1. Vascular Access Considerations Within the Pediatric Population BY: Gail A. Heckler, RN, BS © 2005 Gail A. Heckler, RN, BS All Rights Reserved

2. PSYCHOLOGICAL TRAUMA EXHAUSTED VENOUS ACCESS POOR PATIENT SATISFACTION/ PATIENT RELATIONS POSSIBLE SURGICAL INTERVENTION?

3. Considerations Comfort Pain Control Certified Child Life Specialist  Visual Demonstration  Auditory Demonstration © 2005 Gail A. Heckler, RN, BS All Rights Reserved

4. Developmentally appropriate care is required Wrapping or swaddling in blanket Pacifier © 2005 Gail A. Heckler, RN, BS All Rights Reserved Comfort

5. PATIENT POSITIONING Adequate support for holding (please use caution when restraining – to avoid psychological trauma) Consider using a papoose board Swaddling © 2005 Gail A. Heckler, RN, BS All Rights Reserved

6. Reduces patient anxiety Increases patient/family satisfaction Less likely to move upon initial stick More likely to cooperate for next VAD procedure © 2005 Gail A. Heckler, RN, BS All Rights Reserved Pain Control

7. Sweet Ease Drugs: topical / systemic Child Life © 2005 Gail A. Heckler, RN, BS All Rights Reserved

9. L-M-X4® Ethyl Chloride Lidocaine injection © 2005 Gail A. Heckler, RN, BS All Rights Reserved

10. PEDIATRICS?? May be necessary to use Anxiolysis Sedation General Anesthesia

11. Certified Child Life Specialist CALL CHILD LIFE!!! Use age appropriate techniques

12. Developmental Stages Infant (0-12 months) ISSUES Develop with sensory & motor experiences Minimal language Extension of parents Sensitive to physical environment Little tolerance for unmet Needs Beginning of stranger anxiety FEARS Separation from parents Disruption of routine Loss of normal stimulation Loss of security Impaired basic trust Parents fear of medical environment and loss of parental role

13. Interventions Primary care giving Encourage visiting & holding Incorporate routines Limit abnormal stimulation Cluster intrusive procedures (don’t involve the parents) Lullaby music Offer stimulation during waking hours Speak to child in gentle, smoothing manner Tactile stimulation to comfort child (blanket, bear) Provide familiar objects

14. Developmental Stages Toddler (1-3 years) ISSUES Motor skills rapidly developing Egocentric Receptive language more advanced than expressive Assertive will Making choices, preferences Loves rituals, concerned with change FEARS Separation from parents Fear of dark & loud noises Loss of autonomy Restriction of movement Regression, loss of newly aquired skills

15. Interventions Primary care giving Incorporate routines Involve parents Medical play Age-appropriate activities Provide brief details of sensory information Minimize restraints Offer diversion techniques Allow child to play with equipment Observe and respond to child's cues

16. Developmental Stages Preschool (3-5 years) ISSUES Most vulnerable to hospitalization Rapid language development Poor distinction between fantasy and reality Magical thinking Poor concept of time Literal interpretation of language FEARS Long separation and abandonment Medical procedures seen as punishment Loss of control Loss of newly acquired skills Fear of blood Regression Fear of unknown

17. Interventions Continuity of care Favorite toy/object Allow participation in one’s care(provide choices) Reassure child is not to blame for illness Be honest Use concrete explanations for time Use words familiar to child Offer diversion during procedures Observe and respond to child's cues

18. Developmental Stages Schoolage (6-12 years) ISSUES Want to earn recognition and be successful Some understanding of body function/structure Able to reason/compromise Increased understanding of time Separation from parents is easier FEARS Compromised body image Disgrace, loss of competence Invasion of privacy Loss of status Death and disability Hesitant to reveal fears Loss of bodily control Enforced dependence

19. Interventions Allow participation in own care Encourage verbalization of thoughts/feelings Promote a sense of responsibility Respect fears Explain reasons for procedures Use positive suggestion and soft, non-threatening language Protect privacy Offer diversion during procedures Observe and respond to child's cues

20. Developmental Stages Adolescent (12-18 years) ISSUES Want/doesn’t want parents close by Self determination Decision making Peer approval important Realistic view of death Prone to mood swings Abstract thinking Interest in sexuality FEARS Helplessness more threatening than illness Loss of body image Loss of control Fear of anesthesia Loss of pear acceptance Fear of failure in school Death Denial/non-compliance with drugs

21. Interventions Allow choices & control in care Encourage peer interaction Respect autonomy Honest explanations Protect privacy Soft, non-threatening words Provide opportunities for discussion and guidance Opportunity to write answers to questions is often easier Observe and respond to cues and behaviors

22. Child Life Services Provided Assessment Pre-procedural teaching Procedural Support

23. Assessment Process Coping of past medical experiences Past experiences with procedures Current developmental level/age Patient’s ability to refocus attention during procedure Ability of parents to assist with coping and support Patient’s and parents understanding of process

24. Pre-Procedural Teaching Uses developmentally appropriate hands-on teaching materials (books, med supplies) Utilize appropriate language with child per development level Assists patient and parents in forming plan for coping and support (relaxation, breathing, books, movies, toys)

25. Procedural Support When the child life specialist accompanies the patient to the procedure, the specialist may act in any of the following roles: Spokesperson Coach Support for parents

26. The Power of Words Selecting Appropriate Language * Going for a CT

27. The Power of Words I will feed you now.I’m ready to help you eat your lunch

28. The Power of Words What’s wrong with you?Why did you have to come to the hospital?

29. The Power of Words Use of pronouns It’s time for you to take your bath now. I imagine it is hard for you to get so many needles. It’s time for us to take our bath now. We don’t like it when we have to have a shot, do we?

30. Words This is the time to hold still. Don’t move!

31. Words Converse in normal conversation voice Attend to all verbal and non-verbal conversation Be responsive Use positive directions

32. Ask the child what he/she is feeling. Never tell them what they will feel. Do not say “I am sorry” when doing a procedure Use words that specifically describe certain sensations

33. Will it hurt? Some children tell me it feels like a pinch, other children tell me it feels like a sting. And, some children say they don’t feel it at all. How do you think it will feel to your doll? Afterwards, will you tell me how it felt to you?

34. “Dressing Change” Why are they going to undress me? Will I be naked? Do I have to change my clothes?

35. “Stool Collection” Why do they want to collect little chairs?

36. “Shot” Are they mad at me? When people get shot, they are really bad hurt. Are they trying to hurt me?

37. “We will give you some dye” To make me die?

38. “Flush your IV” Flush it down the toilet?

39. “Put you to sleep” Like my cat was put to sleep? It never came back.

40. Soft vs. Hard Words The medicine will burn Cut you open, make a hole As big as…. As long as….. As much as….. Some children say they feel a very warm feeling. The doctor will make a small opening Smaller than…….. For less time than it takes you to…….. Less than……

41. Avoid telling a child what they experienced-ask them. That was hard for you.How was that for you? Was it the way you thought it would be? Or harder or easier? Is there something else we should tell people about this?

42. Playworks Beyond Play