperature. Hence, for storage, avoid exposure to temperatures above 60C.
382
5. Maintain the oxygen sensor in a horizontal position or with the tip directed downward during
measurement.

CAUTION
The life of oxygen fuel cell is 12 months. This will have to be replaced periodically.

383
 FLUX METER
INTRODUCTION
Flux meter, is also known as irradiance meter or spectro-radiometer or billimeter , is used to
measure the irradiance output of phototherapy units. It consists of a light sensor and a read-out unit. The
light sensor has four components:
a) Optical band pass filter- It determines the wavelength to be measured. Incoming light strikes a diffuser
behind which this filter is placed. Along with the detector diode it determines the response of a particular
flux meter. A well designed filter would have a transmission area of clinical interest (425-475 nm
spectral range) and block majority of wavelengths below and above this range.
b) Infrared wave blocking filter- it blocks infrared waves. It contributes little to the readings.
c) Light sensitive detector- a silicone diode which generates a voltage proportional to the light energy
striking it.
d) Voltmeter- It is a read-out unit for the signal generated by diode.
When phototherapy is being used one must understand the significance of irradiance and duration of
exposure.
i. Irradiance: It is a measure of radiant flux impinging on a unit area. Irradiance is expressed as watt per
square meter or in practical terms, microwatt per square centimeter. Irradiance is measured by the flux
meter.
ii. Duration of exposure: The product of duration of exposure and irradiance will give a measure of the
total radiant energy to which newborn is exposed. It should be realized that the potential for error with
this method is great since actual irradiance impinging on the baby will vary with time due to changing
ambient illumination and changes in position of the baby.

CALIBRATION
The instrument does not need calibration once it is purchased but one must ensure that it measures
the bandwidth that is important for photo-isomerization of bilirubin (bilirubin absorbs 460nm wavelength
maximally). Calibration of flux meter is difficult and it is undertaken by the manufacturer. It should not be
calibrated against a tungsten light source as most phototherapy units have fluorescent or halogen light
sources.

384
 INFUSION PUMP
INTRODUCTION
Accurate fluid infusion and drug administration is crucial for the optimum management of a critically
ill neonate. Continuous and controlled intravenous delivery of common medications, such as ionotropic
agents, vasodilators, aminophylline, insulin, heparin etc. via infusion pump is the preferred mode of therapy
in acute care. This is especially true for drugs with short half lives, so as to maintain a desirable constant
serum concentration and in situations when constant infusion of glucose is needed. Small babies or those
with compromised renal, cardiac or pulmonary function have limited fluid tolerance and hence it is essential
to use infusion pumps so as to prevent inadvertent volume overload.

DESIRABLE SPECIFICATIONS
A good infusion device should be:
1. Reliable and electrically safe
2. Able to deliver the infusion accurately and consistently
3. Easy to set up and use
4. Portable and robust
5. Powered with battery and mains both
6. Equipped with override rapid infusion facility
7. Capable of alerting line occlusion and need to re-change syringe
8. Able to display rate of infusion and volume infused clearly

TYPE OF INFUSION PUMPS

1. GRAVITY CONTROLLED DEVICES
Drip rate regulators rely solely on gravity to regulate the rate of flow. The simplest and cheapest systems
are dial-a-flow/dosiflow which is supplied with standard intravenous fluid administration sets. Infusion
rate is also dependent on pressure difference across the valve i.e. height of fluid or venous
pressure/obstruction. In addition, drip rate controller also relies on gravity to provide the infusion
pressure. A drop sensor attached to the drip chamber senses the drip rate. This feedback system can
adjust the drop rate to a preset value, but, it cannot account for error incurred because of variation in
drop size.

