WEEK 7 INCUBATOR CARE
inlets for oxygen, IV tubing and temperature probes.
INCUBATORS
- INCUBARE (latin)= means to lie on
- A biomedical device which provides warmth, humidity,
and oxygen all in a controlled environment as needed by
the new born.
- Used to care the premature, LBW and very sick babies
in thermo neutral environment.
- Infant incubators provide thermal support for the
neonate (Perlstein and Atherton, 1988). Most incubators
also incorporate means for controlling oxygen levels and
relative humidity of the air the infant breathes.
- Microprocessors incorporated in most modern
incubators assist in the accurate control of temperature,
humidity, and oxygen levels while enabling such features
as graphical data trending of the critical parameters
controlled by the incubator.
INCUBATORE CARE
- Premature infants are unable to control their
temperature with the new environment
- High risk infants with problems with their respiratory
systems so as cardiovascular system.
- Premature and low birth weight
-Unable to adapt with the new environment
(extrauterine).
-Risk to develop hypoxia, hypothermia,
and other many associated adverse conditions, need
special care and attention.
PRINCIPLE OF INCUBATOR
- Infant incubator is in the form of trolley normally with
mattress on the top covered by plastic cover. This
chamber provides a clean environment and helps to
protect the baby from noise, infection, and excessive
handling.
- A low rate of air circulation, ideally not more than 20-30
litre 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
on hearing. A temperature sensor is tapped into the
baby’s skin and the incubator heater adjusts to maintain
the baby at a constant temperature or the temperature is
controlled by thermostat in the heated air stream.
Incubators reduce convective and radiation heat losses
by reducing exposure to air currents and by providing a
warm environment.
- Evaporative losses are minimized by maintaining high
humidity in the incubator and radiation losses are
curtailed by the hood or canopy on the baby or by using
double walled incubators. Access holes, called iris ports,
elbow operated to open and close. The under-deck area
should be corrosive resistant, molded and easy to clean.
Other components include air inlet, filter, fan or blower
system, humidity tray, baby tray with the mattress, and
Good quality equipment should have smooth surfaces
and be free of corners and crevices.
- Additional optional features which may be attached to
the incubator include an intravenous stand, weighing
scale, timer, tilt facility, battery back-up, oxygen analyzer,
resuscitator, vital signs monitor, photo-therapy unit,
oxygen flow meter, suction,
ventilator etc.
PURPOSE OF INCUBATOR
1. Infant incubators provide thermal support for the
neonate (Perlstein an d Atherton, 1988).
2. Provision of desired humidity and oxygenation
3. Observation of very sick neonates
4. Isolation newborn babies from infections, unfavorable
external environment
INDICATIONS OF INCUBATOR
Incubators may be used in the following conditions:
1. For neonates born <35 wk. and/or birth weight <1800 g.
2. For humidification, especially for extremely low birth
weight babies (<1kg).
3. For isolating an infected baby to achieve barrier
nursing.
4. For providing oxygen; depending on oxygen flow rate,
ambient oxygen concentration can be maintained.
5. For transporting babies (using transport incubator).
6. For providing stimulation to an apneic baby, if
incubator has rocking bed attachment.
7. For use at extremely low ambient temperatures
(<20°C) or when there are lot of convection currents
where a radiant warmer fails to work.
TYPES OF INCUBATOR
1. Portable and non portable– Portable incubation can be
used to shift the patient to another area of hospital as
needed.
2. Open box type- It is also known as Armstrong, here
neonate is kept on the Plexiglas bassinet . A radiant
warmer can be attached if needed. The main
disadvantage of this type of incubator is it cannot
maintain thermo neutral environment if lids are open
frequently. Despite it cannot filter the air and neonate is
directly in the contact with external environment. It has
only advantage that neonate in this incubator can be
observed well and can be handled easily.
3. Close type - Close type of incubator has special
function to concentrate fresh air after filtration. It prevents
water loss from radiation. As neonate remain inside the
box the risk of infection is minimum.
4. Double walled- The incubator has two walls. As air is
not good conductor of heat the incubator prevents heat
and fluid loss.
5. Servo-control incubator - Best type and most
frequently desired
- Automatically operated and set the parameters as
per need of neonate
CONTROL PARAMETERS IN INFANT INCUBATOR
Temperature Control(28-32 degree celsius)
- Air temperature mode
- Skin temperature mode
Humidity Control (60-70%)
- Humidity is defined as the percent of water evaporated
molecules in the air.
-Low level of humidity will result to a dry skin.
Oxygen (20-40%)
NURSING CARE OF CHILD IN INCUBATOR
PREPARE THE INCUBATOR
- Pre-warmed to a temperature appropriate to the infant’s
age, size and condition.
- Use in Air mode and must always be switched on with
the motor running if in use for a baby.
- Check and record the incubator temperature hourly.
- Position away from draughts or direct sunlight.
Note: Ensure alarms self-test has been completed
(automatic). If the unit fails the self test, the alarm sounds,
and one or more messages are displayed in the
trend/alarm window.
CARE OF BABY
- Maintain axilla temperature between 36.5°C and 37.2°C
Access baby by using the portholes, limit opening of
large door as this interferes with air temperature.
- Ensure baby is nursed naked apart from a nappy.
-Position baby utilizing rolled towels/cloth nappies to
provide boundaries that support ‘nesting’ and flexion of
limbs but keeping face clear Explain to parents
/caregivers the purpose of an incubator for their baby
- Ensure they are familiar with how to access baby as it is
optimal for parents to continue to touch and provide
comfort.
- Maintain a quiet environment
- There is no tapping on the canopy.
- No equipment is placed on top of the canopy.
- Careful opening and closing of doors.
INCUBATOR TEMPERATURE
- Default incubator temperature in NICU is 35 degrees
- Adjust the incubator temperature by no more or less
than 0.5 of a degree at a time
- Re-check the temperature within half an hour of making
any adjustment
MONITORING
- Axilla temperature is taken on admission into the
incubator and rechecked in the first hour
-Temperature is documented 4-6 hourly as per the
condition.
USE OF HUMIDIFICATION
- Is utilized for incubator care of preterm babies only –
NOT required for babies >32weeks
CLEANING AND STERILIZATION
- When the incubator is occupied, it should be cleaned
daily with mild detergent.
- Humidifier chamber must be emptied and cleaned daily,
fill with fresh distilled water.
- After seven days neonate should be shifted to another
incubator and used incubator should be cleaned with
antiseptic solution.
- 1-2 ml of Glacial acetic acid or vinegar can be added to
water in the humidifier to prevent bacterial growth.
WEEK 8 NBS Heel-prick Method
TIMING OF THE SPECIMEN COLLECTION
-Specimens should be collected after 24 hours of birth. If
a newborn is to be transfused before 24 hours of age,
collect the specimen prior to transfusion.
COMPLETING THE NEWBORN SCREENING CARD
- It is extremely important to fill out the newborn
screening card completely and accurately. The specimen
submitter is responsible for the accuracy and
completeness of the information on the newborn
screening card. The card will be scanned into the
database, so legibility is critical. Press firmly using a
black ball point pen and record the following information
in the spaces provided
INFANT INFORMATION
1. BABY’S NAME: Record last name followed by first
name. If no name is given by the time of specimen
collection, the mother’s last name followed by “boy” or
“girl” should be used. DO NOT LEAVE BLANK.
2. GESTATIONAL AGE: Record weeks of gestation at
time of birth. Note: Do not use fractions.
3. BABY’S ADDRESS: Record the current street
address, followed by apartment or lot number, city,
state, and zip code. This information is needed to
locate newborns in need of clinical evaluation or
retesting.
4. DATE OF BIRTH: Use a six-digit number (mm/dd/yy)
for date of birth. For example, a birth on June 5, 2009
would be recorded as 06/05/09. BIRTH TIME: Record
birth in military time. For example, a birth at 4:30 pm
would be recorded as 1630. Note: This information is
important in determining the age of the newborn at the
time of collection.
5. DATE OF COLLECTION: Use a six-digit number-
(mm/dd/yy) representing the date on which the
specimen was collected.
6. TIME OF COLLECTION: Record time of specimen
collection in military time. For example a collection at
9:30 am would be recorded as 0930.
7. PATIENT/HOSPITAL ID #: Record the birth
hospital’s identification or medical record number for
the infant.
8. BIRTH ORDER: Only fill out this area in instances of
multiple births. Completely shade in a circle to record
birth order by “A”, “B”, “C” to indicate birth order of child.
9. SEX: Completely shade in the appropriate circle to
designate newborn’s gender as male or female.
10. TPN (TOTAL PARENTERAL NUTRITION):
Completely shade in the appropriate circle.
