Peds Proceures

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CIMS COLLEGE OF NURSING, DEHRADUN

Administration of oral medication.

INTRODUCTION: - Medicine may be defined as a substance used to promote health, to prevent, to

diagnose, to alleviate or cure Diseases.

DEFINITION: -administrating oralmedicationit is the most common route and the most convenient

route for most patients.

OBJECTIVES:-

1. To prevent the disease.

2. To obtain desired effect of the medication.

3. To cure the disease

4. To promote the health.

5. To give palliative treatment

6. To give symptomatic treatment.

ARTICLE: - A trolley to take different medicine bottles.

A tray containing :-

1) Ounce glass, dropper, medicine glass,

2) Drinking water in a feeding cup,

3) Mortar and pestle

4) Duster

5) Kidney tray

6) Medicine cards & general order book.

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PREPRATION OF

Parent: -Explain about the action of medication.

Child: -A pos itive, kind, but firm approach wi l l meet the more success than threats stabiles

friendly relationship with child play and talk with child.

Environment:

-proper cleanness,

proper lighting,

free from foul smelling,

wall full with cartoon picture or poster,

play material .

TEPS OF THE PROCEDURE WITH RATIONALE

Prepare the child and family. And identify the child by checking the identification band.

PROCEDURE RATIONLE

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1. Washhands

2 Read the physician order and compare it

with the medicine card

3 After reading the medication card take

the appropriate medicine from the shelf

compare the level with the medicine card

4. Omit the medications,

5. Take the required medicine from the shelf.

Compare the label with the medicine card. Read

the entire label. Before a medicine ticket

is written or a drug administered, the

nurse must calculate the safe dosage

range for the individual child and

compare it with the dosage

prescribed.

6 Take the suspension tablets and capsules first

into the lid and then into the medicine Glass, so

that the drug will not come in contact.

7. Shake the bottle remove Cap of the bottle,

holding cork between ring and little finger. Holdbottle in the light to check for sediment etc.

8. Take a medicine glass in the left hand and place

thumbnail at the level which drug

9. Check drug with medicine chart again

and then pour into the glass.

10. Holding the medicine g1ass at eye level

again check dosages to see that the lower part of

medicine fails on the thumbnail line.

- Replace stopper in bottle and return it to correct

place, again checking the label.

11. Never pour excess medication back into

1 To avoid crossinfection

2 To ensure safety in the

administration of the medication

3 the first safety check to prevent the

possibility of pouring the wrong

medicine

4 It help Prevent wrong dose

5 Recheck the medicine bottle

- It helps give correct medication

Prevent wrong dose

-It helps prevent wrong dose

6 It help to prevent contamination

7 It helps to administered the correct

dose

8. It helps prevent wrong dose

9 . It helps to administered the correct

dose

10 It help to prevent the

administrate the wronge medication

11 To prevent the contamination,

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bottle or container, discard it into the Sink.

12 Prepare separate medicationfor each

patient. Identify the patient with the

medicine card by-

- Reading the name on the case paper.

-Holding the child properly by doing the mimics.

13. First give little water to drink with the

help of spoon and then give Medicines

one at a time.

14. Stay with the child while he takes the

drug.

15. Give water to drink, after he takes the

medicine. Keep the medicine cup

In the bowl of water.

16. Be sure that the child is able to take

the medication as it is prescribed.

12 Proper identification of each medication

assures accurate administration of

correct medication to correct patient

13 It help in the easy sallow wallowing of

the solid medication

14. Ensure the medication is taken

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After care of Patient and Articles

1. Wipe the face of the Child if necessary,

2. Give him comfortable position

3. Take all articles to utility room Clean the articles with soap and

Water and then replace them to their proper places.

4. Wash hands.

Recording and Reporting

1. Record Medication, Dose, Route, Time.

2. Record any reaction observed after the administration of the drug.

3. Report any reaction of the patient to the physician and the ward sister.

MEDICATION CARD

PATIENTS NAME DIAGNOSIS

AGE/ SEX D.O.A.

WARD/BED NO. DR INCHARGE

DATE

TO

CALCULATE

THEPAEDIATRIC

DOSAGE: -

Most of the drugs

are available in

the adult dose.

The nurse needs

to know how to prepare the Paediatric dosage.

1) Youngs rule :- (for children over one year of age ) unto 12 years

Age of the child (in years) X Adult dose =Childs dose

Age of the child (years)+12

2) Clarks rule :- (According to the weight of the child, therefore it can be used for children of all

ages)

Weight of the child in pounds X Adults dose = Childs dose

150

S

r.N

o.

MEDICATION NAME DOSE TIME ROUTE SIGNATURE

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3)Frieds rule :- (For children under 1 year of age)

Weight of the child in pounds X Adults dose = Childs dose

150

CHECK LIST OF ADMINISTRATION OF ORAL MEDICATION

ADMINISTRATION OF ORAL MEDICATION

1. Hand washing is done

1. Follow five rights

2. Explaining procedure to child parents

3. Prepare the articles

4. Checked the vital sign

5. Follow strict aseptic technique

6. Select correct medication

7. Check the manufacture and expiry date

8. Calculate medication dose

9. Administer drug safely

10.Administer drug on time

11.Took medication tray or cart to patients room. Checked

pt bed number against medication card or sheet.

12. Placed patient in sitting position, if the child is able or

not contraindicated.

13.Checked the patients identification asked the child name

her parents.

Yes No

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14.Told the childs parent what type of medication explained

the actions and how it helps to child.

15. If prepackaged medication was used, read label took

medication out of package and put into medication cup.

16. Take a medicine glass in the left hand and place thumbnail at the

level which drug should be poured to get correct dose.

17. Check drug with medicine chart again and then

Pour into the glass.

19. Holding the medicine g1ass at eye level again check dosages

to see that the lower part of medicine fails on the thumbnail

line.

20. Pour the medicine from the bottle on the side

Opposite to the label

21 Replace stopper in bottle and return it to Correct place,

Again checking the label.

22. First give little water to drink with the help of

Spoon and then gave medicines one at a time.

23. Stay with the child while he takes the drug. Give

Water to drink, after he takes the medicine. Keep

the medicine cup in the bowl of water.

Recording

1. Name of Medication, Dose, Route, Time.

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2. General condition of patient

3. Record any reaction observed after the

Administration of the drug.

4. Name and signature of a staff

CARE OF COLOSTOMY8


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INTRODUCTION:- In some childs, cancer or other conditions, such as inflammatory bowel disease

require the surgical removal of all or part of the colon, rectum, and anus, In such cases, the proximal portion

of the remaining bowel may be redirected through the abdominal wall to the abdominal skin surfaces. When

this surgery is performed, it is referred to as a fecal diversion, because the normal route for feces is altered.

The information that a child requires an colostomy is received with great

concern an apprehension by parents and child prepration of child and parents is necessary for both this

included an nature of procedure types of bag

DEFINITION: -

STOMA: - The portion of the intestine brought through the abdominal wall is known as a stoma.

OSTOMY: - It means an opening of an organ or part of body onto the body surface to drain

its contents.

COLOSTOMY: - it is an opening of the colon onto the abdominal surface to drain the faeca

matter.

Or

A bowel diversion surgery that brings a segment of the large colon out to the abdominal skin is

called a colostomy.

PURPOSE

1. To Contains drainage and odors for the comfort of the client

and allows accurate assessment of output.

2. To Protects the peristomal skin from excoriation.

3. To Provides visualization of the stoma and sutures during the

postoperative Purposes

4. To prevent leakage.

5. To prevent excoriation of skin and stoma.

6. To observe the stoma and the surrounding skin.

7. To teach the patient and relatives about the care of ostomy and ostomy collection bag.

SCIENTIFIC PRINCIPLES: -

ANATOMY AND PHYSIOLOGY: - the colon is divided into the caecum, ascending colon

transverse colon, descending colon, sigmoid or pelvic colon, rectum and anal canal.

The four layers of tissue described as the colon, the rectum and the anal canal. The

arrangement of the longitudinal muscle fibers is modified in the colon. In the sub mucous laye

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there is more lymphoid tissue than in any other part of the alimentary tract, providing non-specific

defense against invasion by resident and other microbes.

MICROBIOLOGY: - During dressing sterile technique should be maintained to prevent invasion of

bacteria.. Bacteria in the fecal secretions can cause infection in the incisional area and irritate the skin

Hand washing before procedure is helpful to prevent infection

CHEMISTRY The Zinc oxide used to prevent excoriation of skin and protect skin from breakdown.

Minimizes leakage by providing a smooth surface for applying the skin barrier.

PHYSICS: - maintained proper body mechanics, and height of the bed should be adjusted during

the procedure. During cleaning stoma stroke should be gentle.

PSYCHOLOGY: - Preoperative instructions about colostomy and how it will be managed wil

be important for the child and her parents to adjust with a colostomy. They should know that the

colostomy need not alter their life, but its care will become a routine part of their daily activity. They

may be given chances to talk with someone who has a colostomy and has learned to manag

elimination and over come fears. Such conversations will be reassuring and informative.

