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161. Specimen collection - microbiology and virology

to pathogens. It is therefore essential that appropriate PPE including respiratory protection (FFP2 respirator and a visor) is worn when performing this procedure. Fast the child for at least six hours overnight. Perform hand hygiene and put on PPE Pass a nasogastric tube (refer to GOSH clinical guideline ‘ ’). Aspirate the stomach contents and place in a sterile container. Instil at least 30ml of sterile water down the tube to obtain as much stomach content as possible. Aspirate the contents back (...) . Gently rotate and withdraw the swab and place back in the tube. Remove PPE and perform hand hygiene. Dispatch specimen to the laboratory immediately to ensure maximum chance of growth of the organism. Good quality sputum samples are essential for accurate microbiological diagnosis of pneumonia, but also acute tracheitis and bronchitis. Sputum cultures are routinely used for patients with chronic and often progressive suppurative lung diseases such as Cystic Fibrosis and Primary Ciliary Dyskinesia

2014 Publication 1593

162. Stoma care

passed stools may appear ribbon-like the passage of stools may cease ( ) Granuloma Nodules of granulation tissue can form on the surface of the stoma. These can bleed easily and may cause concern, as they will bleed whenever the stoma pouch is changed ( ). Rationale Rationale 1: Closed end pouches are used when stools are formed. Open ended or drainable pouches are used for loose stools. Rationale 2: Non-refluxing valves prevent urine from washing back into the stoma. Rationale 3: The plug is taken (...) out to allow the bowel to empty. Rationale 4: It is important to observe the colour of a newly fashioned stoma. Applying a two-piece pouch may be too painful to apply. Stools will also be loose in the early post-operative period. Rationale 5: If the stoma is placed in the optimal position the child should find stoma management easier. Rationale 6: As he/she gets older the child will learn to change the pouch and will therefore need to see the stoma, both lying down and standing up. Rationale 7

2015 Publication 1593

163. Re-feeding

critical, re-feeding syndrome is a serious potential complication of commencing feeding in children and young people who have experienced starvation. Re-feeding syndrome is characterised by biochemical abnormalities AND clinical findings. For most children and young people, the most significant finding will be a fall in phosphate. When undernourished patients are re-fed there is an increased requirement for phosphate as the body switches back to carbohydrate metabolism, which can be potentiated (...) be done by reducing the dose by one Sandoz phosphate tablet every two days with serial measurement of phosphate. Side effects of phosphate treatment include diarrhoea and abdominal pain – consider reducing the dose if phosphate is stabilised or the delivering phosphate via an IV route instead of oral. Other considerations and complications during re-feeding: Severe central abdominal pain during re-feeding. Consider pancreatitis or superior mesenteric artery syndrome. Adherence with plan. Rationale

2014 Publication 1593

164. Newborn blood spot screening

45: This can prevent blood from soaking through to the back of the card Rationale 46: This may cause pain and bruising to the baby. Rationale 47: This gives the optimum amount of blood for the laboratory to utilise. Rationale 48: Risk of false-negative result Rationale 49: Applying pressure reduces the density of the sample and can lead to a `suspected’ result being missed. Rationale 50: To disturb the clot and encourage blood flow. Rationale 51: To reduce the amount of pain and bruising caused (...) of the card. Do not allow the heel to make contact with the card (Rationale 45). Do not squeeze the foot in an attempt to increase blood flow (Rationale 46). Allow the blood to fill the circle by natural flow, and seep through from front to back (Rationale 47). Fill each of the four circles completely and do not layer the blood (Rationale 48) Do not compress the blood spot in order to ensure the blood has soaked through to the reverse of the card (Rationale 49). If the blood flow ceases: The congealed

2012 Publication 1593

165. Neurovascular observations

of cardiac dysrhythmias) ( ) Preparing the child / young person and their family An explanation appropriate to the child’s or young person’s age and condition must be given, and the need for the observations should also be explained to the family ( ). Where possible this should be done pre operation/ intervention, alongside an explanation of an appropriate pain assessment tool ( ). Equipment needed A surgical site marker ( ). How to perform neurovascular observations To ensure any deterioration (...) for colour and swelling and compare to the unaffected limb ( ). Check for warmth with the back of your hand this should be done distally and proximally as a temperature variation may be detected on or beyond a point of trauma ( ) ( ). Ooze requires monitoring for wound care and blood loss. It should be marked on a plaster cast for monitoring and documented. Capillary Refill Capillary refill should be measured by pressing on the digit for five seconds, then counting the seconds until the digit returns

