Sharpening Your Skills for Decreasing Needlestick and Procedural Pain and Anxiety: Best Words and Comfort Positions

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1 Sharpening Your Skills for Decreasing Needlestick and Procedural Pain and Anxiety: Best Words and Comfort Positions Poke Program Co-leads Julie Piazza CCLS, MS, Child Life Specialist/Project Manager Sandra Merkel MS RN-BC Clinical Nurse Specialist Take Aim at Pain Series October 16 and 17, 2013

2 Objectives Identify age appropriate words to use when explaining and doing needlestick and procedures Describe comfort positions to use with needlestick and procedures

3 Procedures at C.S. Mott Blood draws inpatient (6mos)= 12,600 Blood draws lab (6mos)= 23,400 Surgical Procedures (12 mos) = 15,000 Children s Emergency Services (CES) (12mos) = 25,000+ IV starts and PIC lines Procedures: CT with contrast (6 mos)= 636 Tube insertions: Foleys and NGs Radiological procedures Dressing changes Chest tube removal Immunizations (2009) Venipuncture and IV insertions are the 2 most common sources of pain in hospitalized children

4 Reducing Anxiety/Pain and providing Comfort C.S. Mott Children s Hospital 1. Assess and communicate about pain routinely with families and patients: Collaborative practice guidelines: Spinal fusion surgery, Duramorph analgesia for urological patients, PRC screen, PACU preop call 2. Create an individualized plan with input from the child/parent Poke Program 3. Ask patients and families about pain and comfort 4. Educate patients and families about pain management practices and options 5. Educate staff about how to talk to children & families about pain and its treatment Pain conferences and CE programs 6. Pain order set in MiChart helps guide multimodal approach Managing needlestick pain and anxiety is the most universal way to decrease children s pain. S Leahy

5 Press Ganey June 2013

6 Fear and Anxiety Exacerbates pain Establishes pain experience/memory Increases complications Preparation and information benefit everyone: provide tip sheets and model for parents/caregivers Distraction and deep breathing are effective especially for school age and adolescents (and adults too!)

7 Reducing anxiety and pain with procedures-the Evidence Get to know the patient Individualize Honoring choices Preparation Best Words Positioning Distraction Parents as helpers and coaches Positive Recognition Drugs and Devices.

8 Contribution of Success to Behavior Treatment Patient/Extratherapeutic - 40% Relationship - 30% Placebo, Hope, and Expectancy - 15% Model/Techniques - 15% LL Cohen, Acapulco, March 11,2010 cited from Hubble et al 1999

9 It s the Small Things that become the Big Deal Asking a 15 yo what would has helped them in the past? Sequence of pre-op and sharing information Asking if the family prefers the curtain open or closed Gloves vs human touch Warm blankets The number of people at bedside at a time Our words make a difference Remember that your voice and your touch are the last thing the patient consciously experiences KS Sibert

10 The Evidence: Preparation Procedures and needlesticks Use Best Words High distress and anxiety Emphasize coping skills vs. information (TMI) Practice Deep breathing/blowing bubbles Positioning Best Word Tips Speak while child is comfortable Keep explanations simple/brief Be truthful and avoid making promises Use soft terms: warm rather than burning A quiet voice helps a child to focus Avoid telling a child how something will feel Common medical terms are often commonplace to staff however, not necessarily to families. Hanley & Piazza Crit Care Nurs Q, 33: 1, 2012

11 More Best Words

12 Case Example Discussions: Preparation and Best Words Key messages 1. Build a relationship to encourage comfort in the environment first what are some ways I can help you get ready? 2. Tell me what you know about your surgery? 3. I need to give you some medicine to help you relax. What makes you most comfortable when you take medicine?

13 The Evidence: Positive Recognition Be specific about what went well Calling out positive behaviors helps the child remember and reinforce future success Prizes do not keep a behavior reinforced Involve child in the plan and refine plan for next time Make praise effective and credible Michael Brandwein

14 Case Example Discussions: Positive Recognition Key messages 1. I really liked the way you helped me by holding still while I checked your temperature. 2. You know a lot about your surgery. You helped us to make it easier to explain what is happening next. Thanks. 3. You listened so well. You really helped us to make you comfortable and safe too.

15 Helping Parent to be Helpful Ask them to help identify pain and anxiety related to procedures and needles Develop a plan What is working? What is not working? Role play or practice techniques Teach/demonstrate techniques Distraction Deep breathing Touch Comfort Positions Hold Buzzy

16 Tips for Positioning for Comfort Forcing a lying down position increases stress Sitting promotes a sense of control Utilize table/furniture to decrease movement Parent participation increases comfort and patient and parent satisfaction

17 The Evidence: Comfort Positions

18 Case Example Discussions: Comfort Position Practice Key messages 1. Sitting up for nasal versed with head tilted back on parent s chest 2. Reduce the number of people in the pre-op area will help increase comfort for all. 3. Best position for throat swab? Safer to sit up and have parent support.

19 Reducing Anxiety and Pain with Procedures Establish a relationship before a procedure Ask about past experiences and what has worked Preparation and use Best Words Make a plan that gives a voice and a choice Include a coach, hold a hand, choose a distraction item Offer/suggest a drug or device Team work and collaboration One voice Communication and Continuity Positive Recognition for what went well