NURSE'S RESPONSIBILITY IN THE COLOSTOMY

1.Check the name, bed number and other identification of the patient.

2.Check the diagnosis and the purpose of colostomy care.

3.Check the type of colostomy done. Make sure of the proximal and distal loop of the colon.

4.Check the childs ability for self care.

5.Check the doctor's orders for specific instructions and the precautions, if any, regarding

the colostomy care, movement of the patient etc.

6.Check the understanding of the patient to follow instructions.

Check the articles available in the patient's unit.

PRELIMINARY ASSESSMENT

Observe color and amount of drainage from stoma.Assess existing pouch for leakage, and note appearance of stoma and incision to determine need to

change pouch. A pouch does not have to be changed if it is not leaking and if the skin barrier is intact,

Inspect condition of peristomal skin for erythema, excoriation, ulceration, or fistulas before selecting

type of skin barrier to apply.

Note presence of skin folds, creases, scars, and abdominal softness or firmness before selecting pouch.

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EQUIPMENT USE FOR COLOSTOMY CARE

A clean tray containing

Cover sheet

Protective sheet and towel

Glovesone pair

Cotton swabs and gauze pieces

Washcloth and towel

Water in a basin

Soap in a dish

Disposable ostomy collection bag with clamp

Stoma measuring guide

Zinc oxide (siloderm) ointment

Skin barrier

Deodorizing solution and dropper

Kidney tray and paper bag

Night drainage system (drainage tubing, collection bag and connector) if required.

Bedpan with cover

PREPARATION OF PATIENT AND ENVIRONMENT

1. Explain the details of this procedure to the child and her parents

2. Gather equipment and place within easy reach.

3. Have the patient assume a relaxed position and provide privacy. The best position may be sitting,

reclining, or Standing.

4. Provide privacy. Remove the undergarments to prevent soiling by the excreta. An old shee

or dhoti may be given to the patient to wear until the irrigation is over.

5. Ask the child or her parents to observe every step, so that he learns the care of the

colostomy. It is desirable to have a family member be present to learn the procedure.

It is desirable to have some reading material or radio nearby to provide

pleasure and diversion of the patient while waiting for the return flow.

STEPS OF PROCEDURE

1.Provide privacy.

2.Wear disposable gloves.

3.Gently remove old appliance. If disposable, discard. If reusable, set aside for washing.

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4. Wash skin thoroughly around stoma with skin cleanser or soap and water. Rinse skin thoroughly and

blot dry. Rationale: Soap residue or dampness can interfere with pouch adhesion, resulting in leakage.

Blotting the area dry minimizes trauma to the stoma.

5. Observe condition of peristomal Skin, the stoma, and the sutures. Teach the client to make these

observations daily. Observation allows monitoring for complications. The stoma is at risk for necrosis

during the first postoperative week, as evidenced by dark color and lack of bleeding. The peristomal

skin is at risk for breakdown from irritating fecal secretions. Infection is more easily corrected if

detected early.

6.Prepare clean pouch: measure stoma and trace circle larger than stoma on the adhesive pape

backing. Cut the stoma pattern. Pattern cut slightly larger than barrier avoids risk of paper cuts to

stoma and ensures a tight seal with the barrier

7. Prepare skin barrier: measure stoma and cut hole in Barrier the same size as the stoma. Be sure edges

are rounded. Close fit of barrier around stoma prevents fecal secretions from contacting and irritating

the skin.

8.If stoma is located in an abdominal increase or the skin is irregular, use a paste barrier to fill the

irregularity. Minimizes leakage by providing a smooth surface for applying the skin barrier.

9. Apply protective skin barrier.

a. Backing off wafer and center stoma in hole.

b. Place on abdomen, pressing lightly over all areas of the barrier to promote adhesion with skin surfaces

Rationale:- A tight fit will prevent leaking and protect the skin underlying the appliance.

10. Attach drainable pouch to skin barrier. Some equipment attaches by means of a plastic flange that snaps

in place; other models adhere through self-adherent tape that is exposed after protective papebacking is removed. Tug gently or inspect for secure fit.

12.Frame every edge of the faceplate with hypoallergenic tape to provide reinforcement. This is called "picture

framing."

13.Fold over bottom edge of pouch and clamp.

14.Dispose of old appliance. Clean and store any reusable supplies

15.Wash hands.

16.Document noted observations.

AFTER CARE OF PATIENT AND ARTICLE

Place the patient in a comfortable Position.

Ask the patient to inform for any discomfort at the stoma site.

Remove, clean, dry and replace the supplies.

If changes of ostomy collection bag procedure have been performed, dispose the bag by burning.

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If bag is to be reused, take it to the toilet, empty.

After making sure that the patient is thoroughly clean, help him to wear his clean

dresses.

Help the patient to get into his bed. Change the dressing of incision using asepti

technique. Make him comfortable. Tidy up the unit.

Take all articles to the utility room. Clean all equipments immediately. Rinse them firs

in cold water then with warm soapy water. Dry and store them in a convenient place for

the next use.

Patients are instructed for the care and cleaning of the colostomy bags to prolong

its life and keep it free of odors. Cleaning with soap or detergent with water and exposing

it to fresh air is sufficient.

RECORDING /DOCUMENTATION

Record the date and time of the pouching system change.

Note the character of drainage, including color, amount, type, and consistency.

Document the appearance of the stoma and the peristomal skin.

Document patient teaching and describe the teaching content.

Record the patient's response to self-care and evaluate his learning progress.

Type and size of the bag used.

Observations with regard to stoma and

the surrounding skin.

Assessment of the ostomy drainage.

COMPLICATIONS: -

1. Diarrhea

2. Faecal impaction and obstruction

3. Excoriation of the skin

4. Stricture of the stoma

5. Failureto fit the pouch properly over the stoma or improper use of a belt can injure the stoma.

PATIENT TEACHING: -

Teach spouses or other family members to assist with ostomy management, especially if the

client is elderly, weak, or has poor fine motor skills.

Provide good nurse-client Communication to help the client develop a positive attitude about

living with an ostomy.

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Provide the client with the name and phone number of an enterostomal therapist, community

support groups, supply vendor, and other resource people to call if they have questions o

problems after discharge.

CARE OF EYE

INTRODUCTION :- A common problem of eyes are secretion that dry on the lashes as crusts. This

be need to be softened and wiped away under sterile condition.

In newborn, the eye are treated soon after the baby is born to prevent ophthalmia neonatorum. Eye

care prevent spread of infection from one eye to the other and to avoid possible recontamination of the

same eye.

DEFINITION :- Eyes are cleaned from the inner to the outer canthusthis prevent the particles and

fluid from draining into the nasolacrimal duct each eye cleaned with separate swabs, swabbing each

eye once only.

OBJECTIVES:-

To prevent infection

To maintain eye hygiene

To maintain normal eye function

To prepare for administration of eye drops and ointment

To prevention for ophthalmia neonatorum in newborn.

NURSING RESPONSBILITY:-

Check the diagnosis of the child

Check the physician order to see the specific precautions regarding the care of eyes, the childs

movement and positioning

Assess the general condition of the childs ability to follow directions

Check the articles available in the patients unit.

ARTICLES REQURIED FOR THE EYE CARE

ARTICLES PURPOSE

A tray containing :-

Mackintosh and towel To protect the pillow and bed linen

Sterile bowl with sterile cotton swabs To clean the eye

Sterile normal saline or any ordered To clean the eye

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solution

Kidney tray and paper bag To receive the wastes

Clean face towel To wipe the face after the

procedure

PREPRATION OF THE PATIENT UNIT :-

1. Explain the procedure to the childs parent.

2. Adjust the bed to comfort able working of the nurse.

3. Arrange the articles conveniently on the bed side table

4. Keep the child flat if the condition permits

5. Remove all pillows leaving one soft pillow under the head

6. Protect the pillow and the bed with a mackintosh and towel placed under the head

STEPS OF THE PROCEDURE WITH RATINALE: -

STEPS OF PROCEDURE RATINALE

1. Wash hand

2. Pour sterile saline into the bowl andwet the cotton swabs

3. Stand in front of the patient clean the

eyes with the sterile swabs. Discard

the swabs into the paper bag.

Continue cleaning till all discharge are

removed from the eyes

To prevent the cross infection

Take the following precaution

Area of the swab touched by the

fingers should not come in contact

with eyes

Squeeze off the excessive water

from the swab

No pressure on the eye ball

Gently wipe the lids from the inner

to the outer corner

One swab for one swabbing

Separate swabs for each eye

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4. For crushed secretionplace a wet

warm gauze piece or cotton swab over

the closed eye. Leave it in the place

until the crust becomes soft.