2. POSITIVE DISPLACEMENT PUMPS

385
 Mechanism of action: These provide a positive displacement of fluid with the help of a motor. They
are designed so as to prevent infusion of a large volume of air or subcutaneous infiltration. Positive
displacement pumps have either a peristaltic or a piston mechanism. Infusion pumps utilize either linear
or rotary mechanisms. Linear peristalsis consists of finger like projections that sequentially compress the
intravenous tubing against a stationary back plate, thus moving the fluid in one direction. Rotator
peristaltic pumps have rollers on a wheel which compress the tubing and thus move fluid in the tubing
towards the patient.
i. DRIP RATE PUMPS: These differ from gravity dependent drip rate controllers in providing a
pumping mechanism to replace gravity as the motive force. Similar to infusion controllers, these
pumps use drip sensor which are attached to administration set to count drops in order to achieve
control of infusion rate. The speed of pumping mechanism is under feedback control from a drip
sensor/counter. With pumping mechanism, occlusion alarm pressure settings above 100 mm Hg are
usual and some are over 200 mm Hg.
ii. VOLUMETRIC PUMPS: These pumps overcome limitation associated with variation in drop size.
They use either:
 Piston type action, or
 Peristaltic pumping action on an accurately made section of tube which forms part of a special
administration set.
These special administration sets increase the cost of each infusion. These pumps are calibrated
in ml per hour. It is capable of precise regulation of the set flow rates and hence delivers accurate
volume infusion.
Volumetric infusion pumps are capable of calculating the volume of fluid with the
microprocessor based calculations, taking into account the size of drop produced and the standardized
diameter of the tubing. It has capability of functioning on mains and on rechargeable batteries. If
bubbles appear in the tube, the alarm lamp and warning buzzer work simultaneously and the pump stop
immediately. It advises the operator when infusion is completed, the battery voltage is low and flow
line is occluded apart from the usual audiovisual alarms of malfunctioning and air-bubbles in the
system.
iii. SYRINGE PUMPS: The most commonly used pumps for the administration of intravenous drugs are
positive displacement syringe pumps that utilize a gear reduction mechanism and lead screw. These
pumps are extremely accurate and have the convenience of not requiring specialized tubing. Probably
the most significant advance has been the introduction of a calculator mode/feature within the pumps
so that clinician can set the weight of patient, the drug concentration and the infusion rate in the mg per
kg per minute and the calculator in pump then calculates the infusion in ml per minute.

386
iv. MULTI-CHANNEL PUMPS: These are now several multi-channel pumps available which permit
simultaneous administration of 2 or 3 infusions. However, one potential problem with such a system is
the possibility of incompatible mixing.
v. AMBULATORY PUMPS: These are pocket size pumps, which use linear peristaltic mechanism and
have a fluid container in the form of a small floppy bag or cassette. The pumps are designed for users
who need to wear them for long periods and they have good alarm and display systems.

ADVANTAGES OF SYRINGE PUMPS

 Cheaper than drip rate pumps
 Precise control of total volume infused
 Suited for small volume
 Low cost of disposables
 Pressure maintains rate inspite of resistance
 Delivery of air impossible
 Portable
DISADVANTAGES OF SYRINGE PUMPS
 Unsuitable for large volume
 Comprehensive alarm system not usually provided

387
 PULSE OXIMETRY
DESCRIPTION
 Used intermittently or continuously to noninvasively monitor arterial oxygen saturation (SaO2).
 Photo-detector slipped over finger measures the transmitted light as it passes through the vascular bed,
detecting the relative amount of color absorbed by arterial blood, and calculating the exact mixed
venous oxygen saturation without interference from surrounding venous blood, skin, connective tissue,
or bone.
 With an ear probe, works by monitoring transmission of light waves through the vascular bed of a
child’s earlobe; results possibly inaccurate if the child’s earlobe is poorly perfused.
EQUIPMENT
 Oximeter
 Finger or ear probe
 Alcohol pads
 Nail polish remover, if necessary.
ESSENTIAL STEPS
 Explain the procedure to the child and his/her parents.
 Put the probe on the parent or nurse so the child can see that it’s painless.
For pulse oximetry using a finger probe
 Select a finger (usually index finger) for the test.
 Remove nail polish from the test finger if applicable.
 Place the transducer (photo-detector) probe over the child’s finger so light beams and sensors oppose
each other.
 Trim long fingernails or position the probe perpendicular to the finger.
 Position the child’s hand at heart level.
 If testing a small infant, wrap the probe around the foot so the light beams and detector oppose each
other. For a large infant, use a probe that fits on the great toe and secure it to foot.
 Turn on the power switch. If the device is working properly, a beep will sound, a display will light
momentarily, and the pulse searchlight will flash.
 After 4 to 6 heartbeats, the pulse amplitude indicator will begin tracking the pulse.