11. . TYPE OF FORMULA: Name of formula newborn
is on at time of collection.
12. WEIGHT AT COLLECTION: Record the current
weight in grams in the boxes provided. Do not use
pounds and ounces.
13. HOSPITAL OF BIRTH: Record the name of the
birth hospital.
14. INFANT BLOOD TRANSFUSION: Completely
shade in a circle “yes” or “no” to indicate whether the
newborn was transfused prior to specimen collection. If
yes, give the date the transfusion occurred (mm/dd/yy).
MOTHER INFORMATION:
1. MOTHER’S NAME: Record last name followed by first
name.
2. MOTHER’S SOCIAL SECURITY NUMBER: Record
mother’s nine-digit social security number. This
information is used to help locate newborns.
3. MOTHER’S TELEPHONE NUMBER OR CONTACT
NUMBER: Record mother’s or her contact’s ten-digit
telephone number (area code plus telephone number).
4. MOTHER’S DATE OF BIRTH: Record the mother’s
date of birth (mm/dd/yy).
PRIMARY CARE PHYSICIAN INFORMATION:
1. PRIMARY CARE PHYSICIAN’S NAME: Record the
last name, followed by the first name of the physician or
health care provider to be notified of a positive or
unsatisfactory newborn screening test.
2. PRIMARY CARE PHYSICIAN’S TELEPHONE
NUMBER: Record Physician’s ten-digit telephone
number (area code plus telephone number).
SENDER INFORMATION:
1. Sender’s Name: Record the name of the sender. This
is the name of the medical provider who collects the
newborn screen. The screening results will be mailed to
the sender.
2. Sender’s Telephone: Record senders ten-digit
telephone number (area code plus telephone number).
3. Sender’s Address: Record the sender’s street
address followed by the city, state and zip code
MATERIALS NEEDED:
• GLOVES
• 70%Isopropyl alcohol pads
• Dry sterile gauze pads
• Sterile sticking device with a point greater than 2.00mm
in depth (lancets)
• Newborn Screening filter paper collection form with
protective envelope
BLEEDING PROCEDURE:
• Preferred puncture site: The least hazardous sites for
heel puncture are medial to a line drawn posterior from
the middle of the big toe to the heel or lateral to a similar
line drawn on the other side extending from between the
4th and 5th toe to the heel.
• Warm the infant’s foot if necessary, using warm water,
a towel, or a chemical pack. Heat sources should not
exceed 42°C and should not be left in contact with the
skin for a prolonged period.
• Disinfect the skin with alcohol pads and allow to air dry.
Vigorous rubbing during this step stimulates blood flow to
the area.
• Puncture the skin in one continuous motion using a
sterile sticking device with a tip <2.0mm. THE USE OF
LONGER TIPS MAY DAMAGE THE HEEL BONE
• Wipe away and discard the first drop of blood since it
may be contaminated by alcohol or tissue fluid.
• Allow the second drop of blood to form by the
spontaneous free flow of blood.
COLLECTING THE BLOOD SPOTS:
• Before collecting the blood, fold back the protective flap
to expose the filter paper. Do not touch or handle the
filter paper before or after applying the blood.
• Lightly touch the filter paper against a large drop of
blood and allow enough blood to soak through to
completely fill the circle. Apply blood to one side of the
filter paper only, allowing full saturation of each circle.
Either side of the filter paper may be chosen. Fill all
circles. Do not layer successive small drops of blood to
the same circle. Avoid touching or smearing the blood
spots.
• If blood flow is diminished, repeat the bleeding
procedure with sterile equipment. • Once all the circles
have been filled, press a sterile gauze pad to the
puncture site and hold the infant’s foot above the level of
the heart until bleeding has stopped.
• Dry the blood spots on a level, non-absorptive surface
away from direct sunlight and at room temperature for at
least 4 hours.
• After blood spots are completely dry, replace the
protective flap over the specimen and place form in the
protective envelope (do not use plastic) and mail to
Laboratory within 24 hours.
GUIDELINES AND POSSIBLE SOURCES OF ERROR:
The following guidelines may help eliminate
unsatisfactory specimens or erroneous test results:
1. Do not touch any part of the filter paper circles before,
during, or after collection.
2. Collect the specimen on the proper Newborn
Screening collection form
3. Complete all the demographic data. This information is
vital for interpretation of newborn screening results and
for identification and location of infants for follow-up of
abnormal test results.
a) Always note any transfusion of red blood cells.
b) Mark TPN feeding if TPN is being administered
at time of collection.
4. Wipe away the first drop of blood to remove tissue
fluids and alcohol. Do not “milk” the puncture site.
5. Do not expose the specimen to heat or humidity at any
time. Do not dry on heater, in microwave, with a hair
dryer, or in the sunlight. Do not place in plastic bags,
leave in hot mailbox area, or hot car; proteins and
enzymes will be destroyed.
6. Ensure that the specimen is properly dried before
replacing the protective flap and before placing in the
protective envelope.
7. Dry specimens in a horizontal position. Hanging wet
specimens will cause heavier red cells to migrate to the
end of the circle causing an uneven saturation.
8. Do not superimpose blood drops on top of each other.
9. Apply blood to only one side of the filter paper.
10. Collecting blood samples after feeding promotes
better blood flow.
11. Do not allow specimens to come in contact with water,
feeding formulas, antiseptics, urine, etc.
PEDIATRIC COMPUTATION-- BMI/IBW
WEIGHT AND HEIGHT
- In children, both height and weight are good
determinants of health and normal nutrition. Until they
can stand well, infants are weighed laying or sitting on an
infant scale. Because diapers can be heavy in proportion
to total body weight, weigh infant nude. Always keep a
protective hand over an infant on an infant scale
(hovering but not touching), as infants squirm readily and
there is danger of them falling. Always cover scales with
scale paper before weighing to prevent spread of
infection from one child to another.
- Children older than age 2 years are weighed on
standing scales, in street clothes (no shoes), or, if in a
hospital, in a gown or pajamas. If children are going to
have serial weights (weighed every day), be sure they
wear the same clothing every time they are weighed so
any discrepancy in weight is truly a difference in body
weight and not a weight change as the result of clothing.
Take the weight at the same time each day (preferably
before breakfast) on the same scale for greatest
accuracy.
- Most children and their parents want to know their
weight. To convert from kilograms to pounds, multiply the
kilogram amount by 2.2 (50 kg " 2.2 = 110 lb.).
- For accurate measurement of height for infants and
older children, see Box 34.8. Plot height measurements
for children on a standard graph, the same as for weight.
Height and weight should follow the same percentiles.
The important thing to look for is consistency of
measurements over time (always at the same percentile).
- To assess whether weight is average for height,
compare the child’s weight with a standardized
height/weight graph. In the standardized scale for
children, all weights between the 10th and 90th
percentiles are considered normal (statistically, a range
of weights that includes two standard deviations from the
mean or the 50th percentile). All children with weight
below the 25th or above the 75th percentiles need close
examination as they are moving close to the end points
of the usual weight continuum.
- As important as the fact that children’s weight falls
between the 10th and 90th percentile on growth charts is
that over time the weight follows one of the percentile
curves—in other words, children are not at the 80th
percentile the first time they are weighed and a month
later at the 40th percentile. Although both readings are
within the normal range, they reflect a weight loss that
would need investigation. Gaining weight in the same
way could be equally serious. A child is defined as “failing
to thrive” if height or weight drops below the third
percentile on a standardized growth chart.
- Nurses are often responsible for measuring growth in
children, so it is essential that they understand the growth
charts. Nurses need to become familiar with determining
BMI, which only requires information about the child’s
weight and height. Because growth is a continuous but
uneven process, the most reliable evaluation lies in
comparing growth measurements over time. It is
important to remember that normal growth patterns vary
among children the same age.
- Once the weight and height of children have been
measured, calculate the body mass index (BMI). The BMI
is a formula used to assess total body fat and nutritional
status. For children, it helps determine if their height and
weight are proportional for their age. A BMI for age under
the 5th percentile indicates the child is underweight. The
child is at risk for overweight when the BMI for age is
greater than the 85th percentile, and the child is
overweight when the BMI is greater than the 95th
percentile.
- Body mass index (BMI) is a calculation based on the
child’s weight and height, or length, and is calculated as
kilograms of weight per square meter of height. This is a
useful calculation for determining if the child’s height and
weight are in proportion and identifies which percentile
the child falls in for each measurement. Children normally
fall between the 10th and 90th percentiles. A
measurement below the 10th percentile, especially for
BMI, may indicate undernutrition, and one over the 90th
percentile can indicate overnutrition. However, it is
important to look at the differences between
measurements. An infant in the 90th percentile for length,
weight, and head circumference is proportional and may
be a naturally large baby. On the other hand, a child who
is consistently in the 10th percentile for all measurements
but is growing steadily and is at a normal development
level, may simply be a small child. Much cultural and
individual variation exists in size.