5. When the eye are clean, stop the

Procedure. Wipe the face with the face

towel

Warm compress makes the crusts to

become soft that it can be removed without

traumatizing the mucosa

AFTER CARE OF THE PATIENT AND ARTICLES:-

Instill any medications that is ordered if any

Remove the mackintosh and towel from under the patients head

Adjust the position of the patients bed

Tidy up the bed and make the child comfortable

Take all articles to the utility room. Replace the articles to proper places

Wash the hand thoroughly

RECORDING AND REPORTING

Record the treatment with date and time. Record the observation made on the nurses record.

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NASOGASTRIC TUBE FEEDING

1. INTRODUCTION.

Nasogastric tube feeding, nasal feeding, or Nasal gavage is the term applied to the process of feeding

the patient by means of a tube introduce directly into the stomach by way of either mouth or nose(The

word gavage comes from the French Gaver, meaning to force feeding of poultry ) this procedure was

used for feeding psychiatric patient formerly. But now it was widely used to give foods to adult who are

unable to take nourishment in the usual way and for weak babies who are not strong enough to suck or

swallow.

2. DEFINITION AND MEANING.

1. The administration of liquid food into a stomach by a Reyles tube inserted through the nostrils is

called Nasogastric tube feeding.

2. Nasogastric tube feeding or Gastric gavage is an artificial method of giving fluids and nutrients

through a tube that has been passed into the esophagus and stomach through the nose, mouth or

through an opening made on the abdominal wall.

Naso:- Nasal

Gastric:- Related to stomach.

Tube Feeding: Administration of food material or medication through elongated flexible tube.

3. OBJECTIVES OF THE PROCEDURE.

TOProvide Nutritional Support Using Gastrointestinal Tract.

4. INDICATION./ REASON FOR PROCEDURE:

When the patient is unable to ingest, chew, or swallow food but is still able to digest and absorb

nutrients, a tube feed is indicated, e.g. unconscious and semi-conscious patients etc.

When the patient is too weak to swallow food or when the conditions make it difficult to take a

large amount of food orally e.g.: acute and chronic infection, severe burns, malnutrition and

prematurity.

When the patient is unable to retain food e.g. vomiting, anorexia nervosa etc.

When the condition of the mouth or esophagus makes swallowing difficult or impossible, e.g. :

surgery of the mouth or throat and esophagus, paralysis of face and throat, fracture of jaw, repair

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Explain the procedure to the patient to gain confidence and co-operation.

Screen the patient to provide privacy.

Place the patient in a sitting or high Fowler's position. If his general condition is weak, raise the

head with extra

pillows.

Place covered treatment mackintosh over the chest to protect garments and bed linen.

Give a mouth wash to clean the mouth.

Clean nostrils if there are secretions or crust formation of nasogastric insertion.

7. STEP OF PROCEDURE WITH RATIONALE.

IMPLEMENTATION:-

Steps Rationale Scientific

Principles

Nursing

Principles

Wash hands with soap

and water.

To prevent cross-infection. Soap and water help

in checking the

microorganisms'

growth (principle of

Microbiology,

Physics).

Principle of safety

Spread the mackintosh

and the towel

To protect bed linen. Microbiology Safety and

comfort

Clean the nostril with a

cotton-lipped

applicator soaked in

saline.

To clean nostril. Microbiology Comfort and

safety

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Take the Ryles tube and

measure the distance for

insertion of the tube

from bridge of the nose

to earlobe plus distance

from ear lobe to the tip

of the xiphoid process of

the sternum and mark

with adhesive.

To determine

approximate length of

the tube to reach the

stomach.

Anatomy and Physics Safety and

individuality

Lubricate the tube for

about 2-4 inches with

thin coat of water

soluble jelly.

Lubrication reduces

friction between mucous

membrane and the tube.

Physics Safety

Hold the tube coiled in

the right hand to

introduce the tube.

Nasal septum is deviated

into the right side.

Anatomy Safety

Tilt back the child's head

before inserting the tube

into the nostril and

gently pass the tube into

the posterior

Nasopharynx quickly

backwards and

downwards.

Passage of the tube is

facilitated by following

the natural contours of

the body.

Anatomy and

Physiology

Safety and

therapeutic

effectiveness

When the tube reaches

the pharynx, the patient

may gag: allow him to

rest for a few moments.

Gag reflex is triggered

by the presence of the

tube. Helps to prevent

the aspiration of fluids or

passing the tube into

Trachea.

Anatomy and

Physiology

Safety

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Hold the child's head in

a partially flexed position

and advance the tube as

he swallows sips of

water.

Flexed head position

makes swallowing easier

and the tube less likely

to enter the trachea.

Swallowing facilitates

passage of the tube by

closing the epiglottis.

Helps in easy passing of

the tube and avoids

coiling it at Pharynx.

Anatomy and

Physiology

Safety

Continue to advance the

tube until it reaches the

previously designated

mark.

Mark on the tube

indicates that it has

reached the stomach.

Physics Safety

Aspirate for gastric

contents with a syringe.

Fluids cannot be freely

aspirated from the lungs.

Glands of mucous

membrane lining the

esophagus and stomach

produce mucus, and

gastric juices.

Anatomy and

Physiology

Safety and

therapeutic

effectiveness

Place the end of the tube

into a bowl of water and

note the rhythm of

escaping bubbles.

If the tube is in trachea

air bubbles will coincide

with the expiration of

each breath. Normal

respiration takes place in

lungs. As a result, air

will be expelled out with

expiration.

Anatomy and

Physiology

Safety

principles

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Ask the patient to speak. The patient will be

unable to speak or hum

if the tube is in the

trachea. Any injury to

vocal cords of Larynx

causes difficulty in

speech and hum and

sounds will not be

produced.

Physics Anatomy and

Physiology

Safety

principle

Confirmation of the

tube's place can be done

by using a stethoscope.

Take 5-10ml of air and

push in

distal end of the tube.

Hushing sound will be

heard on the stomach

while air is pushed. Air

pushed by force

produces a hushing

sound.

Physics Safety.

After the tube is in

place, tape it to the nose

/ forehead. Take 5cm of

tape, split length-wise

and only halfway, attach

up split end of the tape

to the nose / forehead

and cross split ends

around tubing.

Prevents the patient's

vision from being

disturbed, prevents

tubing from rubbing

against nasal mucosa

Psychology Individuality

and comfort

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Wait for some time

before giving the feed.

A few minutes rest will

help to subside the

peristalsis and prevent

nausea and vomiting.

Peristalsis is stimulated

by any irritation to

stomach or by a bolus of

food.

Anatomy and

Physiology

Comfort

Before giving the feed

connect tunnel and

syringe, pour some

water through it and

lower the funnel slowly

so as to expel air.

Expelling air from the

tube before the feed is

given docs not allow the

fluid to run. Air is lighter

than water, liquid exerts

pressure because of

their weight.

Physics Safety

Hold the funnel or

syringe 8 inches above

the bed.

To prevent the damage

of mucus membrane in

stomach. The height of a

column of fluid

determines the amount

of pressure exerted at

the point of application.

Physics Safety

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Slowly introduce feeding

into the funnel or

syringe barrel, keep it

full until total amount

has been introduced.

To prevent distension,

nausea and excessive

peristalsis and to

prevent air entry into

the stomach. Helps in

preventing injury to

gastric mucosa by

reducing pressure.

Physics Safety

When the quantity of

feed is over, clear the

tube by introducing a

small amount of water.

To prevent the blockage

of tube. As the food

remains in tube, it

blocks the lumen and

causes obstruction to

flow.

Physics Safely

Disconnect funnel or

syringe barrel and clamp

the tube to prevent

leakage of fluids.

To prevent the leakage

of gastric fluids back

from the tube. Fluid

flows only when there is

a difference in pressure,

the direction is to the

area of lower pressure.

Physics Safety

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Tube may be removed or

left in the place. To

remove the tube pinch it

b/pulling it out

continuously with a

moderate rapid motion.

To prevent aspiration of

contents into trachea.

Physics Safety

Offer a mouth wash,

clean face and hands.

To clean mouth and

prevent tartar formation

and to moisten the

mouth. As the patient isnot taking food by

mouth there will be less

secretion of saliva and

dryness.

Microbiology Comfort and

safety

Remove the mackintosh

and the towel.

To keep the unit clean Psychology Comfort and

safety

Make the patient

comfortable in bed.

To give a sense of well-

being, comfort.

Comfort

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To take the articles to

the utility room. Discard

water and clean with

soap and water. Dry

them and replace in

their proper place.

To clean them

thoroughly. To prevent

cross-infection. Helps in

checking growth of the

micro-organisms.

Microbiology Safety

Wash hands To prevent cross-

infection.

Microbiology Safety

Record the time, date,

amount of feed, nature

of feed, reaction of the

patient, if any, in the

nurse's notes and

intake-output chart.

To have good

communication in team

and to maintain fluid

balance for future

reference.

Psychology Safety

Therapeutic

effectiveness

If the tube is reusable,

clean it with cold water

first then with a warm

soapy solution. Pushingwater several times

through the lumen boil

it, dry it and replace.