Using a ear probe

 Using an alcohol pad, massage the child’s earlobe for 10 to 20 seconds.

388
  Mild erythema indicates adequate vascularization.
 Securely attach the ear probe to the child’s earlobe or pinna.
 Use the ear probe stabilizer for prolonged or exercise testing. (Periodically rotate sites for probe
placement to prevent skin breakdown under the probe).
 After a few seconds, a saturation reading and pulse waveform will appear on the oximeter’s screen.
 Leave the ear probe in place for 3 or more minutes.
 After the procedure, remove the probe, turn off and unplug the unit, and clean the probe by gently
rubbing it with an alcohol pad.
NURSING CONSIDERATIONS
 The pulse rate on the pulse oximeter should correspond to the child’s actual pulse. If it doesn’t, assess
the child, check the oximeter, and reposition the probe.
 Factors that interfere with accuracy include:
- Elevated bilirubin level
- Elevated carboxyhemoglobin or methemoglobin levels
- Lipid emulsions and dyes.
- Excessive light
- Excessive patient movement
- Excessive ear pigment
- Hypothermia
- Hypotension
- Vasoconstriction
 Use the bridge of the nose if the child has compromised circulation in his extremities.
 If SaO2 is used to guide weaning the patient from forced inspiratory oxygen, obtain arterial blood gas
analysis occasionally to correlate pulse oximetry readings with SaO2 levels in the blood.
 If an automatic blood pressure cuff is used on the same extremity used for measuring SaO 2, the cuff
will interfere with SaO2 readings during inflation.
 If light is a problem, cover the probes.
 If patient movement is a problem, move the probe or select a different probe.
 If ear pigment is a problem, reposition the probe, revascularize the site, or use a finger probe.
 An ideal SaO2 level for a child is greater than 92%.
 Lower levels may indicate hypoxemia that warrants intervention.
 There may be a need to resuscitate the child immediately.
 The physician should be notified of any significant change in the child’s condition.

389
 RADIANT WARMER
INTRODUCTION
Radiant warmer provide intense source of radiant heat energy. They also reduce the conductive heat
losses by providing a warm microenvironment surrounding the baby. The radiant warmer also called ‘open
care system’ was developed as an ‘open incubator’ that ensures ready access to the baby.

DISCRIPTION OF RADIANT WARMER

The overhead quartz heating element produces heat which is reflected by the parabolic reflector on to
the baby on the bassinet. The quantity of heat produced is displayed in the heater output display
panel. Temperature selection knobs select the desired skin temperature.
This information is processed by the microprocessor inside the control panel and matched against the
actual temperature of the baby. If the temperature of the baby is lower than the set temperature, the
microprocessor will send feedback to the quartz rod heater to increase the heat output till the baby’s
temperature reaches the set temperature. At this point, the heater output will be reduced.
This system in which the heater output is determined automatically based on skin temperature
information is called servo system.
Servo system is the preferred method of running the open care system. The heat output from the
quartz heating rod could also be increased or decreased manually. This is done by the heater output

390
 control knobs. This is called the manual mode of operation. In the servo mode, whenever the baby’s
temperature rises by more than 0.5C above the set temperature, a visual/ audible alarm is activated.