INTERPRETATION:
Status Category:
• BMI 1st to 4th percentile: Underweight
• BMI 5th to 84th percentile: Healthy Weight
• BMI 85th to 94th percentile: Overweight
• BMI 95th to 100th percentile: Obese
WEEK 9 GASTRIC LAVAGE
- Gastric lavage is the washing out of the stomach via a
nasogastric tube or stomach tube. Lavage is ordered to
wash out the stomach (after ingestion of poison or an
overdose of medication, for example) or to control
gastrointestinal bleeding. If the patient does not have a
nasogastric tube in place already, the physician will order
the insertion of the appropriate tube.
- For a stomach wash, the physician will probably order
the insertion of an Ewald stomach tube or a large lumen
nasogastric tube. To control gastrointestinal bleeding, a
large lumen Levine tube or Salem sump tube will be
inserted. In the event of severe bleeding, as in the case
of esophageal varices, a Sengstaken-Blakemore tube will
be inserted. A large lumen tube is preferred, since
particles of food or other material may occlude the lumen
of a small tube. The tube must be checked to verify
proper placement in the stomach prior to proceeding with
lavage. - Nasogastric or orogastric tubes are not only
inserted to provide nutrition to infants. This is also used in
infants requiring gastric lavage. Gastric Lavage is a
procedure used to aspirate gastric contents and irrigate
stomach. It is also used to assist in the evacuation of
toxic substances that are only partially digested.
- The practice of performing gastric lavage in infants born
with meconium-stained amniotic fluid (MSAF) after
stabilization has been a routine in most hospitals. It is
believed that meconium is an irritant and its presence in
stomach causes gastritis and vomiting. Doctors usually
advise gastric lavage with normal saline but others
advocate use of soda bicarbonate for stomach wash.
- Researches show that this practice is not based on
scientific evidence. In a study by Gidaganti et al (2017), it
was found that gastric lavage performed in the labor
room has no effect in reducing either meconium
aspiration syndrome or feeding intolerance in infants born
with meconium-stained amniotic fluid.
- Feeding intolerance may be developed in infants born
with meconium-stained amniotic fluid during first few
days after delivery. In a similar study conducted by Shah,
et al (2015), findings conclude that there is no significant
difference in the prevalence of vomiting between the
gastric lavage group and the no lavage group. Feeding
intolerance was found to have no relationship with
gestational age, gender, birth weight, and mode of
delivery. The study concluded that gastric lavage is not
required in neonates born with (MSAF).
- Conditions that may be appropriate for the use of
gastric lavage include presentation within 1 hour of
ingestion of a toxin, ingestion in patient who has
decreased gastrointestinal motility, the ingestion of a
toxic amount of sustained-release medication, and a
massive or life-threatening amount of poison (Criddle,
2007; Madden, 2008).
- When gastric lavage is used, the patient requires a
protected airway, possible sedation, and the largest
diameter tube that can be inserted to facilitate passage of
gastric contents.
Purpose:
• To remove the ingested poisons or any irritating matter
from the stomach.
• To diagnose and stop gastric hemorrhage. • To cleanse
stomach before diagnostic procedures or as preparation
for surgery. • To obtain specimen from the stomach for
laboratory analysis.
Contraindications:
• Compromised airway protective reflexes (unless patient
is intubated)
• Ingestion of corrosive substances (acids or alkalis)
• Hydrocarbons (unless containing highly toxic
substances such as pesticides)
• Known esophageal strictures
• History of gastric bypass surgery
Solutions used:
• Plain water (if poison is unidentified) • Normal saline
solution
• Weak solution of sodium bicarbonate or boric acid in
corrosive poisoning.
• Specific antidotes: if the poison is identified
o Physical antidotes: it is the one that mixes with
the poison and dilutes the poison or prevents its
absorption or soothes and protects the mucus membrane.
o Chemical antidotes: these reacts with the
poison and neutralizes it.
o Physiologic antidotes: these have a systemic
effect opposite to that of the poison. If the poison has
depressive action, the antidote has stimulating effect on
the body
Materials needed:
• Nasogastric tube (NGT):
o POISONING: Adults – F36- F40; children F24
to F28
o DIAGNOSTIC PURPOSES: F16 TO F20
• Lavage (Irrigating) fluid – NaCl or other prescribed
solution
• Syringe 20ml for aspiration and 50 ml for lavage
• Water soluble lubricating Jelly
• Specimen container with lab request form
• Emesis basin
• Graduated container; wash basins (to collect solutions)
• Protective sheet/ bath towels
Preparation:
- Prior to beginning the procedure, check to be certain
that all materials have been gathered. In most gastric
lavage procedures, the physician’s order will be to lavage
“until clear.” This means that the lavage procedure will be
repeated until the stomach contents that are returned are
clear, that is, nothing returned except the irrigating
solution itself. This requires that be prepared with at least
6 liters of solution. It may not be needed to use all, but
have it available at the bedside.
- If the lavage procedure is being done to control
gastrointestinal bleeding, the order will probably be “ice
lavage.” Chilling the solution with ice will promote
constriction of the blood vessels, thereby helping to
control bleeding. Again, a need to have quite a bit of iced
solution on hand and ready for use.
- Position of the patient for lavage will depend upon the
patient’s tolerance and the physician’s preference.
Lavage may be done with the patient sitting or lying.
Placing the patient on his left side with the head of the
bed elevated 15 degrees will allow the tip of the tube to
lie in the greater curvature of the stomach.
Lavage Technique:
- There are two basic techniques used in performing
gastric lavage. The technique used depends upon the
reason for the procedure and the physician’s preference.
Check the doctor’s orders to see which method is
specified. The two techniques used are as follow:
1. Solution is instilled and aspirated 50cc at a time, using
a catheter tip syringe. The procedure is repeated until the
stomach contents return clear, the entire amount of
prescribed solution has been used, or otherwise directed.
2. Solution is slowly poured into the tube through a funnel,
allowing the solution to enter the stomach by gravity. Up
to 500cc of solution may be instilled at a time, depending
upon the size and tolerance of the patient. The tube is
then lowered below the level of the patient, allowing the
solution to drain out of the stomach by gravity. When
using this technique to lavage, it is imperative that the
patient be assessed carefully for abdominal distension.
Repeat the procedure until the stomach contents return
clear, the entire amount of solution has been used, or
otherwise directed.
Procedure:
1. Verify doctor’s order.
2. Gather the equipment and perform hand hygiene.
Ensure that a suction device and a suction source are
functional and within reach in case the patient vomits
during the procedure.
3. Greet patient and explain the procedure.
4. Position the patient and place an emesis basin and
paper tissues within reach.
5. Provide privacy.
6. Don gloves.
7. Drape a towel or a disposable pad over the patient’s
chest to protect clothing.
8. If no NGT inserted yet:
a. Insert NG tube slowly and gently to prevent
trauma to tissues. Lubricate the tube with water soluble
jelly to make the insertion easy and to prevent friction.
b. If in case vomiting takes place, immediately
turn the patient to a three-quarter prone position to
prevent aspiration of fluid into the lungs.
c. Ensure proper placement of the tube in the
stomach. The stomach contents can be aspirated only if
the tube is placed in the stomach.
d. Secure the tube with adhesive tapes to
prevent displacements of the tube. When the tube is in,
aspirate the gastric contents completely and save it for
laboratory analysis. Label them properly and send to
laboratory.
9. If NGT is already placed:
a. Verify tube placement by aspirating stomach
contents.
b. Place the stomach contents in a labeled
specimen container for examination by the physician
and/or laboratory analysis.
10. Instill lavage solution, using one of the techniques
described above.
11. Remove the lavage solution, using one of the
techniques described above, as appropriate to the
method of administration.
12. Continue to lavage until stomach contents return
clear, the prescribed amount of solution has been used,
or as otherwise directed.
13. If any blood appears in the outflow, stop the
procedure and inform the doctor. During the procedure,
continuously observe the patient for cyanosis, increased
respiration, gagging, and attempts to vomit. If the patient
vomits, support the chin in hyperextension to keep the
airway open and prevent aspiration.
14. Continue the treatment till the return flow is clear, or
the desired effect is obtained. Clamp the tube if it is to
remain in place.
15. If the tube is to be removed, clamp or pinch off the
tube and withdraw it quickly and smoothly. Place it in a
basin or discard.