Disposable tubes to be

discarded.

Usually disposable ones

can be discarded.

Rubber tubes arc kept

ready for the next use.

Microbiology and

Physics

Safety and

comfort

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8. AFTER CARE OF PATIENT AND ARTICLE.

After the procedure replace the article by cleaning thoroughly and ask the child how he felt is there any

partial satisfaction of fulfilling appetite, provide fowlers for a while or if child can able to walk then give

little time to walking this will help for digestion.

9. RECORDING AND REPORTING.Record the time, Date, Amount of fluid given, toleration. And signature of the nurse who carried out

procedure. Report if any adverse effect or intoleration etc.

10. SUMMARY AND CONCLUSION.

Nasogastric tube feeding or Gastric gavage is an artificial tube feeding through nose, mouth

oesophagus to the stomach. It should be given by doctor's order only. It has more advantages than

parentral feeding. Gastric gavage may be nasogastric, orogastric and gastrostomy feedings. The

procedures for all these are the same except some points.

As a nurse while proceeding the procedure she must also understand the following points.

GENERAL INSTRUCTIONS

Screen the elder child for privacy.

Tube feeding is given only by the doctor's order.

If the elder child is conscious, explain the procedure and reassure him/her to win his confidence

and co-operation.

A rubber tube may be placed in a bowl of ice to cool and stiffen.

Lubricate the tube with a suitable lubricant preferably with a water-soluble jelly, e.g., mineral oils

(glycerine, liquid paraffin) are used; it should be applied to the minimum with a soft paper or

cotton. (A drop of mineral oil, if

dropped into the respirator)' passage acts as a foreign body because the lung tissue does not absorb

it).

If the tube is dipped in a liquid or lubricant before insertion, make sure that the blind end is not left

filled with the fluid or lubricant, because this may drop into the larynx and choke the child.

All equipment used for feeding should be clean. The food has to be prepared, handled and stored

under hygienic conditions because many organisms enter the body through food and drink.

Every time before giving the feed, make sure that the tube is in the stomach by aspirating a small

quantity of (5 to 10ml) stomach contents.

While removing the tube, pinch the tube and pull it out gently and quickly so that the fluid may

not trickle down the pharynx.

During the introduction of the tube, never use force as it may cause injury to the mucous

membrane.

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Avoid introducing air into the stomach during each feed by :

-Expelling air from the tube by lowering the tube below the level of the stomach.

-Pinching the tube before the fluid runs into the stomach completely from the syringe.

Restraints use should be limited to the minimum. For infants and restless children, some form of

restraints may be necessary, but they should not feel that they are punished.

Feedings may be given at intervals of two, three or four hours and the amount is not exceeding 50to 100ml per feed. The total amount in 24 hours varies between child to child and weight. If the

drip method is used, the speed of the flow should not exceed 10 to 20 ml per minute. This

minimizes distension, nausea, regurgitation and excessive peristalsis usually associated with too

much and too rapid administration. The food calories should be calculated according to the

condition of the disease.

Intake and output are to be recorded accurately.

Watch for complications such as nausea, vomiting, distension, diarrhea, aspiration, pneumonia,

asphyxia, fever, water and electrolyte imbalance. These may be reflected in changes in the skin,and mucus membrane thirst vital signs, intake and output chart, level of consciousness, body

weight etc.

Patients receiving tube feeding should receive frequent mouth care to prevent complications of

neglected mouth care.

Warm the feed to room temperature "before administration.

Use gloves as per universal precaution.

TYPES OF GASTRIC GAVAGE

Gastric gavage may be divided as follows, based on the route of insertion and method of

administration: Route of insertion :

Nasogastric tube feeding: A tube is passed through the nose and oesophagus into the stomach. It is

also called nasal feeding.

Oro-Gastric feeding: A tube is passed through the mouth and oesophagus. So the food reaches the

stomach.

Gastrostomy tube feeding: Giving a liquid diet through a tube or catheter, which is introduced into thestomach through the abdominal wall, is called Gastrostomy feeding (gastro = stomach, ostomy = making an

opening into).

Methods of Administration

Continuous Feeding Method: Used for critically ill clients. Continuous drip-feeding helps to minimize

cramping, nausea and diarrhea; the gravity flow of fluid by an infusion pump is used at the rate of 50ml/hr.

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Intermittent Feeding Method: Feeding given periodically. Each time 400 ml over 30 minutes duration and

four to five times a day by the drip method.

Bolus Feeding Method: Pour a prescribed amount of fluid (250-400ml) slowly into the barrel of a

syringe or funnel attached to the end of the tube. The fluid flows by gravity into the stomach.

The gastric gavage procedure is similar for infants, children and adults except for the size of the tube andthe length passed and the amount of feeding given.

Methods of tube feedings :

Nasogastric (NG) feeding Nasoduodenal feeding Nasojejunal feeding

Jejunostomy (JT) feeding Gastrostomy (GT) feeding

RELATED LITERATURES TO THE NEXT PAGE:

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COLLEGE OF NURSING BHARATI VEEDYAPEETH, PUNE.

Final Year Msc Nursing [Pediatric Specialty]

STUDENTS NAME:-___________________________DT:__

CHECKLIST FOR NASOGASTRIC TUBE FEEDING

SR.

NO

PARTICULARS YES NO N.A

* BEHAVIORAL GUIDES

1. APROACHES THE CHILD/PARENT WITH CONFIDENCE.

2 GIVES A RELAVANT EXPLAINATION INWAYS THATCHILD OR PARENT CAN UNDERSTAND.

3. ORIENTS THE CHILD/PARENT THE POSIBLEDICOMFORT AND TO HIS ROLE DURING THE

PROCEURE.

4. ANTICIPATES CHILDS EMBARSEMENT AND

PROTECTS PRIVACY.

5. MAKES ALLOWANCES FOR INDIVIDUALDIFFERENCES IN TOLERANCE OF TREATMENT.

6. SHOW PATIENCE.

7. NOTICES CUES INDICATING CHILDS DISCOMFORT

AND ATEMPTS TO ALLEVIATE IT.

8. PLACES THE PROCEDURE APROPRIATELY TOTOLERANCE AND/OR CONDITION OF CHILD.

9. FOCUSSES ATTENTION ON THE PROCEDURE TOTHE EXTENT THAT READINESS TO RESPOND

TO OTHER EVENTS IS LIMITED.

10. INDICATES AWARENESS OF RESPONSIBILITY TO

THE CHILD FOLLOWING THE PROCEDURE.

* FEEDING OBSERVED NOT

OBSERVED

11. ENSURE 30-45DEGREE UPRIGHT POSITION OF

CHILD IF UNLESS CONTRAINDICATED.

12. ENSURE TUBE IS CORRECTLY POSITIONED.

13. CHECK THAT PRESCRIBED FLUID IS ATAPPROXIMATELY NORMAL BODY TEMPERATURE.

14. INTRODUCED ORDER AMMOUNT OF FLUIDTHROUGH THE TUBE.

15. INSERTS MININMUM 10 ML OF WATER FOLLOWING

FEED TO FLUSH THE FEED.

TOTAL

N.A = NOT APPLICABLE. POINTS: /15

COMMENTS:

STUDENTS SIGN:-

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OXYGEN THERAPY IN CHILDREN

11. INTRODUCTION.

Air, water and food are the three essentials of life. Oxygen, the most important component of air

is vital to all existence. Oxygen is given when there is interference with normal oxygenation o

body tissues. Inhalation is also one of the common routes of administration of drugs. Drugs may

be given by inhalation for either a systemic or a local effect. The systemic effect is produced

immediately, because of the large surface area of lungs and the rich supply of blood vessels. Drugs

used for a local effect may be in the form of medicated steam and fumes. The fumes method is

rarely used.


Oxygen is acolorless, odorless, tasteless and combustible gas. Oxygen therapy is defined as the

administration of oxygen by inhalation from a cylinder, piped in system liquid oxygen reservoir or

oxygen concentration by various methods to relieve anoxemia.


To facilitate normal metabolism of the tissues.

To reduce / correct arterial hypoxemia (low concentration of oxygen in the blood) and tissue

hypoxia.

14. SCIENTIFIC PRINCIPLES.

15. Anatomy and physiology: The anatomical structure of respiratory tract is an important

aspect of O2 Administration procedure nurse must know of its basics before initiation of the

procedure for normal alignment.

16. Microbiology: As a procedure is related to human subject there may be a chances of

spreading nosocomial infection so as a nurse she must take care to provide aseptic procedure

17. Pharmacology: sometimes with oxygen some drugs used in a procedure are mostly

bronchodilator which are the chemical composition and may produce the side effect so the

nurse must aware of pharmacokinetics of the particular drug before administration.

18. Physics: use the body mechanics is important while transferring the oxygen cylinder.

19. Psychology: Nursemust aware of mental status of the child and his parents to provide

anxiety free procedure.

