Sacred Cows in Pediatric Nursing Janice Selekman DNSc, RN, NCSN, FNASN Professor University of Delaware Do You Say. But we have ALWAYS done it that way But that s the way I was taught Where did YOU go to school We don t do it that way here; you ll have to learn how WE do it, since that s the only RIGHT way Restraints Evidence-Based Practice Where is the Evidence??? the integration of best research, clinical expertise, and patient values in making decisions about the care of individualized patients (Institute of Medicine What findings are relevant and applicable to clinical situations and aim at better patient outcomes? Restraint Findings Policies regarding restraints were either under safety policies or those that spoke to protective devices or restraints Most policies indicated that the purpose of restraints was preventive and protective Also to facilitate an examination and carry out procedures Prevent interference with tubes Most policies provided no guidance on how to determine the need for restraint Except for threat to others or self There are over 25 different types of restraints identified Only 3 policies included references
Restraint study #2 Asked nurses why, when, and how they used restraints Highest perceived need was between ages 1 and 6 Findings differed by type of hospital (peds general, pediatric unit, peds rehab, psych) Wide range of reasons Parents not there to watch the child Might do something Rarely did they seek alternatives Causes of treatment interference Bored Hungry Uncomfortable Desaturating THINK ALTERNATIVES Q 4 h vital signs Think of all the protocols you do each day Who taught you to do them? Where is the science behind them? Why? Middle of shift? Related to patholophysiology of patient or treatments given Influence of diurnal rhythms Why not in morning on awakening and early evening? NPO after midnight American Association of Anesthesiologists 2 hours for clears 4 hours for breast milk 6 hours for formula 6 hours for a light non-fatty meal and nonhuman milk 8 hours for fatty foods For those who are not compliant measure the outcomes Instill saline before suctioning OK for clearing tube of mucus 9 studies show oxygen saturation decreases with the use of saline and continues for up to 5 minutes Increases patient anxiety in older adults and increases heart rate for 4-5 minutes Contributes to bacterial colonization, leading to nosocomial pneumonia There is NO benefit to instilling saline And it causes GREAT harm DON T DO IT
Suctioning Do not hyperventilate before suctioning Forces secretions back into lungs Shallow suctioning is just as effective as deep suctioning and causes less trauma Deep suctioning is associated with increased lengths of stay r/t babies with RSV No agreement on what to do with your thumb Use minimal rotation of the tube NG testing for placement Testing ph of aspirated fluid no longer reliable x-ray is best, but not practical Air insufflation was never documented as accurate in differentiating lungs and stomach Questioned in 1980s Visual inspection of aspirated fluid not reliable NEW: presence of Carbon Dioxide in tube NG Tubes Where do you measure? Gravity or pump? Stop doing Trendelenberg Engorges head and neck veins Impairs oxygen and ventilation; compromises pulmonary exchange Increases aspiration risk Increases risk of retinal detachment and cerebral edema DOES shift fluid, but engorges and dilates right ventricle, leading to decreased cardiac output and DECREASED BP EBP Modified Trendelenberg Just elevate lower extremities Without head-down tilt This supports blood pressure without negative consequences Dress code Artificial nails DO harbor bacteria What about body piercings and tattoos?
Areas where we still have to change practice to match research Vision Screening Get rid of Tumbling E charts for vision screening Now using Sloan letters for 6 and up and LEA symbols or HOTV charts for younger children Areas to change practice to match research Children with GER can sleep on their backs Children as young as 5 can manage their PCA pumps Parents should be allowed to be present during code and report Eliminate heparin flushes of IVs Pacifiers are OK <6 months Use the ventrogluteal site for injections Areas where there is NO supportive research Treatment measures for vomiting BRAT diet for diarrhea How often a child should go to the dentist Sequencing of introduction of foods to infants Evaluation of chronic pain When is a medication considered late? Areas still needing research How to treat colic Care for fiberglass casts Impact of fetal surgery on the changing nature of anomalies Non-nurses giving glucagon Long term impact of concussions Communicating with the school nurse for continuity of care More areas to research What is the long term impact of all the psychotropic drugs our children are on How will it affect their children? What is the impact of genomics on nursing What is the impact of complementary therapies on children What is the future for children with autism More areas to research Impact of chronic pain Impact on pediatric nursing of the decrease in didactic content and clinical experiences
Policies and protocols What is the outcome I want? Morbidity Cost to the institution Impact on staff time Patient and staff satisfaction Is there more than 1 way to get there? Outcomes Outcomes Outcomes Compared to what? Target group compared to.. Who is the policy designed to help? What should evidence-based practice do? Answer questions related to practice or service Search to find short-cuts to quality evidence Critically appraise research findings Apply results to our own practice Evaluate our own practice WHY ARE WE DOING THIS? What else bugs me! I can t understand the study! This study needs to be replicated What are we doing in the interim? How are we getting the word out to educators to change what they teach? How do we get the word out to inservice educators and those who write hospital policy? One More Thing How are we teaching research to nursing students? Why are they turned off to research? Why don t we make it applicable to their practice? Many faculty hate doing it There has to be a better way. Approaches Be a leader Digging for dinosaurs! Have vision Ask why And never accept the answer Help move pediatric nursing forward