16. Remove all used equipment from the bedside.
17. Measure the total lavage return. Estimate the amount
of stomach contents by subtracting the known amount of
solution used from the total. Record on the I & O
worksheet.
18. Discard lavage solution.
19. Dispose of equipment in accordance with the
institutions policy.
20. Record the procedure and note the following
information:
a. Type and amount of lavage solution used.
b. Appearance, odor, color, and amount of
gastric return.
c. Patient’s tolerance to procedure.
 d. Disposition of specimens.
Complications:
• Trauma due to tube insertion
• Instillation of lavage fluid into lungs/ aspiration
• Cardiac dysrhythmias
• Hypoxia
• Laryngospasm
• Fluid and electrolyte disturbances
• Hypothermia
PAIN ASSESSMENT
- Pain is a difficult concept to define because it is
experienced uniquely. It is important to remember that it
is subjective (experienced by the person), not objective
(able to be determined by observation). McCaffery’s
classic description of pain (Pasero & McCaffery, 2004) is
the one most useful with children: “The sensation of pain
is whatever the person experiencing it says it is, and it
exists whenever the person says it does.”
- Preschoolers and younger children lack an
understanding of time, which makes it difficult to explain
when the pain will go away. Children may feel frustrated
or angry because no one can prevent their hurt or give
them relief. Because children may have difficulty
describing pain in a manner adults can understand, it is
difficult to assess the extent of their discomfort.
- Because pain is an individualized sensation, it may be
experienced and expressed differently by different
children. In some families, for example, pain may be
expressed very openly and freely.
- In others, children are expected to be stoic about pain.
Because the expression of pain is culturally determined
this way, two children who have the same degree of pain
may express it very differently (Eccleston et al., 2009).
- Children’s perception of the situation influences their
response to the situation, independent of intensity of the
pain. This means that children experiencing procedures
that are less intrusive but who are feeling maximum
anxiety may describe the degree of pain felt as more
intense than they otherwise might, because of the
accompanying anxiety.
- Pain in children occurs for one of four reasons: reduced
oxygen in tissues from impaired circulation, pressure on
tissue, external injury, or overstretching of body cavities
with fluid or air. The stimuli causing pain are not always
visible or measurable. Pain conduction consists of four
major steps: transduction (sensing the pain sensation),
transmission (routing the pain sensation to the spinal
cord), perception (the brain interprets the sensation as
pain), and modulation (steps taken to relive pain).
Transduction begins in the peripheral nerves when a
mechanical, thermal, or chemical stimulus activates
nociceptors, a specialized group of sensory receptors.
Several neurotransmitters (ex. substance P) are also
stimulated and involved in conducting pain.
- Sharp pain impulses are conducted by both A-alpha
and A-beta fibers (large fibers that are myelinated and
conduct the response at a rapid rate).
- Light pressure and vibration are conducted by A-delta
fibers, fibers that are smaller and conduct at a slower rate.
C fibers are smaller yet and conduct at an even slower
rate.
- Pain impulses join central nervous system (CNS) fibers
in the dorsal horn of the spinal cord. Here the impulses
are projected upward to the brain, where they will be
perceived as pain.
Types of Pain:
1. Acute pain is sharp pain. It generally occurs abruptly
after an injury. Paper cuts are examples of lacerations
that cause acute pain.
2. Chronic pain is pain that lasts for a prolonged period
(often defined as 6 months). Acute pain usually causes
extreme distress and anxiety; chronic pain can lead to
depression and less ability to achieve (Eccleston et al.,
2009).
3. Cutaneous pain is pain that arises from superficial
structures such as the skin and mucous membrane. A
paper cut is an example.
4. Somatic pain is pain that originates from deep body
structures such as muscles or blood vessels. The pain of
a sprained ankle is somatic pain.
5. Visceral pain involves sensations that arise from
internal organs such as the intestines. The pain of
appendicitis is visceral pain.
6. Referred pain is pain that is perceived at a site distant
from its point of origin. Right lower lobe pneumonia, for
example, is often first thought to be abdominal pain
because the pain of this is referred to the abdomen.
- Pain threshold refers to the point at which the child first
feels pain. This varies greatly from person to person and
is probably most influenced by heredity. All people also
have a point above which they are not willing to bear any
additional pain. This is a person’s pain tolerance. Pain
tolerance levels are probably most affected by cultural
influences.
Assessing type and degree of Pain
- Pain assessment is difficult with children, not only
because children have difficulty describing pain but also
because some children will suffer with pain rather than
report it, unaware that someone could make it go away.
Other children may distract themselves by methods such
as concentrating on play. Some children may sleep, not
from comfort but from the exhaustion caused by pain.
- Pain assessment in children is also difficult because
techniques vary widely from assessment of a nonverbal
infant to an older adolescent. Keep in mind a child’s
developmental level as well as chronological age when
assessing for pain.
1. Infant
• Pain is pre-verbal, observing for cues such as diffuse
body movement; tears; a highpitched, sharp, harsh cry;
stiff posture; lack of play; and fisting are all cues to reveal
discomfort
• Instinctively guard a body part by holding an extremity
still or tensing the abdomen.
• When pain is present in infants, they cannot be
comforted completely.
• In premature infants, be alert for subtle alterations in
facial expression, such as eyes squeezed shut or a
quivering chin, that might be a signal of pain.
2. Toddler
• They may not have a word in their limited vocabularies
to describe the sensation they feel.
• Refer to pain as “my boo-boo” or some other word
instead of “pain.”.
• Difficulty comparing the pain they feel now to past pain
(is it better or worse?) because they have had little
experience with past pain.
• Words such as “sharp,” “nagging,” or “aching” have no
meaning in relation to pain until a child has experienced
each type.
• Use the child’s term or teach the child that “pain” is the
same as “boo-boo.”
• For toddlers, pain is such a strange sensation that,
aside from crying in response to it, they may react
aggressively (pounding and rocking) as if to fight it off.
• May avoid being touched or held.
3. Preschooler
• Can describe they have pain but continue to have
difficulty describing its intensity.
• Use comforting mechanisms, such as gritting teeth,
pressing a hand against a forehead, pulling on their ear,
holding their throat, rubbing an arm, or grimacing, to
control or express pain.
• Do not think to mention they have pain because they
believe it is something to be expected or, because of
their egocentric thinking, they assume adults are already
aware of their pain.
• May think pain is punishment for some act, so this is
what they deserve.
• Do not yet have a perception of time. Soothing
statements such as, “It’s only for a minute” are not
comforting to the preschooler who does not know how
long that is.
• Young children may regress or become very withdrawn
when in pain.
• Deviations from usual behavior may, in the absence of
any other verbal description, be signs a child is in pain.
4. School-Age
• Difficulty envisioning that a word like “sharp” applies
both to knives and to the feeling in their abdomen.
• Assume that an adult being an authority figure, already
know they have pain.
• Regress with pain such as baby-talk or lying in a fetal
position.
• Can understand that if pain will last only an instant,
such as with an injection, it can be controlled through
nonpharmacologic activities such as distraction
techniques.
• Children may be in middle school before they can
understand how to use a numerical pain rating scale or
that the scale intensifies from left to right.
• A scale of 1 to 5 can be used in younger children if 1 to
10 seems overwhelming. Yet another technique is to turn
the scale vertically so it measures bottom (little pain) to
top (a lot of pain).
5. Adolescent
• Use adult mechanisms for controlling pain.
• Some are even more tolerant in the face of pain than
adults, trying to avoid stereotypes of “crybaby” or
“chicken.” • Body motions that could indicate pain, such
as clenched hands, clenched teeth, rapid breathing, and
guarding of body parts, not as helpful as it may be in
adults.
Pain Assessment techniques/ Tools
- The techniques to assess pain must vary depending on
the age of the child and the type and extent of pain.
Although monitoring for physiologic findings such as a
change in pulse or blood pressure may give some
indication that a child is under stress, these are not the
most dependable indicators of pain. Because pain is a
subjective finding, once children can speak, asking them
to tell you about their pain (self-reporting on a pain rating
scale) is the most accurate method for assessment.
- A variety of pain rating scales have been devised for
use with children. None has been proven to be
consistently better than the others, mainly because both
children and the type of pain they can be experiencing
vary so much. As a rule, pick a well-documented effective
scale and use that consistently for a child rather than
asking a child to adapt to different assessment
techniques. Be sure to follow the specific instructions for
that scale.
1. Pain Experience Inventory
- The Pain Experience Inventory is a tool consisting of
eight questions for children and eight questions for the
child’s parents. It is designed to elicit the terms a child
uses to denote pain and what actions a child thinks will
best alleviate the pain. Such a form can be used when a
child is admitted to an acute care facility or on an initial
home care visit.