20. INDICATION./ REASON FOR PROCEDURE:

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The indications for oxygen therapy are as follows:

Breathlessness or laboured breathing.

High altitudes.

Shock and circulatory failure.

child under anesthesia.

Children who are critically ill .

Child with a decreased respiratory capacity.

21. ARTICL REQUIRED FOR PROCEDURE.

Sr.No. Articles Rationale

1. Oxygen cylinder with stand ,or

central supply oxygen with a

flow meter, humidifier /Wolffs

bottle and connecting.

2. A tray containing:

To deliver oxygen.

To humidify oxygen

3. a) Nasal catheter / canula /

oxygen /flow meter & mask of

an appropriate size clean /

disposable type in a covered

container.

To check the amount of oxygen going

to the patient.

4. b) Water and soluble

lubricating jelly

To lubricate the nasal catheter.

5. c) Adhesive tape To attach the nasal catheter.

6. d) A bowl of water To check oxygen flow.

7. e) Swab sticks and normal

saline in a container.

For cleaning nostrils.

8. f) No smoking (indicator) To take fire precautions

22. PREPARATION OF THE PATIENT. /UNIT.

Preparation of the patient

Check name, bed No. and other identification marks of the patient.

Check the diagnosis and the need for oxygen therapy,

Check doctor's orders for initiation of the therapy and dosage.

Assess the child for any sign of clinical anoxia.

Assess the child's vital signs and breathing patterns carefully before starting

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therapy.

Explain the need of oxygen therapy; and the sequence of the procedure.

Gain the patient's confidence.

Keep the child in a propped up position or Fowler's position.

23. STEP OF PROCEDURE WITH RATIONALE.Steps Rationale Scientific

PrinciplesNursingPrinciples

Wash hands Reduces transmission of micro-organisms.

Soap and water reduce surface tension

and thus remove dirt and check the

growth of micro-organisms.

Microbiology Safety

Attach canula / catheter mask

to oxygen tubing and

humidified oxygen source

adjusted to the prescribed

flow rate.

Prevents drying of nasal and. oral

mucous membranes and airway

secretions. Use of a humidifier prevents

drying of mucus membranes.

Physics Safety, comfort

Place lips of canula into the

patient's nares. If mask,

apply snuggly to face.

Directs flow of oxygen into the upper

respiratory tract. Prevents loss of

oxygen.

Therapeutic

effectiveness.

Safety,

economy of

Check cannula/equipmcntevery eight hours.

Ensures patency of canula and oxygenflow. Also ensures safe delivery of

prescribed oxygen.

Safety

Keep the humidification jar

filled al all times.

Prevents inhalation of dehumidified

oxygen. Prevents drying of mucus

membranes.

Safety and

therapeutic

effectiveness.

Observe the patient's nares

and superior surface of both

ears and skin breakdown.

Oxygen therapy can dry nasal mucosa.

Pressure on ears from canula

tubing/elastic can cause skin irritation.

Safety, comfort

Check the oxygen flow rate

and the physician's orders

every eight hours.

Ensures delivery of the prescribed oxygen

flow rate.

Safety Therapeutic

effectiveness.

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Wash hands before removing

the oxygen mask pr tube.

Reduces transmission of microorganisms Microbiology. Safely

Inspect the patient for relief

of symptoms associated with

hypoxia.

Indicates that hypoxia is

reduced/treated.

Anatomy and

Physiology

Therapeutic

effectiveness.

Record procedure in the

nurse's notes.

Documents correct use of oxygen therapy

and the patient's response.

Safety, good

workmanship


Stay with the child ti ll he/she is at ease.

Keep the child warm and comfortable.

Evaluate the childs progress by observing the vital signs and symptoms.

Watch the child for any deteriorating symptoms after the removal of oxygen

inhalation. Inform the doctor.

Request for an arterial blood gas analysis at specified intervals to make sure

hypoxia is treated.

Take all articles to the utility room.

Clean nasal catheter with cold water, then warm soapy water and finally withclean water (if not

disposable). Boil and store or send for sterilization.

15. RECORDING AND REPORTING.

Record procedure with date, time.


As we sum up the procedure a Nurse also must keep following points in a mind that

Methods of Oxygen Delivery

Nasal Catheter: Nasal Catheters are used less frequently these days. It involves

inserting an oxygen catheter/simple rubber catheter into the nose upto the nasopharynx. It

needs to be changed at least every eight hours and inserted into the other nostril, it is also

painful and can cause trauma. Thus, it is less desirable.

Nasal Canula : A nasal canula is a simple comfortable device. The two canula, about 1.5

cm (1/2 in) long, m the centre of a disposable tube and are inserted into the nares.

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Trans-tracheal Oxygen : In trans-tracheal oxygenation, oxygen is delivered directly into the

trachea via a catheter

(small intravenous-size) into the trachea through a surgical opening in the lower neck.

Oxygen masks / B.L.B. Mask (Boothby Lovelace and Bulbulian) : Oxygen mask is a device

used to administer

humidified oxygen, it is strapped to fit snugly to the mouth and nose and is secured in place with a

strap.

Oxygen tent / the Seymour tent: When a patient has facial injuries or for any other reason

cannot tolerate an oxygen mask, then this method can be used. The tent is first flooded with

oxygen and then a flow of 4-5 liters per minute is given. This will maintain a service of 40 % - 50%

in the tent.

General Instructions

Oxygen should be treated as a drug; the five rights of medication

administration also pertain to oxygen.

When using an oxygen cylinder or central supply oxygen, use a regulator and

humidifier.

Every part of the apparatus should be clean to prevent infection.

Change nasal catheters at least every eight hours or more often to prevent blockage of the nasal

catheter by a mucus plug.

When oxygen therapy is to be discontinued, it should be done gradually.

Pay attention to conditions that can interfere with the flow of oxygen from source to the patient.

This may include tubing, loose connections and faulty humidifying apparatus.

Always keep a spare oxygen cylinder in close vicinity.

Watch the patients receiving oxygen therapy continuously to detect the early

signs of oxygen toxicity.

Since oxygen supports combustion, fire precautions are to be taken when oxygen is on flow, e.g.

smoking, use of matches, lighters etc.

Contraindications

Administer with caution to the patient with COPD (Chronic Obstructive Pulmonary Disease) as

it induces hypoventilation.

Atelectasis.

Oxygen toxicity.

Paraquat poisoning.

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Match the correct delivery device with your assessment of the patient:

Device F

low

Concentration Indications Considerations

Cannula 1-6

liters

Low flow

24% -

44%

Use in infants who are

obligatory nose breathers or if

you do not have a correct size

mask

Simple

mask

6-10

liters

Moderate

flow 35% -

60%

Must maintain a minimum of 6

liter flow

Blow by 6-15

liters

Mod. - High

flow Depends

on flow rate

and proximity to

face

Can be used in

all

patients

Use for infants and young

children. Use a simple mask,

corrugated tubing, or 02

tubing threaded through the

bottom of a paper (not

Styrofoam) cup.

Non-

rebreather

--mask

12-15

liters

High flow

80% -

90%

Partial airway

obstruction

Respiratory distress

Inhaled poison

Altered mental

status Shock

Trauma

Bag

Valve Mask

15

liters

High flow

= 90%

Be familiar with the pop-off

valve and manometer port if

present

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NEBULIZATION IN CHILDREN24. INTRODUCTION.

The simplest and most natural route of drug delivery to the lungs is the inhaled one. From the historica

and medical point of view, it was a Greek, Pedanus Discorides, the father of the science of pharmacy,

who, during the first century prescribed inhaled fumigation. Pipes were also used to inhale

hallucinogenic substances. All shamans knew the psychotropic effects of poisonous plants such as

Datura stramonium, especially Red Indians, in their peace calumets; but Indians of Madras used

fumigations ofDaturaferoxto treat asthma. Since 1803, this therapeutic was imported in Great Britain

and cigarettes with leaves of datura were used by asthmatics until 1992. In the middle of the

nineteenth century, to treat grapevines diseases and in response to the fashion of inhaling thermal

waters, spray technology was developed for the effervescent waters at the thermal spas. The onslaught

of tuberculosis, similar to AIDS a century later, brought back into practice the inefficacious use of

antiseptic aerosol therapy. With the discovery of adrenaline, ephedrine aerosols enjoyed a rebirth. The

perfecting of jet nebulizers by R. Tiffeneau, father of FEV1 and M.B. Wright, father of peak-flow,

allowed a better practice of inhalotherapy. In 1949, the United States, ultrasonic nebulizers made their

first appearance in the form of humidifiers, but doctors were quick to add medications to produce

therapeutic aerosols. After 150 years, with the improvement of nebulizer systems and new nebulized

medications, the nebulization story is still not concluded.


Nebulisation is a process of giving Nebulizer, and Nebulizer is a device for producing fine spray of

liquid. It can be with medicine or without medicine.


To deliver continuous nebulization through a fine droplets of a medicine or plane solution to the child that

are in a closely monitored area in the hospital.