PARTS OF OPEN CARE SYSTEM

 Bassinet: - for placing the neonate.
 Quartz rod: - provides radiant heat.
 Skin probe: - when attached to the baby’s skin, displays skin temperature.
 Control panel: - has a collection of display and control features/knobs.
 Heater output display: - indicates how much the heater output is.
 Heater output control knobs: - for increasing or decreasing the heater output manually.
 Temperature selection panel: - select either set temperature or skin temperature.
 Temperature selection knobs: - select a desired set temperature.
 Temperature displays: - display temperature as selected, either of the baby’s skin (via skin probe) or
the set temperature.
 Mode selector: - selects manual or servo mode.
The heating element (silicon quartz/ infrared/ ceramic/ quartz crystal), the control panels (electronic/
electrical/ microprocessor based) and alarms (air over temperature/ skin over temperature/ air sensor
fails/ power failures etc.) forms the basic unit of all the warming devices. Power consumption is around
750 watts. In good equipment, temperature stability is usually with an accuracy of ± 0.5°C.1

STEPS FOR USE OF WARMER

1. Connect the unit to the mains. Switch it on.
2. Select manual mode.
3. Select heater output to 100% for some time to allow quick pre-warming of the bassinet covered with
linen.
4. Select servo mode.
5. Select the desired set temperature of baby as 36.5°C.
6. Place the baby on bassinet.
7. Connect the skin probe to the baby’s abdomen with sticking tape.
8. If you want the manual mode to be used, select the desired heater output.
9. In the manual mode, record baby’s axillary temperature at 3 minutes and then 2 hourly.
10. Respond to alarm immediately. Identify the fault and rectify it.

USE OF CLING WRAP TO DECREASE INSENSIBLE WATER LOSSES

391
 Use of cling wrap (transparent polythene used covering fruits or vegetables for storage) over the baby,
tied across the panels of warmer, has been shown to reduce insensible water losses and result in better
thermal control for VLBW (< 1.5 kg) babies.

USEFUL TIPS FOR USE OF RADIANT WARMERS

a) Don’t use the warmer in a cold room. It works best when the environmental temperature is above
20°C.
b) Keeping the warmer where there is lot of air currents reduces its efficiency.
c) The warmer must be pre-warmed around 20 minutes before the arrival of the baby or till the set
temperature is reached with less than 50% of total heater output.
d) While using the manual mode in a warmer without a temperature displays, record the baby’s
temperature regularly, preferably 2 hourly.
e) Train junior doctors and nurses about the proper use of servo and manual modes.

DISINFECTION
When the equipment is in use, all approachable external surfaces should be cleaned daily with an
antiseptic solution like 2% bacillocid or gluteraldehyde. Spirit or other organic solvent must not be
used to clean the glass side panels or display panel. For disinfection of reusable probe, isopropyl
alcohol swab should be used.
Every seventh day, after shifting the baby to another cot, the used equipment should be cleaned
thoroughly, first by light detergent solution and then by antiseptic solution. All detachable
assemblies are to be treated similarly.

MAINTENANCE
Ongoing maintenance is the key to increase the mean time between failures. The hospital
biomedical engineer must regularly check equipment but the authorized company engineer must be
called for preventive checks and major breakdowns. The control and power units should be
calibrated every 4-6 months and thorough servicing should be done annually. Temperature
calibration should ensure sensitivity to

392
 INCUBATOR
INTRODUCTION
Lack of attention to thermoregulation continues to be a cause of unnecessary deaths in the neonatal
population. Maintaining a stable body temperature is essential to ensure optimal growth. Newborn babies, in
particular the preterm and low birth weight are exquisitely predisposed to hypothermia.

No other equipment is identified more with the special care of newborn babies than the warming devices,
namely incubators and radiant warmers. Incubator reduces the convective and radiation heat losses by
reducing exposure to air currents and by providing a warm environment.