2. CRIES Neonatal Postoperative Pain Measurement
Scale
- The CRIES inventory is a 10-point scale on which five
physiologic and behavioral variables frequently
associated with neonatal pain can be assessed and rated
(Krechel & Bildner, 1995):
• Amount and type of crying
• Need for oxygen administration
• Increased vital signs
• Facial expression
• Sleeplessness Each area is scored from 0 to 2, and
then a total score is obtained. On the scale, infants with a
score of 4 or more are most likely to be in pain and need
interventions to reduce discomfort. The scale cannot be
used with infants who are intubated or paralyzed for
ventilatory assistance because they would have no score
for cry, and because their faces are obscured, it is
difficult to rate them for facial expression.
3. . COMFORT Behavior Scale
- The COMFORT behavior scale is a pain rating scale
devised by nurses to rate pain in very young infants (van
Dijk et al., 2005). On the first part of the scale, six
different categories (alertness, calmness/agitation, crying,
physical movement, muscle tone, and facialexpression)
are rated from 1 to 5. Six is the lowest score (no pain),
and 30 is the highest (a great deal of pain).
- In addition to rating physical parameters, the infant is
then observed for 2 minutes, and the evaluation of the
baby’s pain is documented on an analogue (1-to-10)
visual scale.
4. FLACC Pain Assessment Tool
- The FLACC Pain Assessment Tool (Merkel et al., 1997)
is a scale by which health care providers can rate a
child’s pain when a child cannot give input, such as
during circumcision. It incorporates five types of
behaviors that can be used to rate pain: facial expression,
leg movement, activity, cry, and consolability. Data
indicate the scale is reliable and valid. Because a child
does not provide active input, an older child may
experience a loss of the self-control that can come from
active participation by using this scale.
5. Poker Chip Tool The Poker Chip Tool (Hester &
Barcus, 1986) uses four red poker chips placed in a
horizontal line in front of the child. The technique can be
used with children as young as 4 years of age, provided
the child can count or has some concept of numbers.
- To use the tool, tell the child, “These are pieces of hurt.”
- Beginning at the chip nearest the child’s left hand and
ending at the one nearest the child’s right hand, point to
the chips and say, “This is a little bit of hurt, this is a little
more hurt, this is more hurt, and this [the fourth chip] is
the most hurt you could ever have.” Then ask the child,
“How many pieces of hurt do you have right now?”
Children without pain will reply they don’t hurt; others will
point to one of the poker chips.
- To gain more understanding of how much pain the child
is feeling, clarify the child’s answer by a follow-up
question such as, “Oh, you have a little hurt?
- Tell me about the hurt.” This is an effective tool for
young children because the poker chips are concrete
items and children are concrete thinkers
6. FACES Pain Rating Scale
- This scale consists of six cartoon-like faces ranging
from smiling to tearful. Explain to the child that each face
from left to right corresponds to a person who has no hurt
up to a lot of hurt (Wong & Baker, 1996). Use the words
under each face to describe the amount of pain the face
represents.
- Next, ask the child to choose the face that best
describes the child’s pain and record the number under
the face the child chooses.
- Children as young as 3 years can effectively use this
scale. The scale appeals to health care providers
because it is cute; however, because it is not as concrete
a measure as the Poker Chip Tool, it, therefore, may not
be as effective with all children.
7. Oucher Pain Rating Scale
- The Oucher (Beyer, Denyes, & Villarruel, 1992) scale
consists of six photographs of children’s faces
representing “no hurt” to “biggest hurt you could ever
have.”
- Also included is a vertical scale with numbers from 0 to
100. To use the photograph portion, point to each
photograph and explain what each photo represents. Ask
the child to point to the photo that best represents the
child’s degree of hurt.
- To use the numbered scale portion, point to each
section of the scale and explain 0 means “no hurt”; 1 to
29 means “a little hurt”; 30 to 69 means “middle hurt”; 70
to 99 means “big hurt”; and 100 means “the biggest hurt
you could ever have.”
- Ask the child to point to the section of the scale that
represents the present level of hurt. Children as young as
3 can use the tool by pointing to the photograph that best
describes their level of pain. If the child can count to 100
by ones and understands the concept of increasing value,
the numbered scale can be used.
8. . Numerical or Visual Analog Scale
- A numerical or visual analog scale uses a line with end
points marked “0 " no pain” on the left and “10 " worst
pain” on the right. Divisions along the line are marked in
units from 1 to 9.
- Explain to children that the left end of the line (the 0)
means a person feels no pain. At the other end is a 10,
which means a person feels the worst pain possible.
- The numbers 1 to 9 in the middle are for “a little pain” to
“a lot of pain.” Ask children to choose a number that best
describes their pain.
- As soon as they can count and have a concept of
numbers, children can use a numerical scale.
- Be certain to show school-age children the scale; do not
just say score your pain from 0 to 10.
- Until children reach late adolescence, they use concrete
thought processes so need the help of seeing the line to
rate their pain accurately
9. Adolescent Pediatric Pain Tool
- The Adolescent Pediatric Pain Tool (APPT) combines a
visual activity and a numerical scale (Savedra et al.,
1992). On one half of the form is an outline figure
showing the anterior and posterior view of a child. To use
the tool, tell a child to color in the figure drawing where
pain is felt.
- In addition, on the right side of the form, tell the child to
rate present pain in reference to “no pain,” “little pain,”
“medium pain,” “large pain,” and “worst possible pain.”
- For a third activity, tell children to point to or circle as
many words as possible on the form that describe their
pain (words such as horrible, pounding, cutting, and
stinging).
- The scale is suggested for use in children 8 through 17
years. As many children below this level need so much
help reading and interpreting the multitude of words that
describe pain it makes the form impractical below this
age. - This is a useful tool for involving parents to talk
with their child about pain. Reading the words together
helps children examine the type, location, and level of
pain they are experiencing. It also helps parents to better
understand what their child is experiencing
10. . Logs and Diaries
- Having children keep logs or diaries in which they note
when pain occurs and then rate the pain each time it
occurs is useful for assessing children with chronic but
intermittent pain.
- Examining such a diary can not only reveal when pain
occurs but also provide direction for pain management.
- For example, if the diary shows the child always
awakens with pain in the morning, the child may need a
longer-acting analgesic to take at bedtime; if pain is
worse during weekends spent at a grandparent’s house,
investigate whether something different is happening in
that setting than at home that is causing increased pain.
Pain Management
- Pain management techniques, like assessment
techniques, vary greatly depending on the age of a child
and the degree and type of pain a child is experiencing.
Children with chronic pain or pain not relieved with
standard approaches may benefit from a referral to a
pain management specialist or team. Relief of frequent
pain episodes or prolonged pain may require intense,
consistent assessment and intervention, which is difficult
to achieve in an acute care setting or during infrequent
office visits.
- Whatever assessment tools or methods of pain relief
are used, staff should become familiar and comfortable
with their use. It is important that pain be assessed in an
organized and consistent manner so relief and
interventions do not vary based on the health care
provider.
Nonpharmacologic Pain Management
1. Distraction technique
• Aim at shifting a child’s focus from pain to another
activity or interest.
• Examples: Blowing bubbles, oral glucose, breastfeeding
2. Substitution of Meaning or Imagery
• A distraction technique to help a child place another
meaning (a non-painful one) on a painful procedure.
• Children are often more adept at imagery than adults
because their imagination is less inhibited.
• Works well with quick, simple procedures such as
venipunctures or chronic pain.
• Be certain a child thinks of a specific image. Help the
child elaborate on the image to make it more concrete
each time it is used so the child’s mind stays on the
image (what color is the rocket ship? Are there stripes on
the sides? What does the pilot look like?).
3. Thought Stopping
• A technique in which children are taught to stop anxious
thoughts by substituting a positive or relaxing thought.
• Help children to think of a set of positive things about
the approaching feared procedure.
• It allows children to feel in control of their thoughts,
which is different from merely saying, “Don’t think about
it.”
• This technique does not suppress thoughts; rather, it
changes them into positive ones.
• The secret for success is for the child to use the
technique every time the disturbing, anxious thought
appears even if, at first, such thoughts crowd in as
frequently as every few minutes
4. Hypnosis
• Not a common pain management technique with
children but can be very effective when a child is properly
trained in the technique.
• A child needs to train with a therapist before anticipated
pain so at the time of the pain, the child can produce a
trance-like state to avoid sensing pain.
5. Aromatherapy and Essential Oils
• Based on the principle that the sense of smell plays a
significant role in overall health.