27. SCIENTIFIC PRINCIPLES.

a) Anatomy and physiology: The anatomical structure of respiratory tract is an important aspect

of Nebulisation procedure nurse must know of its basics before initiation of the procedure for

normal alignment.

b) Microbiology: As a procedure is related to human subject there may be a chances of spreading

nosocomial infection so as a nurse she must take care to provide aseptic procedure

c) Pharmacology: Drugs used in a procedure are mostly bronchodilator which are the chemical

composition and may produce the side effect so the nurse must aware of pharmacokinetics of

the particular drug before administration.

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d) Physics: Compressor of Nebulizer works on principles of physicsand the nurse here also must

use the body mechanics.

e) Psychology: Nursemust aware of mental status of the child and his parents to provide anxiety

free procedure.

28. INDICATION./ REASON FOR PROCEDURE:1. Provide long term bronchodilation for children with serious asthma exacerbation of COPD

bronchitis and pneumonia.

2. Liquefaction of thick secretion.

3. Improvement of clearance of secretion.

29. ARTICLE REQUIRED FOR PROCEDURE.

1. HOPE tm Nebulizer.

2. Oxygen and or / medical air at 50 Psi.

3. Blender, [O2 Analizer] (Optional).

4. Cardiac monitor if indicated and pulse oximeter.

5. Aerosol tubing, mask [ or other delivery device].

6. Sputum cup.

30. PREPARATION OF THE PATIENT. /UNIT.

Nurse must take care of following headings

1. Preparation of Environment

Note: Room temperature

Ventilation Clean and tidy Privacy2. Preparation of Patient

Note: Explanation and reassurance Privacy Position

Comfort Culture

3. Preparation of Equipment

Note: Hand washing

Collect all required equipment prior to commencement.

Check equipment is in working order.

Consider cost and reuse.

Consider if the procedure for the patient is really required.

4. Completion of procedure :

Note: Leave patient clean and comfortable, equipment disposed off and cleaned correctly.

Area left clean and tidy. Hand washing.

5. Documentation

Note: Maintain nursing record.

Ensure replacement of used equipment.

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31. STEP OF PROCEDURE WITH RATIONALE.

PROCEDURE:

A. Therapy must be initiated in either the ER, Critical Care Unit, pediatric area or in an area in which

the patient's EKG may be monitored continuously.

B. The treatment must be reordered every 24 hours by a physician. After an order has been received,

the therapist is to verify the order in the patient's chart.

C. After checking the patient's ID, the therapist is to explain the procedure to the patient and answer

any questions they may have.

D. Wash hands and assess patient's heart rate, breath sounds, respiratory rate,

peak flow, color, use of accessory muscles, patient's oxygen needs (current ABG)

or SaO2.

E. The therapist then sets up a continuous pulse oximeter to establish a baseline and monitor

the patient.

F. Attach flow meter to 50 psi gas source.

G. Attach HOPE1 to flow meter or blender.

H. Attach corrugated tubing to the HOPE11" Nebulizer output and to the aerosol

mask or other delivery device.

I. PREPARE MEDICATION [ Eg. Albeterol 0.3mgto 0.5mg/kg/hour.]

J. Pour medication into the HOPE Nebulizer reservoir using aseptic technique. K. Set flow meter

to 10 liters per minute and adjust FiO2 per chart or blender to

meet patient needs after attaching appropriate size mask to the patient. L.

Monitor the patient for adverse reactions and check the HOPE Nebulizer Q 30

minutes x 2 hours.

M. To determine approximate use of medication, look at the marks on the side

of the Nebulizer (marks on Nebulizer are in 25 ml increments). Adjust flow

meter by small increments to achieve desired output of 25 ml/hour without

auxiliary flow.

N. When using auxiliary flow, output increases. Mix one more

hour of medication to accommodate increased output.


A. Pulse before, during treatment, Q 30 minutes x 2 hours, then Q

2, and post treatment.

B. Breath sounds before, during and post treatment.

C. Pulse oximeter before, during and post treatment.

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D. In pediatrics a TCM may be used to monitor patients pre, post and during the treatment to

monitor PaCO2,

E. Peak flow rates before treatment, during treatment Q 1x2, then Q 2 and post treatment.

F. Sputum production.

G. Subjective statements by patient.

H. Patient position, color and level of cooperation.

I. Complications or problems noted during therapy.

J. Electrolyte levels at physician discretion, if patient is receiving beta agonist

therapy > 4 hours.

K. Re-evaluate patient after initial 2 hours for possible decrease in drug dosage level.

l. Ensure replacement of used equipment.

33. RECORDING AND REPORTING.

A. Check the patient and document the following information Q 30 minutes for the first 2 hours,

then Q 2 on the Continuous Bronchodilator Therapy Work sheet

1.FiO2.

2.Heart rate.

3.Respiratory rate.

4.Breath sounds.

5.Oxygen saturation/TCM reading or ET CO2.

6.Peak expiratory flow.

7.Side effects and remarks

8.Respiratory Care Practitioner signature

9.Date and time.

10.ABG information.

11.Mental status.


As Nebulizer produces a shower of fine droplets that can be breathed in by blowing compressed aithrough a reservoir containing a solution of the bronchodilator drug. Younger children who may find i

difficult to operate an aerosol it is manage best with a compressor Nebulizer which delivers medicine

through a face mask over several minutes. In hospitals, the compressed air or oxygen is used to

nebulize drugs used in the emergency treatment of asthma.

If the child is prone to frequent attacks consider buying a Nebulizer . This is a very handy for use

during an acute attack However a metered dose inhaler with an easily available spacer device and

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facial mask is considered better than a Nebulizer for the treatment of acute wheezing in children less

than 2yrs.

As a nurse she also take care of following headings.

HAZARDS:

A- Exhaled aerosol or patient coughing may spread active pulmonary infections.

SAMPLE MEDICATION CALCULATION:

This is a sample calculation. Ideally, when setting up CNBT, the initial fill and dosage should be

for 3 hours.

A. MEDICATION + DILUENT - OUTPUT OF NEBULIZER (25 ml/hr. @ 10 lpm

Albuterol 0.5% (5 mg - 1 ml, 10 mg=2 ml, 15 mg-3 ml, 20 mg=4 ml)

1.Mg/hr of medication ordered x 0.2= ml of medication used per hour.2.(Output of nebulizer) - (ml of medication) = ml of diluent (normal saline)

3.Multiply diluent and medication times hours you want to deliver, up to 8 hours @ 10 pm

(maximum volume of nebulizer is 220 ml).

CONTRAINDICATIONS:

A. Absence of the above indications.

B. Increased heart rate of >25 beats or as defined by the physician.

TREATMENT COMPLICATIONS:

A. A complete reassessment is indicated any time the patient

vomits. Failure may include, but is not limited to the following.

1.Failure to significantly respond in 8 hours.

2.Decreasing aeration over time or increased wheezing

without a simultaneous increase in operation.

3.Worsening blood gases.

4.Decreasing pulse oximeter readings or an increasing need

for higher FiO2's to maintain the same saturation.

5.Decreasing level of consciousness or decreased ability to

awaken the patient.

6.Increased work of breathing.

7.Anything that leads you to believe, through your patient

assessment, that the patient is getting worse.

B. When treatment failure is suspected, re-evaluate the patient and

contact the physician immediately.

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NOTES: Nebulization to emptymay lead to evaporative concentration of the drug at the bottom of

the nebulizer. When nebulizing for a long period of time, it may be appropriate to change the

medication solution when 10% is left in the bottom of the nebulizer.

Neonatal resuscitation-Protocol

During the intrauterine life the baby gets oxygen through the placenta. As soon as the baby is born

the respiratory center is stimulated and lungs expand and the baby initiates spontaneous breathing.

Most newborn babies breathe spontaneously after birth and may not require resuscitation measures. I

the newborn does not breathe spontaneously nor has breathing problem then the baby is asphyxiated,

so immediate steps should be taken to resuscitate the newborn. About 5-10% of newborns need

resuscitation. Nearly one million newborns are die because of birth asphyxia. Hence it is essential tha

knowledge and skills required for resuscitation be taught to all involved in neonatal care.

INDICATION

Maternal condition- pregnancy induced hypertension, placenta previa or placenta abruptio, prolonged

or obstructed labour, fever in labour, post- term pregnancy, maternal sedation, prolonged rupture o

membrane,

Fetal conditions umbilical cord around the babies neck, short cord, knot on the cord, prolapsed cord

During or after the birth- premature baby (before 37 weeks of pregnancy) difficult delivery,(breech

multiple birth, stuck shoulders, vacuum extraction, forceps) meconium in the amniotic fluid, congenita

anomalies.

PREPARATION OF PATIENT

Anticipation and preparation are very important for effective resuscitation. Anticipation of likelihood o

resuscitation is only possible if proper antenatal history and all the maternal documents are available

before delivery, which can help to identifying the high risk infants. It is important to keep resuscitation

articles before delivery. When a baby has asphyxia, you must start resuscitation immediately.