SETTTING OF AN INCUBATOR
 The incubator is a closed system with a heating element underneath and a transparent hood or canopy
around the baby tray.
 Air or air-oxygen mixture is sucked in through a microfilter and streamed over the heating element and
humidifier using a quite fan. The warm humidified air is then circulated through the hood to attain a
uniform temperature within. A low rate of air circulation, ideally not more than 20-30 liter per minute,
minimizes convective heat losses due to fast currents around the baby.
 Noise level within the incubator is kept below 60 dB to avoid deleterious effects of hearing.
 The hood or canopy (acrylic/Plexiglas’s/fiberglass) in incubators should provide clear vision for several
years. Hood design may be single or double walled.
 Access holes, called iris ports, are often elbow operated to open and close.
 The under-deck area and conditioning chamber should be corrosive resistant, moulded and easy to clean.

393
 Other components include air inlet, filter, fan or blower system, humidity tray, baby tray with the
mattress, and inlets for oxygen, IV tubing’s and temperature probes. Good quality equipments should
have smooth surfaces and be free of corners and crevices. Additional optional features which may be
attached to the incubator include an intra-venous stand, weighing scale, timer, tilt facility, battery
backup, oxygen analyzer, resuscitator, vital signs monitor, phototherapy unit, oxygen flow meter,
suction, ventilator etc.

TEMPERATURE CONTROL MODES

There are generally two modes which are used.
1) AIR MODE: -
In the air mode, desired temperature around the baby is set and the heater output adjusts itself to maintain
this. The appropriate set temperature is decided by using thermo-neutral temperature charts as applicable to
an individual baby based on gestation and postnatal age. The air temperature sensing probe should be placed
near the baby and care should be taken that it is not displaced or covered.

Neutral range of environmental temperature (°C) for low birth weight babies
Birth weight (gm)
Age < 1200 1200-1500 1501-2500
1st Day 35.0 ± 0.5 34.3 ± 0.5 33.4 ± 1.0
2nd Day 34.5 ± 0.5 33.7 ± 0.5 32.7 ± 1.0
3rd Day 34.0 ± 0.5 33.5 ± 0.5 33.0 ± 1.0
≥ 4th Day 33.5 ± 0.5 32.8 ± 0.5 32.2 ± 1.0

2) SERVO CONTROLLED MODE:-Or the skin temperature controlled mode, the desired skin
temperature is set at 36.5°C. The baby’s temperature is monitored by a skin probe, fixed firmly using a
tape on the anterior abdominal wall. The feedback system modifies heater output to keep the baby’s
temperature constant. The advantage of this method is a reduced need for close monitoring of the
newborn temperature. However, this method may mask hypo or hyperthermia in the baby and may
cause accidental overheating due to displacement of the skin probe.

HUMIDIFICATION
Humidification of incubators reduces the insensible water loss. It is achieved by filling the
humidification tray with ½ liter of distilled water with 1-2 ml of glacial acetic acid or vinegar to prevent
bacterial colonization.
394
DISINFECTION
a) When the equipment is in use, all approachable internal and external surfaces should be cleaned daily
with an antiseptic solution like gluteraldehyde. Spirit or other organic solvents must not be used to
clean the incubator hood or panel.
b) Every seventh day, after shifting the baby to another clean incubator, the used equipment should be
cleaned thoroughly, first by light detergent solution and then by antiseptic solution. All detachable
assemblies, especially from the under deck area, are to be treated similarly.
c) After drying, the parts are reassembled and sterilized using a vaporizing agent and/or fumigation.
Adding 50 ml of formalin to 50 ml of distilled water in humidity tank and plugging it for 4 hours
leads to fumigation of the incubator. Gluteraldehyde (2%) is a good alternative. After fumigation it
should be thoroughly aired. The sleeves of the access windows must preferably be changed daily and
cleaned.

MAINTENANCE
a) The hospital biomedical engineer must regularly check equipment but the authorized company
engineer must be called for preventive checks and major breakdowns.
b) Air filters generally require change every 3 months or if they are visible dirty. One can use vacuum
cleaner to remove dust from filter but washing with water should be avoided. A clogged filter
reduces the oxygen entry and promotes carbon dioxide build up in incubator.
c) The control and power units should be calibrated every 4-6 months and thorough servicing should be
done annually. Temperature calibration should ensure sensitivity to ± 0.5° of the set value.