2014 Publication 1593

166. Peripheral venous cannulation of children

into a peripheral vein ( ). While the insertion of a cannula is a routine event for health care professionals (HCP), many children and families associate it with dramatic events and serious illness. Cannulation can be both traumatic and painful for the child and stressful for the family. They will require support and encouragement to deal with the procedure ( ). The implications of cannulation should not be underestimated. The introduction of a foreign body into the vein is an extraordinary intervention (...) procedure to the child and family including the reason for the cannulation, avoiding medical jargon and language. Information must be given according to the child’s age and developmental understanding ( )( ). Previous experience needs to be considered, together with preferred methods of coping, timing of the preparation and readiness of parent/carer(s) to take an active role ( ). There is evidence that tolerance to pain increases with age and maturity when the child no longer perceives medical

2014 Publication 1593

167. Nasopharyngeal airway (NPA)

is to be sized correctly in patients: if the airway is too short it will fail to separate the soft palate from the pharynx and if too long it can pass into the larynx and aggravate cough and gag reflexes ( ). The NPA primarily acts as a 'splint' which maintains patency of the airway, or keeps the tongue from falling back on the posterior pharyngeal wall and occluding the airway, therefore preventing airway obstruction, hypoxia and asphyxia ( ). NPAs are generally well tolerated by conscious children (...) the correct positioning and patency of the NPA skin integrity parental teaching to support safe discharge. Care of the skin Clean the nostrils as required to prevent excoriation. Change leukoplast tape daily or as required. The strong adhesive backing ensures a secure bond onto the tube holder and duoderm. Caution: for children with a latex allergy, an alternative medical adhesive tape must be sourced which is strong and durable enough to secure the NPA. Observe pressure areas for redness or breakdown

2014 Publication 1593

168. Mouth care

and/or an enlarged or protruding tongue: may be mouth breathers and consequently can experience dry mucosa with an increased risk of mucosal deterioration. Friable mucosa may be experienced by children with epidermolysis bullosa (EB). In addition, dystrophic EB causes severe microstomia which can limit or prevent access to back molar teeth. Restricted movement of the tongue due to surgery or pain may lead to the body’s usual removal of debris being ineffective. Chronic constipation: may cause a foul mouth (...) Mouth care Mouth care | Great Ormond Street Hospital Google Tag Manager Navigation Search Search You are here Mouth care Mouth care ). The principal objective of oral care is to maintain the mouth in a good condition. More specifically it aims to" Keep the oral mucosa and lips clean, soft, moist and intact. Remove, and prevent the build-up of food debris/dental plaque without damaging the gingiva. Alleviate pain/discomfort. Prevent halitosis and freshen the mouth. Maintain oral function

2014 Publication 1593

169. Immunoglobulin infusions: intravenous and subcutaneous

is responsible for all aspects of homecare: obtaining funding for homecare if relevant prescribing treatment monitoring treatment look-back in the event of any transmissible infections. The child/young person must be reviewed at least every six months by the prescribing team. During these reviews, an annual follow-up form must be completed as per the Department of Health's Demand Management Programme ( ): For non-primary immunodeficiency patients at GOSH, this should be returned to Pharmacy. For primary (...) of an acute infection, the infusion may need to be postponed until antibiotic treatment is started and / or pyrexia settles. Infusing when patient has acute infection can lead to adverse events. Rationale 20: To calculate the appropriate dose. Any significant change may indicate a need for dose increase or (less likely) reduction. Rationale 21: To monitor the effectiveness of treatment Rationale 22: To enable look-back in the event of an outbreak of infection. Rationale 23: To avoid medication errors

2015 Publication 1593

170. Halo traction

the head and back of the neck (without applying any pressure) or next to the cheek will assist with the feeling of normality. ( ) Pain should be assessed regularly using a recognised pain assessment tool and analgesia should be administered as required and a relaxant considered if the CYP is extremely frightened. ( ) The CYP should be returned to the ward setting as soon as clinically stable. ( ) Dysphagia can occasionally occur following placement of a halo. ( ) Discharge care Specific needs regarding (...) in reassuring the CYP. Rationale 35: Placement of a halo vest system feels abnormal and uncomfortable and may result in initial difficulty with sleep and relaxation for the wearer. Rationale 36: To reduce pain, and assist in reducing fear and anxiety. Rationale 37: Placing the CYP back in a more familiar environment will help reduce anxiety and allow better access for the family to comfort them. Rationale 38: Care should be taken when introducing diet and fluids; should dysphagia persist,any hyperextension