PREPARARTION OF ARTICLES

Warm environment

Place to do the resuscitation (resuscitation corner)

Personnel

Equipments

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Supplies

Keeping a newborn baby in a warm environment saves the babys energy for breathing. There are

many ways to keep a baby warm. This includes the baby in a warm room, providing heat by various

means, drying the baby etc.

Warm environment: keep the room warm (at least at a temperature of

25 degree c) and keep it free from air currents.

Providing heat: place the baby under a radiant warmer or use heater or 200 watt bulb above the

baby. For babies needing routine care, use skin to skin contact for providing warm.

Drying the baby: dry immediately after the birth, then remove the wet sheet/cloth and cover the

baby with another warm, dry sheet/or cloth. Resuscitation place

The resuscitation must be done on a flat surface. A table or trolley in the room can be used or it can

be done in a place next to the mother. The place needs to be clean and warm.

Personnel

It is essential that at least one person skilled in neonatal resuscitation should be present at every

delivery. For performing complete resuscitation two persons must be available for ventilation and

chest decompression.

NEONATAL RESUSCITATIONS SUPPLIES AND EQUIPMENTS:

De Lee trap

Mechanical suction

Suction catheters No. 12FG, 14FG

Feeding tube 6F and 20ml syringeBag and mask equipment

Neonatal resuscitation bag

Face masks, term and pre term size

Oxygen with flow meter and tubing

Intubation equipment

Laryngoscope with straight blades No. 0(pre term) and No. 1 (term)

Extra bulbs and batteries for laryngoscope

Endotracheal tube; 2.5, 3, 3.5, 4.mm internal diameter

Scissors

Medication

Epinephrine

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Naloxone hydrochloride

Normal saline

Sodium bicarbonate

Sterile water

Miscellaneous

Watch with second hand

Linen and shoulder role

Radiant warmer

Stethoscope

Adhesive tape

Syringe 1,2,10,50ml

Gauze pieces

Umbilical catheters

Three way stopcocks

Sterile gloves

Routine care

Nearly 90% of newborns are vigorous term babies with no risk factors and clear amniotic fluid

These babies do not need to be separated from their mothers to receive initial steps. Receive the baby in a

warm and dry sheet. Dry the baby and wrap in another dry and warm sheet covering the head put the baby

on mothers abdomen while drying. Keep the baby in direct skin to skin contact maintains warmth and

prevent hypothermia. Clear the airway by wiping the babys nose and mouth with sterile cloth. At birth you

must make quick assessment and assess/look for following.

Was the baby born after a full-term gestation?

Is the amniotic fluid clear of meconium and evidence of infection?

Is the baby breathing or crying?

Does the baby have good muscle tone?

If the answer to any of these question is yes then you must give routine care to the babys given above

If the answer to these question is no, then you must start the initial steps

Initial steps

Preventing heat loss

Positioning

Suctioning

Evaluation

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Tactile stimulation

Free flow oxygen

Preventing heat loss

An important step in the Care of the newborn is to prevent the heat loss of body heat. This can be

especially critical in a newborn who needs resuscitation. Even healthy term infants have a limited ability

to produce heat when exposed to a cold environment, particularly during the first 12 hours of life.

Drying the infant

As soon as the baby is placed under the radiant warmer, the baby should be quickly dried to remove

the amniotic fluid to prevent the evaporate heat loss. It is preferable to dry the infant with a pre

warmed towel or blanket. After drying remove the wet towel or blanket from the infant and lay the

infant on another prewarmed towel or blanket. This will further reduce the heat loss.

Using radiant heat source /other means to keep the infant warm

Prevention of heat loss can be achieved by placing the baby under the radiant warmer which should be

switched on manual mode before the delivery of the baby. An overhead radiant heater provides a

suitable thermal environment that minimizes radiant heat loss. It is important to switch on the radiant

warmer so that the infant is placed on a warm mattress. A radiant warmer allowed easy access to the

baby and provides the full visualization of the infant.

If heat source is not available, a lamp with 200w bulbs or a suitably fixed room heater can be used for

keeping the baby warm.

Positioning

Place the neonate on his or her back or side with the neck slightly extended or in shifting position.

Prevent hyperextension or under flexion of the neck since either may decrease air entry. Maintain the

correct position by placing a rolled blanket or towel under the shoulders, evaluating them to 1 inch

if the infant has copious secretions coming form mouth, turn the head to the side. This will allow

secretion to collect in the mouth, from where they can be easily removed.

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Suctioning

If no meconium is present, suction the mouth and nose. The mouth is suctioned first to preventaspiration which can happen if nose is suctioned first. A bulb syringe or a mechanical suction can be

used to remove the secretions. Be carefully not to be too vigorous as you suction and do not insert the

catheter deep in the mouth. Stimulation of the posterior pharynx during the first few minutes after the

birth can produce a vagal response, causing severe bradycardia or apnea. If bradycardia occurs stop

suctioning and re evaluate the heart rate.

Evaluation

The infant should be evaluated on the basis of three vital signs

1. Respiration: observe and evaluate the infant respiration by observing the chest movements.

If breathing spontaneous, go on to check the heart rate. If not, begin tactile stimulation. If still no

spontaneous respiration, start positive pressure ventilation (ppv).

2. Heart rate: check heart rate by ascultating the heart or by palpating the umbilical pulsations by 6

seconds. Whatever the number or pulsation multiply by by 10 to obtain the heart rate per minute.

If heart rate more than 100 beats per minute, look for color. If less than 100 beats per minute, initiate

PPV.

3. Color : if the infant is breathing spontaneously and the heart rate is more than 100 beats per

minute, evaluate the infants color by looking by cyanosis at lips/ tongue(central cyanosis)

If central cyanosis is present administer the oxygen.

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Providing tactile stimulation

Both drying and suctioning the infant produces stimulation, which for many babies is enough to induce

respirations. However, if the infant does not have adequate respiration, additional tactile stimulation by

stepping the sole or flicking the heel and / or and quickly rubbing the newborns back (rub twice) may

be briefly provided to stimulate breathing . if you choose to provide tactile stimulation , free flow

oxygen should be given along with while you are stimulating the infant. Tactile stimulation can be

safely and appropriately provided by following two methods.

Slapping or flicking the soles of the feet

Rubbing the infants back

Slapping in back

Squeezing the rib cage

Forcing thigh on abdomen

Using hot or cold compress

Shaking

Using free flow oxygen

Free flow oxygen refers to blowing oxygen over the nose of the baby to enable the baby to breath

oxygen enriched air. This can be done by holding the end of an oxygen tube close to the nose, within a

cupped hand or by holding the oxygen mask over the mouth and nose.

Free flow of oxygen is used when an infant has established regular respirations and the hear

rate is greater than 100 beats per minute but central cyanosis persists. In these circumstances free

flow 100% oxygen at 5 L/min be given. Once the infant becomes pink while breathing room air. Icyanosis persists despite 100% free flow oxygen , a trial of bag and mask ventilation may be

indicated.

Bag and Mask Ventilation

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One or two slaps or flicks to the soles of the feet or rubbing the back once or twice will usually

stimulate breathing in an infant with apnea. However, if the infant remains apneic , tactile

stimulation should be abandoned and bag and mask ventilation initiated immediately.

Continued use of tactile stimulation in an infant who does not respond is not warranted and may

be harmful, since valuable time is being wasted.


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Objectives: Participants will be able to learn

When to give positive pressure (bag and Mask) Ventilation.

Selection of bag and mask equipments.

The similarities and differences among flow inflating bags and self inflating bags and T- piece

resuscitators

The operation of each device to provide positive pressure ventilation.

The correct placement of masks on the newborns face.

Identify the indications and contraindication of bag and mask.

Ventilation of Lungs is the single most important and most effective steps in cardiopulmonary

resuscitation of the compromised newborn baby.

Bag and Mask Equipment

Resuscitation bags: Two types

1. Flow inflating bag (Anesthesia bag )

2. Self inflating bag

1. The flow inflating bag fills only when gas from a compressed source flows into it. It is

collapsed like a deflated balloon when not in use. It inflates only when a gas source is forced

into the bag and opening of the bag is sealed, as when mask is placed lightly on a babys face.

Peak inspiratory pressure is controlled by the flow of incoming gas, adjustment of the flow

control valve and how hard the bag is squeezed. Positive and expiratoratory pressure (PEEP) or

(CPAP) is controlled by an adjustable flow control valve.

Preparation of resuscitation devices for an anticipated resuscitation.

1. Assemble all the necessary equipments.

2. Testing the equipments.

Bag and Mask procedure

Indications: Apneic or gasping following initial stimulation. Heart rate < 100 \ min in a spontaneously breathing baby.

Spontaneously Breathing infant cyanotic despite free flow oxygen

Contra Indication:

Diaphragmatic hernia

Non- vigorous baby born through meconium stained liquor.