• When an essential oil is inhaled, its molecules are
transported via the olfactory system to the limbic system
in the brain. The brain responds to aromas with
emotional responses.
• When applied externally, the oils are absorbed by the
skin and then carried throughout the body.
• Essential oils may be able to penetrate cell walls and
transport nutrients or oxygen to the inside of cells.
Jasmine and lavender are oils thought to be responsible
for relieving pain. When a drop of lavender oil is placed
on the skin, a child should be able to taste it within 15
seconds.
6. Magnet Therapy
• Based on the belief that magnets can control or shift
body energy lines to restore health or relieve pain.
• Magnets can be applied as jewelry or sewn into clothing
or shoes.
• Although many people find relief from magnet therapy,
the relief may be more of a placebo effect than an actual
change in pain level.
7. Music Therapy
• Use of music for calming or improving well-being and
can be effective even for premature infants.
• It can help to relieve pain both because it can be
relaxing and is a distraction.
8. Yoga and Meditation
• Involves a series of exercises that were originally
designed to bring people who practice it closer to God.
• It offers a significant variety of proven health benefits,
such as increasing the efficiency of the heart, slowing the
respiratory rate, improving fitness, lowering blood
pressure, promoting relaxation, reducing stress, and
allaying anxiety.
• Exercises consist of deep-breathing exercises, body
postures to stretch and strengthen muscles, and
meditation to focus the mind and relax the body.
• Yoga may be helpful in reducing pain through its ability
to relax the body and possibly through the release of
endorphins.
9. Acupuncture
• Involves the insertion of needles into critical positions
(meridian lines) in the body to achieve pain relief.
• This level of stress can make it an unattractive option
for pain management for children.
• Children who consent to having it done, however,
particularly those with chronic pain, report that the overall
process is pleasant, and the method offers good pain
relief.
10. Crystal or Gemstone Therapy
• Some people believe that gemstones or crystals have
healing powers, which are magnified when they are
positioned around the body.
• If these are being used, be careful when changing
bedding or rearranging equipment in a child’s room that
you do not tip them over.
• A child may feel they may lose their pain-relieving
powers if placed in a different position
11. Herbal therapies
• Some examples include chamomile tea (inflammation
reduction), garlic (antiinflammatory, anticancer), ginger
(nausea or vomiting reduction), goldenrod (urinary tract
inflammation reduction), or peppermint (abdominal pain
relief).
• Always ask when taking health histories if a child is
being given any herbs, both to be informed about
common herbs and to be certain that what the child is
receiving will complement, not interfere with, the effects
of a pain medication.
12. Biofeedback
• Belief that people can regulate internal events such as
heart rate and pain response.
• A biofeedback apparatus is used to measure muscle
tone or the child’s ability to relax.
• Biofeedback can be effective with adolescents but is
less effective with schoolage and younger children
because they tend to resist the biofeedback information
or cannot concentrate for long enough for training to be
effective.
• Children who want to use biofeedback need to attend
several sessions to condition themselves to regulate their
pain response.
13. Therapeutic Touch and Massage
• Use of touch to provide comfort and relieve pain.
• Based on the concept that the body contains energy
fields. When these are plentiful, they lead to health, but
when they are in lesser supply, ill health results.
• Therapeutic touch may also be effective as it serves as
a form of distraction.
14. Transcutaneous Electrical Nerve Stimulation
(TENS)
• Involves application of small electrodes to the
dermatomes that supply the body portion where pain is
experienced.
• Principle underlying this technique is the same as
rubbing an injured part: the current interferes with the
transmission of the pain impulse across small nerve
fibers.
• Used to manage either acute or chronic pain.
• Not recommended if the child is incontinent or has a
wound that is likely to cause the electrodes to get wet.
15. Heat or Cold Application
• Cold reduces pain by constricting capillaries and
therefore reducing vessel permeability and edema and
pressure at an injured site.
• After the first 24 hours of an injury, applying heat may
be more helpful because this dilates capillaries,
increases blood flow to the area, and again helps reduce
edema.
Pharmacologic Pain Relief
1. Topical Anesthetic Cream
• To reduce the pain of procedures such as venipuncture,
lumbar puncture, and bone marrow aspiration, a local
anesthetic cream or a solution of lidocaine and
epinephrine can be used.
• Applied to the skin, and the site is then covered with an
occlusive dressing or plastic wrap. To be most effective,
it must be applied at least 1 hour before an expected
procedure.
2. Oral analgesia
• Cost-effective and relatively easy to administer.
• Examples: OTC analgesics – acetaminophen, NSAIDS
– Ibuprofen, Naproxen; Opioids - morphine, codeine, and
hydromorphone (Dilaudid).
• Children should not receive acetylsalicylic acid (aspirin)
for routine pain relief, especially in the presence of flulike
symptoms, because there is an association between
aspirin administration and the development of Reye
syndrome. • Codeine may be given in combination with
acetaminophen.
3. Intramuscular Injection
• Opiates are available as intramuscular injections •
Rarely given using this route, as injections are associated
with pain on administration and also produce great fear in
children.
• Also associated with several risks, including uneven
absorption, unpredictable onset of action, and nerve and
tissue damage.
4. Intravenous Administration
• The most rapid-acting route and is the method of choice
in emergency situations, in the child with acute pain, and
in a child requiring frequent doses of analgesia but in
whom the gastrointestinal tract cannot be used.
• Common opioids given by this route include morphine,
fentanyl, and hydromorphone (Dilaudid).
• Can be given by bolus injection or by continuous
infusion.
• If a child’s pain is frequent or constant, continuous IV
administration may be necessary to reduce the level of
pain.
• Side effects: nausea, pruritus, vasodilatation, cough
suppression, and constipation.
• If toxicity with opioids should occur, naloxone (Narcan)
can be administered to counteract the effects.
5. Patient-controlled Analgesia (PCA)
• A form of IV administration that allows a child to self-
administer boluses of medication, usually opioids, with a
medication pump.
• The pump is set with a lock-out time so that after each
dose the pump will not release further medication even if
the button is pushed again; because of this, children
cannot overmedicate themselves.
• If pain is constant, a continuous infusion should be used
so that pain relief continues even while the child sleeps.
The pump can still be programmed for bolus dosing to
cover episodes of increased pain.
6. Conscious Sedation
• Refers to a state of depressed consciousness usually
obtained through IV analgesia therapy
• Allows a child to be both pain-free and sedated for a
procedure.
7. Intranasal Administration
• A short-acting adjuvant sedative that can be
administered intranasally by nasal drops or nasal spray
before surgery or procedures such as nuclear medicine
scanning.
• Has a very short duration of action, it may require
repeat administration.
8. Local Anesthesia Injection
• Local anesthetics stop pain transmission by blocking
nerve conduction of the impulse at the site of pain.
• Example: Lidocaine for procedures such as bone
marrow aspiration and peritoneal dialysis.
9. Epidural Analgesia
• Injection of an analgesic agent into the epidural space
just outside the spinal canal, can be used to provide
analgesia to the lower body for 12 to 24 hours.
• Often combined with a long-acting anesthetic, is
instilled continuously, or administered intermittently.
• Commonly used for childbirth.
Assessment procedure:
In preparation for the interview, clients are seated in a
quiet, comfortable, and calm environment with minimal
interruption. Explain to the client that the interview will
entail questions to clarify the picture of the pain
experienced to develop the plan of care.
A. Subjective Data: (Interview)
1. History of present health concern
• Character – describe the pain
• Onset – when did the pain start?
• Location – where is it felt? Does it radiate or spread?
Does it occur anywhere else?
• Duration – how long does it last? Does it recur?
• Severity – what were the client doing when the pain first
started?
• Pattern – is the pain continuous or intermittent? If
intermittent, how often do the episodes occur and for how
long do they last?
• Associated factors – are there any other concurrent
symptoms accompanying the pain?
o What factors relieve the pain?
o What factors increase the pain?
o Is the client on any therapy to manage the pain?
o Does the pain have any special meaning to the
client?
o Is there any information the client wants to add?
2. Personal Health History
• Any previous experience with pain?
• Has the client taken any medications (prescribed, OTC,
or herbal) for Pain relief? If so, what medications, doses,
and over what time period?
3. Family History
• Anyone in the family experience pain?
• How does pain affect the family?
4. . Lifestyle and Health Practices f. Identify patients with allergies to povidone-
• What are the concerns about pain? iodine (Betadine) ; provide an alternative such as
• How does pain interfere with the following? chlorhexidine.
o General activity
o Mood/ emotions SPECIMEN COLLECTION TECHNIQUES
o Concentration A. Urine Specimen Collection: Midstream (clean-
o Physical ability voided) urine
o Work 1. Assessment:
o Relations with other people 1. Two patient ID.
o Sleep 2. Patient & Family’s understanding of the
o Appetite purpose of the test & method of collection.
o Enjoyment of life 3. Pts. ability to assist with urine specimen
collection.