2014 Publication 1593

171. Extravasation and infiltration

) or necrosis if it escapes from the intended venous pathway ( ). Concentration of vesicant; the amount extravasated; and the type of vesicant are all factors which will influence the severity of the extravasation ( ). The degree of injury ranges from mild skin reaction to severe necrosis ( ). Other possible consequences include: infection; complex regional pain syndrome; and loss of function ( ). In severe cases extravasation injury may lead to amputation ( ). There has been little research (...) ; difficult to secure inadequately secured needle in implanted port inadequately secured catheter inappropriate needle length for Implanted Intravenous Access Port (IVAP) (ie too short to reach back of reservoir) development of fibrin sheath/thrombus at catheter tip IVAP (port)/catheter separation, catheter fracture or catheter dislodgement flushing with a small gauge syringe Drug-related vesicant potential volume of drug/fluid infiltrated concentration of vesicant drug/fluid repeated use of the same vein

2014 Publication 1593

172. Epidermolysis bullosa (EB): management of the newborn infant with EB

-uterine and/or birth damage has been healed ( ) ( ). For removal of tape without damaging skin Use a Silicone Medical Adhesive Remover (SMAR) ( ) such as Appeel® (Clinimed), Niltac® (Trio healthcare) or Peeleasy® (m&a pharmachem ltd). If SMAR not available, cover with 50% liquid/50% white soft paraffin, which will dissolve the adhesive and enable safe removal ( ). When removing the tape, roll the tape back on itself rather than lifting it from the skin ( ). Do not attempt to remove tape whilst (...) a validated neonatal pain assessment tool to ensure adequate analgesia (opioid analgesia is usually required) given prior to wound care (avoid the administration of rectal medication if possible as this can blister the anal margin). ( ). Prepare a clean trolley with clinical waste bag, hypodermic needles, all dressings (cut to shape using supplied template) and tape cut into short lengths ( ). See below for template. Wash hands using 7 step technique using liquid soap (plain or antimicrobial) for at least

2014 Publication 1593

173. Glomerular filtration rate measurement: Iohexol(TM) method

/carer(s) to take an active role ( ). There is evidence that tolerance to pain increases with age and maturity when the child no longer perceives medical interventions as punitive ( )( ). For communication to be effective, the non-verbal aspects of the practitioner-parent-child relationship must be understood ( ). If a CVAD is not being used, a topical anaesthetic should be offered and/or applied to two potential vein sites on separate limbs , prior to commencing the test ( ). Alternatively the child (...) or gauze. If an occlusive transparent dressing was used, remove by stretching parallel with the skin ( ). Confirm with the child, if appropriate, that the cream has caused numbness of the skin effectively ( ). Apply an appropriate size tourniquet 5-8 centimetres above the chosen vein but not so tight to occlude arterial supply. Indications of occluded arterial supply include: loss of colour, compromised pulse and pain ( ). Lightly tapping the vein or instructing the child to clench or pump the fist can

2014 Publication 1593

174. Epilepsy surgery: invasive monitoring for epilepsy surgery, nursing management

to return to patient hotel, to return to ward for 7.30am on the day of surgery. Morning of the procedure Ensure that the child’s preoperative checklist has been completed and the child is ready to go to theatre and ensure pre op check list is completed including ( ): identity band/theatre site marking appropriately fasted morning anti-epileptic drugs given Accompany the parent/carer(s) back from the anaesthetic room and obtain parental contact numbers to ensure full contact can be maintained (...) bleeding or fluid leak to medical staff ( ). The Neurosurgical team may have to be contacted to review the child if there are any concerns about bleeding from the wound site. Apply a pressure bandage to the area of bleeding and check the site regularly to monitor if bleeding is continuing. Headache Monitor the child’s pain level by observing the child’s behaviour and vital signs observations utilising an appropriately chosen pain assessment tool. ( ). Administer analgesia and monitor effectiveness

2014 Publication 1593

175. Gastrostomy management

or young person, and if it is too loose it will cause the tube to move back and forth. This would cause irritation to the tract, and could result in stretching of the tract diameter, and cause stomach contents to leak on to the skin. Rationale 10: To detect signs of bleeding, infection or tube migration. Rationale 11: To keep the child or young person pain free, and allow a comfortable recovery period. This will also allow the child or young person to accept the tube and make handling and accessing (...) to comply with the hospital policy on informed consent. Provide appropriate written information to back up any discussion with the family. Ensure the child or young person and family understand the reason for insertion of gastrostomy and gastrostomy feeding ( ). Explain to the family how long the procedure will take ( ). Provide the booklet ( ), ensuring to fill out the type and size of device as well as the contact details for the hospital gastrostomy CNS. Written information should also be given