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Selecting bag and mask equipments: Size of bag (240-750 M1): it deliver a tidal volume of 6-

8 ml per kg.

Oxygen capability: Oxygen source, Reservoir.

Safety Features : - Pop off valve , pressure Gauge (optional )

Mask Size: 0 and 1 (cover chin, mouth nose) Cushioned Edges.

Forming Seal:

Positioning the infant

Position of resuscitator

Forming and checking the seal:

Positioning and holding the mask: Enclose chin, mouth and nose , ensure snuff seal , avoid

pressure over neck and eyes.

Squeeze the bag with fingertips: Dont squeeze or empty the bag with whole hand.

Observe chest movements noticeable rise and fall of chest , shallow and easy breathing

Rate: 40-60 Breaths per minute. Squeeze two three squeeze

Pressure : Increase in heart rate if noticeable rise and fall or chest

Initial breath pressure 30-40 cm of H20 later 15-20 cm of H20

Improvement assessment

Increasing Heart rate

Improving color

Spontaneous breathing

No improvement \ deterioration

Chest movement not adequate

Inadequate seal

Reapply mask

Blocked airway : Reposition

Clear Secretion

Ventilate with open mouth

Reliably.

A good resuscitation bag:

Size 200-750 ML

Capable of avoiding excessive pressure

Capable of giving 100% Oxygen

Appropriate sized mask.

Masks: Cushioned \ non cushioned marks

Round \ anatomical shaped

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A mask comes in a variety of shapes, sizes and materials. Selection of mask fro use with particula

newborns depends on how well the mask fits to the newborns face will achieve a tight seal between

mask and newborns face available ; size 0 or 1.

Be sure to have a various sized mask available. Effective ventilation of a preterm baby with term

infant size mask is impossible. Use correct size and correct position of the mask.

Advantages: Delivers 100% Oxygen at al time.

Easy to determine the adequacy of seal.

Stiffness of Lungs can be felt.

Can be used to deliver 100% free flow Oxygen.

Disadvantage: Requires a tight seal to remain inflated.

Requires a gas source to inflate

No safety pop off valve.

Requires more experience

The self inflating bag Fills spontaneously after it is squeezed pulling gas (Oxygen of ai

mixture of both) into the bag .

Advantages:

Does not need a gas source to inflate

Pressure release valve is there

Easier to use

Disadvantages:

Will inflate even if there is not a seal between mask and patients face.

Requires Oxygen reservoir to provide high Concentration 100% Oxygen

Cannot be use to deliver free flow oxygen

Insufficient pressure

Increasing pressure

Deterioration:

Check delivery system

Check Oxygen supply

Check Oxygen Tubing

Preterm Newborns

Avoid Excessive chest wall movements (Large tidal volume )

Monitoring of pressure and avoiding unnecessary high pressure

CPAP after resuscitation may be helpful.

Bag and mask ventilation procedure

Points to be keep in mind

Select bag & connect Oxygen source capable of giving 100% Oxygen

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Select Appropriate size mask

Test Bag

- Good pressure

- Pressure release valve working

- Pressure manometer 30-40 cm H20

Baby need bag & mask ventilation

- Position your self at head end or side of baby

- Position babys head in sniffing position

- Position bag and mask properly on baby.

- Begins ventilation at appropriate rate and pressure

- Check easy chest rise during first 2-3 breaths

CHEST COMPRESSIONS

Objectives:

Identify the indications of chest compression

Locate the site of chest compression

Demonstrate technique of chest compression on manikin

Introduction:

The newborn babys survival is dependent on his ability to adapt to his extra uterine environment. This

involves adaptations in cardio pulmonary circulation and other physiological adjustments to replace

placental function and maintain homeostasis. Simultaneously newborn has to make adjustment in

respiratory and circulatory system as well as maintain body temperature. These initial adaptations are

crucial to his subsequent well being and should be facilitated by trained and skilled nursing personnel.

The heart circulates blood throughout the body, delivering oxygen to vital organs. When an infant

becomes hypoxic, the heart rate slows and myocardial contractility decreases. As a result, there is a

diminished flow of blood and oxygen to the vital organs. The decreased supply of oxygen can lead to

irreversible damage to the brain, heart, kidneys and bowel. Chest compressions are used to

temporarily increase circulation and oxygen delivery.

Indication of Chest Compression:

The decision to initiate chest compression is based on neonate heart rate. Chest compression isindicated when heart rate is below per minute after30 seconds of positive pressure ventilation with 100

percent oxygen.

Technique of chest compression:

The neonate should be posited on flat firm surface and neck slightly extended Ensure that neonates

back is firmly supported so that heart can be compressed between the sternum and spine. Two trained

personnel are needed i.e one for chest compression and another for positive pressure ventilation.

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Chest compressions must always be accompanied by ventilation with 100% oxygen ventilation must be

performed to ensure that the blood being circulated during chest compression gets oxygenated.

There are two ways for chest compression:

Two finger method: The tip of the middle and the index finger should be used for compression. Othe

hand can be placed under back of the neonate to provide support.

Thump technique: Thumbs of both hands are placed either side by side or one over the other win

fingers encircling the ribcage. The thumbs are used to compress the sternum while fingers provide

support to the back of the chest. The chest should not be squeezed by the hands but sternum

compressed with thumbs.

Site: Lower one third of the sternum i.e the area just below the inter nipple line and above

xiphisternum.

Rate of compression: The sternum should be compressed at the rate of 120 beats per minute and

the ventilation is given at the rate of 40 to 60 breaths per minute. Rate of cardiac massage should be

coordinated with ventilatory support i.e. three chest compression and one breath.

One and two and three and squeeze should be the sequence followed for chest compression and

positive pressure ventilation.

Compress the chest to a depth of one third of the anterior posterior diameter of the chest.

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Maintained a steady rate and depth of compression.

After 30 seconds of chest and ventilation evaluate heart rate and make your decisions based on the

heart rate.

If heart rate is below 60 per minutes continue chest compression and ventilation

If heart rate is above 60 per minute discontinue chest compression whereas ventilation should be

continued till the heart rate is above 100 per minute and neonate is breathing spontaneously.

Complications

If the technique of chest compression is incorrect it can cause trauma to the heart, lungs or liver.

Excessive pressure over the ribs and xiphoid and lead to fractured ribs , laceration of liver and

pneumothorax.

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FORMULA FEEDING

Introduction:

Nutrition is an important component of the care of al babies for their survival and proper growth and

development. Full term new born normal babies usually has food sucking reflex and they have breas

feed easily whereas low birth weight babies especially babies who cannot suck breast feed those

require to be fed by watty spoon.

Definition:

Formula feeding is method of giving synthetic milk and nutrients to a new born by using clean and

boiled watty spoon for their proper growth and development.

Purposes:

1. To promote appropriate nutrition

2. To ensure adequate physical growth and should mimic intrauterine growth curves in case of

preterm baby

3. Provide nutrients specially required for preterm to prevent micro and macro nutrient deficiency

and

4. To ensure normal land term neurodevelopment outcomes.

Indication

1. The baby >34 weeks and weight less than 2000 grams.

2. Poor swallowing and sucking reflux.

3. The baby is risk for aspiration

4. Congenital anomalies like cleft lip and cleft palate.

Principles

1. The baby should be fed in upright position and burped after each feeds.

2. The milk should be always directed to the side of the mouth

3. All utensils used for feeding have been boiled in water for at least 10 minutes.

Articles:

Feeding tray contains

- Boiled watty and spoon

- Boiled cooled warm water

- Recommended feeding powder like lactogen , lactose .

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- Napkin

- Preparation of environment parents and baby.

- Establish rapport with babys mother by explaining properly.

- Prepare clean bed well light & ventilation

- Check babies cloth, if it is wet change it.

- Wash hands and prepare feed and cover & keep ready.

Procedure:

1. Wash hands

2. Take boiled Wati spoon with boiled

water & warm 30 ml.

3. Take boiled Wati spoon with boiled

water & warm 30 ml

4. Add 1 spoon powder in 30 ml of water

and mix it with spoon evenly.

5. Hold the baby gently in lap. To

stimulation just tap the sole of feet.

6. Elevate 30degree head of baby on our

left hand.

7. Give small quantities & spoon feed to

baby to prevent vomiting

8. Let the baby swallow completed then

give other spoon this way slowly feed the

baby.

9. After 10 ml of milk burp the baby

by holding in an upright position &

support the head and neck while

gently patting or rubbing the back.

1. To prevent infection

2. Boiled articles to prevent

gastrointestinal infection to baby.

3. Boiled articles to prevent

gastrointestinal infection to baby.

4. to avoid lump of powder becoming &

to prepare proper milk

6. To prevent aspiration & milk while

swallowing

7. to prevent vomiting

8. this provides comfort to the child

9. It helps to prevent the regurgitation

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10. Clean the mouth lips & neck.

11. Place the baby in a bed on the left

lateral si

Peds Proceures

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