B. Objective Data: Physical Examination 4. Assessed for allergy to cleansing agent, signs
- Objective data for pain are collected by observing the of UTI (pain or burning sensation upon urination, low
client’s movement and responses to touch or descriptions back pain)
of the pain experience. Choose an assessment tool 5. Referred to agency procedures for collection
reliable and valid to the client’s culture. methods.
- Explain to the client the purpose of rating the intensity of 2. Planning:
pain. Ensure the client’s privacy and confidentiality. 1. Provide fluids to drink 30 mins before
- Respect the client’s behavior towards pain and the collection unless contraindicated; if patient does not feel
terms used to express it. Understand that different the urge to void.
cultures express pain differently and maintain different 2. Explain procedure to the patient:
pain thresholds and expectations. a. Reason why midstream is necessary.
1. General Inspection b. Ways that the patient and family can
• Observe posture help.
• Observe facial expression c. Ways to obtain the specimen free of
• Inspect joints and muscles feces.
• Observe skin for scars, lesions, rashes, changes, or d. The use of plain language and visual
discolorations aid as needed, to explain the procedure.
2. Vital signs (HR, RR, BP) 3. Implementation:
1. Performed hand hygiene , checked labels & completed
WEEK 10 SPECIMEN COLLECTION laboratory requisition for container.
2. Provided privacy, allowed mobile patient to collect
Purpose of Specimen Collection: to determine the specimen in bathroom.
presence of microorganisms and/or the function of the 3. Collected clean-voided urine specimen:
body system involved. a. Applied clean gloves, gave patient supplies to
Specimen Collection Techniques clean perineum or assisted patient in cleansing perineum,
A. Urine Specimen Collection removed and disposed of gloves.
• Midstream (clean-voided) urine b. Opened package of commercial specimen kit
• Sterile Urinary Catheter using aseptic technique.
B. Stool specimen c. Poured antiseptic solution over cotton balls, if
C. Obtaining Vaginal or Urethral Discharge Specimen necessary.
D. Obtaining Sputum Specimen by Expectoration d. Opened specimen container, maintained
E. Blood Glucose Monitoring Safety Guidelines Ensure sterility of inside of container, placed cap properly.
PATIENT SAFETY: e. Assisted or allowed patient to cleanse
a. Clear communication to the team perineum & informed patient antiseptic would feed cold.
b. Assess and incorporate the patient’s priorities
of care and preferences For Male Patient
c. Use the best evidence when making decisions a) Held penis with one hand, cleansed meatus
about the patient’s care properly, had patient retract foreskin, if necessary,
d. Follow principles of surgical and medical returned foreskin when done.
asepsis as indicated. b) Rinsed area and dried if agency procedure
e. Identify patients at risk for latex and/or food indicate.
allergy, asthma. c) After patient-initiated stream.
 ❖ If foreskin is retracted for spec collection, • Recording and Reporting
replace it over the glans. Swelling and constriction can 1. Recorded collection of specimens in appropriate log.
occur, causing pain and possible obstruction to urine flow. 2. Documented evaluation of patient learning.
3. Reported any abnormal findings to health care
For Female Patient provider
a) Spread labia minora with fingers of nondominant
hand or had patient assist.
b) Cleansed urethral area appropriately, used fresh
swab for each fold.
c) Rinsed area and dried with cotton ball if
agency procedure indicate.
d) Passed specimen container into urine stream
after patient initiated stream.
e) Removed specimen container before flow
stopped and before releasing labia or penis assisted with
personal hygiene as appropriate.
f) Replaced cap on container, touched only
outside. Cleaned urine from exterior surface of container.

Collected urine from INDWELLLING URINARY

CATHETER
a. Explained use of needleless syringe and that patient
would not experience discomfort.
b. Explained need to clamp catheter for 10 to 15 minutes
before obtaining specimen and that it could not be
obtained from drainage bag.
c. Clean gloves, clamped drainage tubing below
withdrawal site.
d. Positioned patient properly, located port, cleansed port
with disinfectant and allowed to dry.
e. Attached needleless Luer-lok syringe to port
appropriately.
f. Withdrew appropriate amount for culture or for routine
urinalysis.
g. Transferred urine from syringe to appropriate container.
h. Placed lid tightly on container.
i. Unclamped catheter, ensure urine is flowing freely.
j. Secured label to container, completed label properly.
k. Disposed of soiled supplies, removed and discarded
gloves, performed hand hygiene.
l. Sent specimen and request to lab within 20 minutes or
refrigerated as necessary (may stay only for 2 hrs.)

• Evaluation:
1. Inspected clean-voided specimen for contamination.
2. Evaluated patient’s urine C&S report for bacterial
growth.
3. Observed urinary drainage system to ensure it was
intact and patent.
4. Asked patient to explain steps in procedure.
5. Identified unexpected outcomes.
a. Urine specimen is contaminated with feces or
toilet paper.
b. Specimen is spilled or accidentally discarded
• Repeat urine collection.
 4. Transfer feces to cup without touching outside
surface of cup. Place seal on cup.
5. Dispose of wooden applicator by wrapping it
with a paper towel; remove gloves over wrapped
applicator, disposed in proper receptacle; perform hand
hygiene.
6. Secured label to container, complete label
properly.
7. Sent specimen and request to the lab within
20 minutes

4.Evaluation
1. Asked patient to explain spec collection.
2. Noted character of stool specimen.
3. Identified unexpected outcomes.

5. Recording and Reporting

1. Recorded results of test and stool
characteristics in appropriate log.
2. Document evaluation of patient learning.
3. Report positive test results to health care
provider.

B. Collecting the Stool Specimen

1. Assessment:
1. Identify patient using 2-identifiers, compared
identifiers with info in MAR.
2. Assessed patient or caregiver for
understanding of need for stool exam.
3. Assessed patient’s ability to cooperate with
procedure and collect specimen.
4. Assessed patient’s medical history for GI
disorders.
5. Reviewed patient’s medications for Rx that
contribute to GI bleeding.
6. Referred to health care provider’s orders for
medication or dietary modifications before test.

2. Planning
1. Identify expected outcomes.
2. Explained procedure to patient or family
member, discussed reason for collection how patient can
help feces must be free of contaminants.
3. Arranged for any needed dietary or medication
restrictions.

3. Implementation:
1. Performed hand hygiene.
2. Applied clean gloves; obtained
uncontaminated spec in clean, dry container.
3. Used tip of wooden applicator to obtain
approximately 2-3 cms (1 inch) of stool.

C. Obtaining Vaginal or Urethral Discharge Specimen
1. Assessment
1. Identified patient using two identifiers,
compared identifiers with MAR.
2. Assessed patient understanding or need for
culture and ability to cooperate with procedure.
3. Performed hand hygiene; applied clean
gloves
4. Assessed condition of external genitalia and
urethra, meatus & vaginal orifice
5. Observed for redness, swelling, tenderness
and discharge that was whitish;
6. Removed and discarded gloves; performed
hand hygiene.
7. Asked patient about dysuria, localized pruritus
of genitalia, or lower abdominal pain.
8. Gathered and recorded sexual history of
patient if symptoms suggested STI.
9. Referred to health care providers order to
determine if culture was to be vaginal or urethral.
2. Planning
1. Identified expected outcomes.
2. Explained procedure to patient and/or family.
3. Discussed reason for specimen collection and how
patient can help.
4. Instruct female patient not to douche 24 hours before
obtaining culture.
5. Instruct male patient not to urinate 1 hour before
obtaining urethral culture.
3. Implementation
1. Performed hand hygiene, applied clean gloves.
2. Provided privacy.
3. Assisted patient to appropriate position, raised gown,
draped body parts to be exposed properly.
4. Directed light source onto perineum if needed.
5. Opened culture tube, held swab in dominant hand.
6. Instructed patient to deep breath slowly.
7. Obtained specimen properly:
Female patient:
1. Separate labia with non-dominant
hand to expose vaginal orifice.
2. Touched tip of swab into discharge
pool or vaginal orifice, did not touch skin or
mucosa.
3. Exposed urethral meatus, pulled labia
minora upward and back.
4. Used clean swab, applied tip to
meatus where discharge was visible, avoided
touching labia.
For Male Patient:
1. Grasped penis appropriately, gently
retracted foreskin if necessary.
2. Held swab appropriately, applied to
area of discharge.
3. Introduced swab into meatus if
necessary.