USEFUL TIP FOR USE OF INCUBATORS

a) Double-walled incubators or dome shields may be used if environmental temperatures are low.
b) Room temperature between 21-28°C is ideal.
c) Positioning the incubator parallel to the wall should be avoided because it hampers air circulation.
d) Avoid humidification unless insensible water losses are high as in a baby weighing < 1 kg. Water
must be changed daily if humidification is being used.
e) Whenever front panel is opened in the servo mode, one should change over to air control mode.
f) Do not use alcohol to clean the canopy; this will make the Perspex foggy.

395
 CENTRIFUGE MACHINE
INTRODUCTION
When a solid particle suspended in a liquid medium is allowed to stand in a tube, the solid particles
gradually settles down in the bottom of the tube by the effect of gravity. However, it takes a long time. This
process of sedimentation can be accelerated when a force greater than gravity such as centrifugal force is
used.

DEFINITION
The process of separation of solid from liquid is called centrifugation and the equipment used for this
purpose is called centrifuge.

PRINCIPLE OF CENTRIFUGATION
Let’s consider an example of blood. Blood contains cells suspended in plasma. When it is rotated at a
high speed in a centrifuge, a centrifugal force is generated which moves heavier and denser cells away from
the centre. Plasma gets separated and collects in the part of the tube closer to centre. The centrifugal force
generated can be calculated by the following formula:
Cf = 1.118 x 10-5 x R x N2
Where Cf is centrifugal force, R is rotational radius (centre of axis to the tip of the tube) and N is the
speed of rotation (in revolutions per minute or rpm).
Following are the factors affecting centrifugation:
1) The speed of revolution.
2) Duration of application of centrifugal force.
3) Particulate matter concentration i.e. packed cell volume. Higher the PCV more is the force needed for
separation.

TYPES OF CENTRIFUGE
1) Hand held centrifuge: Here centrifuge has a handle, which is manually rotated. It generates low speed
only.
2) Motor driven centrifuge: here, a motor powered by electricity is used for rotating tubes. It can be of
two types-
a) Angle headed- here tubes are held fixed at an angle of 30° -50°. They can rotate at a higher speed
but sediment is formed at sidewall of the tube.

396
 b) Horizontal headed- here, tubes are attached to central axis by a trunion. Tubes are placed vertically
and when they are rotated, they move outwards and assume horizontal position.
3) Micro centrifuge- they are specially used for packed cell volume determination of blood. They
accommodate capillaries and can rotate at a high speed of 10,000 – 15,000 rpm.
4) Other types such as super centrifuge and ultra centrifuge are used in specialized laboratories.

APPLICATIONS OF THE CENTRIFUGE IN NEONATOLOGY

1. Measuring hematocrit in a micro capillary sample.
2. Separation of plasma from RBC for measurement of bilirubin in a capillary sample.
3. Centrifugation of urine for examination of sediment.
4. Centrifugation of CSF for examination of bacteria.

397
 REFRACTOMETER
INTRODUCTION
This is a hand-held optical instrument used for the estimation of specific gravity of urine and also for
estimation of serum or plasma protein. In the neonatal unit, its use is primarily to assess hydration of the
babies and plan fluid therapy based on the urine specific gravity.

DISCRIPITON
The clinical refractometer has been designed for simple, rapid microanalysis in medical and paramedical
fields. Scales are calibrated in terms of protein concentration of plasma or serum (gms/100 ml) and specific
gravity of urine and refractive index difference. Determinations are precise and rapid. It requires only a drop
of fluid sample. One simply reads the value on the appropriate scale as seen through the eyepiece where the
sharp boundary between dark and light fields crosses the scale.