2014 Publication 1593

176. Entonox: Ward administration of

experienced by the child or young person ( ): On the audit form attached to the Entonox trolley. In the child or young person’s health care records. Entonox cylinders should be kept in a designated storage cupboard when not in use ( ), at GOSH this is in the VCB theatres, situated near the reception desk. The cylinder should be 'signed out' of the store and ‘signed back in’ by the person collecting and returning the cylinder. The Pain Control Service and the Biomedical Engineering Department are jointly (...) Entonox: Ward administration of Entonox: Ward administration of | Great Ormond Street Hospital Google Tag Manager Navigation Search Search You are here Entonox: Ward administration of Entonox: Ward administration of ). It is a potent analgesic with properties comparable to that of strong opioids. It can provide short-term pain relief, sedation and reduced anxiety during a wide range of painful procedures such as chest drain removal, pin site dressings, physiotherapy and lumbar punctures

2014 Publication 1593

177. Coagulation factors

to coagulation factor eg ( ): rigor laboured breathing/wheezing chest pain back or loin pain/darkened urine loss of consciousness sudden collapse Infuse/inject product - reaction management If the reaction is unexpected: Stop transfusion ( ). Infuse 0.9% sodium chloride ( ). Obtain medical assistance ( ). Record incident in child’s health care records ( ). Complete an incident report form. Continue administration when possible. If child had potential for a reaction: Stop transfusion. Infuse 0.9% sodium

2015 Publication 1593

178. Bone marrow biopsy

monitored and documented on the CEWS chart until they are fully awake ( ). Whilst waiting for the child to regain consciousness, the noise levels in the room should be kept to a minimum ( ). Once the child is rousable, the child's parents should be invited to return ( ). The child should be taken back to their bed and if they wish to sleep they should be placed in a semi-prone position. If awake the child can be nursed however they are comfortable ( ). Oxygen and suction should be available (...) by the child's bed ( ). Prescribed analgesia may be required if the child is in pain. It should be repeated as necessary ( ). The child should be permitted to eat and drink whenever they are fully awake and wish to do so. The puncture site should be observed for signs of bleeding or oozing of serous fluid. This must be documented in the child’s health care record. The child's doctor should be informed if any of these occur ( ). The child's parents should be advised that their child may have a bath/shower

2012 Publication 1593

179. Blood sampling, neonatal capillary

accurate results: blood cultures coagulation studies The procedure is not without risk. The main problems are: pain local trauma damage to nerves, blood vessels and bones bleeding and blood loss infection scarring These problems can be avoided by using a good technique. Good quality sampling ensures accuracy of results, reduces the risk of avoidable repeat samples, reduces delays in obtaining results and limits potential distress to the baby. Blood sampling: neonatal capillary Preparation Gather (...) , the time the baby cried, and the need to repeat the sample ( ). Manual lancets must not be used ( ). Before commencing the procedure Capillary blood sampling is a painful procedure. Comfort measures and analgesia are recommended to reduce the pain and discomfort caused to the neonate during the blood sampling process ( ) ( ). An assessment of the baby's ability to tolerate handling must be made prior to obtaining the sample. A full explanation should be given to the parents before the procedure

2014 Publication 1593

180. Blood glucose monitoring

for these patients as well as a step-by-step plan to follow if the blood glucose is outside of these specified ranges . If the blood glucose level is outside of the parameters of 4-7mmol/L or the child is symptomatic, the advice of an experienced nurse or doctor should be sought . Symptoms of hypoglycaemia include pale pallor, lethargy, clammy skin, irritability, seizures Symptoms of hyperglycaemia include increase thirst, increased urination, irritability, abdominal pain, weight loss Acknowledge the child (...) if other samples are required to be taken. An arterial sample should not be used solely for blood glucose monitoring ( ). If not, recommended puncture sites vary with age: for neonates, follow the e under one year - side of heel ( ). over one year - side of fingertip or toe; avoid thumb and index finger The back of the heel and tips of fingers should be avoided . The chosen puncture site should be continually rotated . Excessive squeezing should be avoided . White soft paraffin and alcohol impregnated

2014 Publication 1593

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