4. Returned foreskin to natural position.
8. Returned each swab to culture tube, secured top.
9. Wrapped ampule with gauze, if using commercial
culture tube, crushed ampule, pushed tip into fluid
medium.
10. Removed and discarded gloves performed hand
hygiene.
11. Labeled each culture tube with ID label, affixed
request and conformed identifiers in front of patient.
12. Sent specimen immediately to lab or ref.
13. Assisted patient to comfortable position, assisted with
personal hygiene as needed, replaced gown, removed
and discarded drape.
Evaluation
1. Reviewed lab results for evidence of pathogens.
2. Continued to monitor whether discharge was present &
if it was, observed color and amount.
3. Asked patient to explain steps of procedure.
4. Identified unexpected outcomes.
Recording and Reporting
1. Recorded types of cultures and date and time sent to
laboratory in the appropriate log.
2. Documented evaluation of patient learning.
3. Reported lab results to nurse in charge or health care
provider.
D. Collecting a Sputum Specimen by Expectoration
1. Identified patient using 2 patient identifiers; compared
Info with MAR.
2. Provided opportunity to rinse mouth with water. (Check
with Agency protocol)
3. Performed hand hygiene, applied clean gloves,
provided sputum cup, instructed patient not to touch
inside of container.
4. Had patient take deep breaths with full exhalation and
then take full inhalation followed by a forceful cough,
ensured sputum was expectorated directly into specimen
container.
5. Repeated until enough sputum had been collected.
6. Secured lid on container, wiped outside of container
with disinfectant.
7. Offered patient tissues and mouth care, disposed of
tissues properly.
8. Removed and disposed of gloves, performed hand
hygiene.
9. Attached completed ID label and requisition to side of
container, confirmed identifiers in patient’s presence.
10. Enclosed specimen in biohazard bag.
WEEK 11 INTRAVENOUS THERAPY
(IVT) USING INFUSION PUMP
Intravenous Therapy (IVT)
- Intravenous therapy is an efficient and effective method
of supplying fluids directly into the intravascular fluid
compartment and replacing electrolyte losses.
- Intravenous therapy is usually ordered by the physician
and the nurse is responsible for administering and
maintaining the therapy.
Purpose of Intravenous Therapy
• To supply fluid when clients are unable to take in an
adequate volume of fluids by mouth
• To provide salts and other electrolytes needed to
maintain electrolyte imbalance
• To provide glucose (dextrose), the main fuel for
metabolism
• To provide water-soluble vitamins and medications
• To establish a lifeline for rapidly needed medications.
Intravenous solutions/ fluids are classified into three,
namely:
1. Isotonic solutions expand both the intracellular fluid
and extracellular fluid spaces, equally. It does not cause
red blood cells to shrink or swell. Isotonic solutions are
often used to restore vascular volume. Examples of
Isotonic solutions are 0.9% NaCl (PNSS), Lactated
Ringer’s solution (a balanced electrolyte solution), and
5% Dextrose in water (D5W).
2. Hypotonic solutions have a lesser concentrate of
solutes. They cause fluid shifts from the extracellular fluid
compartment into the intracellular fluid compartment to
achieve homeostasis, therefore, causing cells to swell
and may even rupture. Hypotonic solutions are used to
provide free water and treat cellular dehydration. These
solutions promote waste elimination by the kidneys.
Examples of hypotonic solutions are: 0.45% NaCl (half
normal saline) and 0.33% NaCl (one-third normal saline).
3. Hypertonic solutions have a greater concentration of
solutes than plasma and cause fluids to move out of the
cells and into the extracellular fluid compartment in order
to normalize the concentration of particles between the
two compartments. This effect causes cells to shrink and
may disrupt their function. Hypertonic solutions are also
known as volume expanders as they draw fluid out of the
intracellular spaces and interstitial compartments into the
vascular compartment, expanding vascular volume.
Example of hypertonic solutions are 5% Dextrose in
normal saline (D5NS), 5% Dextrose in 0.45% NaCl (D5
1/2NS), and 5% Dextrose in lactated Ringer’s (D5LR)
- Intravenous solutions can also be categorized
according to their purpose.
- Nutrient solutions contain some form of carbohydrate
(dextrose, glucose, or levulose) and water. Water is
supplied for fluid requirements and carbohydrate for
calories and energy.
- Nutrient solutions are useful in preventing dehydration
and ketosis but do not provide sufficient calories to
promote wound healing, weight gain, or normal growth in
children.
- Common nutrient solutions are 5% Dextrose in water
(D5W) and 5% Dextrose in 0.45% NaCl. Electrolyte
solutions contain varying amounts of cations and anions.
- Commonly used solutions are normal saline, Ringer’s
solution (which contains sodium, chloride, potassium,
and calcium), and Lactated Ringer’s solution (which
contains sodium, chloride, potassium, calcium, and
lactate).
- Alkalinizing solutions like Lactated Ringer’s solution
may be given to treat metabolic acidosis. Acidifying
solutions, in contrast, are administered to counteract
metabolic alkalosis. Examples of acidifying solutions are
5% dextrose in 0.45% NaCl and 0.9% NaCl solution.
- Volume expanders are used to increase the blood
volume following severe loss of blood or loss of plasma.
Examples of expanders are dextran, plasma, and
albumin.
 which is same as infiltration but include symptoms as:
burning, stinging pain; and redness followed by blistering,
tissue necrosis, and ulceration.
- Once symptoms appear, immediate interventions
(stopping of infusion and removing IV cannula,
reinsertion of IV to another site, applying compress, etc.)
could help prevent severe complications.
- The site chosen for venipuncture varies with the client’s
age, length of time the infusion is to run, the type of Starting an IV infusion using infusion pump
solution, and the conditions of the veins. For adults, veins procedure:
in the hand and arm are commonly used. While for 1. Determine the type and amount of solution to be used,
infants, veins in the scalp and dorsal foot veins are often exact amount of medications (if any) to be added, and
used. flow rate or time the infusion will be completed.
- Larger veins are preferred for infusions that need to be 2. Prepare the patient by proper patient identification,
given rapidly and for solutions that could be irritating explaining the procedure, and providing privacy.
(certain medications). 3. Perform hand hygiene or hand washing.
- The metacarpal, basilic, and cephalic veins are 4. Open and prepare the infusion set and IV solution.
commonly used for intermittent or continuous infusions. 5. Spike the IV solution container.
- Equipment needed during IV therapy are: IV fluids, 6. Apply an IV label indicating name and room no. of
infusion set, IV cannula or needle, tourniquet, clean patient, name of IV solution, amount, flowrate, name of
gloves and alcohol swabs, dressing & stabilization supply, added medication (if any), and the time IV will be infused.
IV pole, and infusion pump. 7. Hang the solution container on the IV pole.
- An external infusion pump is a medical device used to 8. Partially fill the drip chamber with solution and prime
deliver fluids into a patient’s body in a controlled manner. the tubing
There are many different types of infusion pumps, which 9. Fix the infusion pump on the stable IV pole
are used for a variety of purposes and in a variety of 10. Power on the infusion pump. Set up information (IV
environments. fluid, flowrate, amount of IV, and # of hours to run) into
- Infusion pumps may be capable of delivering fluids in the infusion pump.
large or small amount and may be used to deliver 11. Insert the IV tubing into the loading set properly.
nutrients or medications – such as insulin or other 12. Unclamp or open the roller clamp
hormones, antibiotics, chemotherapy drugs, and pain 13. Connect to tubing to the patient’s IV cannula
relievers. Operating infusion pumps depends on what 14. Press start on the infusion pump to start the infusion.
type and brand is available in the Institution. 15. Document the procedure and relevant data
- Early detection and interventions will help prevent any
complications. It is the responsibility of the nurse to
assess and monitor condition of clients during IV therapy.
- IV therapy common local complications include:
Infiltration, Phlebitis, and Extravasation.
- Infiltration is the unintended administration of a non-
vesicant drug or fluid into the subcutaneous tissue.
Infiltration can be caused by puncture of the vein during
venipuncture, dislodgement of the catheter, or a poorly
secured infusion device.
- Phlebitis is an inflammation of the vein of which there
are three types.
- Mechanical phlebitis is caused by too large of a catheter
in a small vein causing irritation of the vein.
- Chemical phlebitis occurs when a vein becomes
inflamed by irritating or vesicant solutions or medications.
- Bacterial phlebitis is inflammation of the vein and a
bacterial infection, which can be caused by poor aseptic
technique during insertion of the IV catheter and/or
breaks in the integrity of the IV equipment.
- Extravasation is the unintended administration of
vesicant drugs or fluids into the subcutaneous tissue