PRINCIPLE OF THE ANALYSIS

The concentration of a solute in solution related to its refractive index and hence a measurement of
refractive index can be used to measure concentration. The accuracy of the determination of total solids or
water in plasma and urine from measurement of refractive index and measurement of specific gravity of
urine from refractive index has been well documented.
The refractive index of serum or plasma depends mainly upon its protein concentration, as proteins
are one of the major constituents. The instrument has been designed to use refractive index method for
measuring total protein in serum. The concentration of water in serum (gms/100 ml) and percent water in
serum (gms/dl) can be determined from conversion table provided.
The instruments are temperature compensated for temperature between 60°F and 100°F, so that the
reading need not be adjusted for either the temperature of the sample or the temperature of the room in
which instrument is kept.

SCALE ADJUSTMENT
Before measuring the specific gravity or serum protein concentration, the instrument should be
checked as follows:
1. Raise the daylight plate and place a few drop of distilled water on the face of the prism. Close the
cover plate gently but firmly. This spreads a minimal volume of sample in a thin even layer over the
prism.

398
2. Bring scale into focus by turning the eyepiece. If the boundary line does not coincide with Wt (water)
line or specific gravity of 1.000, make an adjustment by rotating the scale adjusting screw by a screw
driver. This setting need not be changed as long as the same individual continues to use the instrument.
MEASURING METHOD
 Open the daylight plate and place one or two drops of the sample on the prism surface. Close the
daylight plate gently so that the plate comes into contact with the prism.
 Point the end of the daylight plate in the direction of a bright light, rotate the eyepiece while looking
through it until the image is correctly adjusted and the scale becomes clearly visible.
 A boundary line that separates the brighter and darker sides at the upper and lower portions
respectively appears in the fields of vision. The reading is shown by this boundary line and indicates
the protein concentration or urine specific gravity.

PRECAUTIONS
1. The refractometer is an optical instrument, do not drop it or handle it roughly.
2. The prism has a relatively soft surface, be careful not to scratch it.
3. Use soft cloth or soft tissue moistened with water for wiping the prism. Dry the prism with a soft cloth
or tissue. If the prism surface or cover plate is not well cleaned before the next sample is loaded, an
erroneous or fuzzy reading may result.
4. If the prism surface is smeared with oil or similar liquids, it will repel the sample and obstruct the
measurement resulting in erroneous or fuzzy reading. Wipe off the oil smear with weakened detergent.
5. Do not immerse the eye piece or the black focusing ring in the water.

399
 LAMINAR FLOW
INTRODUCTION
The control of microbial and particulate contamination has become increasingly in areas catering to
patients whose normal defense mechanisms are impaired. This apply especially to a neonatal intensive
care unit (NICU) with immunologically immature preterm babies. A practical solution to the control of
microbial contamination in the NICU is the use of laminar air flow system.

PRINCIPLE OF LAMINAR AIRFLOW

Laminar flow is the movement of air with uniform velocity in one direction along parallel flow lines,
either horizontally or vertically. This flow, being devoid of turbulence and backflow, creates an
environment with extremely low levels of contamination.

COMPONENTS OF LAMINAR FLOW SYSTEM

These systems contain 3 basic elements
a) HEPA filter
b) Blower &
c) Plenum

High Efficiency Particulate Air (HEPA) filter

HEPA filters are designed to remove particles, including microorganisms, from the air. Though
very effective at trapping particulates and infectious agents, they are not able to remove volatile
chemicals or gas.
These filters are made of boron silicate micro fibers that are made into a flat sheet by a process
similar to paper making. The flat sheets are pleated to increase the overall surface area of the filter.
Pleats are separated by aluminium baffles that direct the airflow in the filter.
A HEPA filter acts by one of three mechanisms: diffusion, interception or impaction. It can
reliably remove 99.97% of all the particles of 0.3 µ size (i.e. 9,997 of every 10,000 particles). 0.3 µ
size is known as the most penetrating particle size (MPPS).
Particles that are smaller or longer than 0.3 µ size are trapped with even higher efficiency. Since
the critical particle diameters for deep lung deposition are in the range of 1 to 5 µ and also the size
of most of the bacteria being > 0.3 µ, the actual efficiency of HEPA filters is more than 99.97%.

400
MECHANISM BY WHICH A LAMINAR FLOW SYSTEM WORKS
The contaminated room air that enters the unit is initially filtered with a pre-filtration system to remove
the larger dust particles. Then it is driven by-
a. A motor or blower through the HEPA filter. Clean air then vacates the unit through the exhaust vent in a
unidirectional way along parallel flow lines. Unidirectional airflow showers the work zone with a
continuous supply of filtered air. This showers effect serves to sweep the contaminants out of the
environment through the air exhaust system. The speed of contamination removal is very high since the
filtered air moves through the system in a single pass. In addition, the UV light (present in most of the
laminar flow systems) keeps the area bacteria-free.

CLASSIFICATION OF LAMINAR FLOW SYSTEM

Laminar airflow devices can be classified into 3 major categories depending upon the direction of the
airflow within the device/unit.
Classification of laminar airflow system
Horizontal airflow units Vertical airflow units Curvilinear units
1. Rooms with wall to wall 1. Rooms with grated floors 1. Rooms
airflow. and solid walls. 2. Work hoods
2. Work hoods. 2. Portable units with curtains
3. Walk-in booths. for walls.
3. Work hoods
4. Biological safety cabinets.

a) Laminar airflow rooms

This indeed forms the nucleus of ‘Clean Room Technology’. Though it is desirable for every
NICU to have a laminar airflow, there are certain practical difficulties in implementing it.
Advantages of laminar flow rooms
1) Clean down capacity- the airflows carry away the contamination generated within the unit.
2) Improved control of humidity and temperature.
3) Air particles have minimum contact with the protected items.
4) Reduced maintenance of the equipments.

Disadvantages of laminar airflow rooms

1) High cost
401
 2) Higher air velocities require larger fans, motors and ducts.
3) Clearance required for vertical airflow rooms – 4 to 6 ft of additional vertical height is needed.
b) Laminar flow hoods (Work stations)
Ideally, any fluid/drug preparation in a NICU including the preparation of IV fluids, drugs and total
parenteral nutrition (TPN) solutions should be done using a laminar flow hood.

MAINTENANCE
a) Laminar airflow hoods are designed to be operated continuously. If a laminar-airflow hood is turned
off between aseptic processing, it should be operated for 30 minutes to allow complete purging of
room air from the critical area and then disinfected before use.
b) The critical area work surface and accessible interior surfaces of the hood should be disinfected with
either bacillocid or 70% isopropyl alcohol using sterile gauze at the beginning of each shift and
periodically thereafter.
c) The glass surfaces should be cleaned daily with sap/detergent. HEPA filters should be tested every 6
months and pre filters should be cleaned monthly.
d) Before usage (if not in continuous use), the front panel is closed and the UV light is switched on for 30
minutes. After 30 min, the UV light is switched off and the front panel opened. The fluorescent tube
light and air blower are turned on. Air flow is adjusted according to the LCD display. After use, the
panel is again disinfected with bacillocid and the front panel is closed.

402
 BIBRLIOGAPHY

1. “PADMAJA A.”, TEXT BOOK OF PEDIATRIC NURSING PROCEDURE MANUAL, 1st edition
2014, Jaypee Brothers Medical Publishers(P) Ltd.
2. “K KAVITHA” ,TEXT BOOK OF A COMPREHENSIVE MANUAL OF PEDIATRIC NURSING
PROCEDURES, 1st edition 2015, Jaypee Brothers Medical Publishers(P) Ltd.
3. www.wikipedia.com

4. www.studenthealthcenteremanual.com
5. www.medilineplus.com

6. www.medscape.com

7. http://emedicine.medscape.com/article/1348931-overview Accessed

403