EHS: WOW-Beyond First Do No Harm: Principles of Atraumatic Care

Wong on Web Paper
Beyond First Do No Harm: Principles of Atraumatic Care

Donna L. Wong, PhD, RN, PNP, CPN, FAAN

Definition of Atraumatic Care

Atraumatic care - is the provision of therapeutic care in settings, by personnel, and through the use of interventions that eliminates or minimizes the psychologic and physical distress experienced by children and their families in the health care system (Wong, 1989).

Therapeutic care - prevention, diagnosis, treatment, or palliation of chronic or acute conditions

Setting - any place care is given

Personnel - anyone involved in providing therapeutic care

Interventions - strategies aimed at reducing distress

Psychologic distress - may include anxiety, fear, anger, disappointment, sadness, shame, guilt, embarrassment, loss control, helplessness, hopelessness

Physical distress - may range from sleeplessness and immobilization to disturbing sensory stimuli, e.g., pain, temperature extremes, loud noises, bright lights

Identification of Child and Family Stressors

Physical Stressors

Pain and discomfort (injections, venipunctures, intubation, suctioning, dressing changes, rectal exam, other invasive procedures)
Immobility (use of restraints, bedrest)
Sleep deprivation
Inability to eat or drink
Changes in elimination habits

Psychologic Stressors

Separation from child
Lack of privacy
Inability to communicate (if intubated)
Inadequate knowledge and understanding of situation
Severity of illness
Parental behavior (expression of concern)
Child behavior (looking very ill)

Environmental Stressors

Unfamiliar surroundings (crowding)
Unfamiliar sounds (equipment noise, such as monitors, telephone, suctioning, computer printout; human sounds, such as talking, laughing, crying, coughing, moaning, retching, walking)
Unfamiliar people (health care professionals, patients, visitors)
Unfamiliar and unpleasant smells (alcohol, adhesive remover, body odors)
Constant lights
Activity related to other patients
Sense of urgency or lack of urgency/concern among staff
Unkind comments

Principles of Atraumatic Care

PREVENT OR MINIMIZE PHYSICAL STRESSORS

Avoid or reduce intrusive and painful procedures

Circumcision - provide informed consent to parents and analgesia to infant
Arterial blood gases - obtain baseline oximetry; use local anesthetic
Urethral catheterization - insert Xylocaine 2% jelly into urethra before inserting catheter (Gray, 1996)
See related article on the use of buffered xylocaine for venipuncture.
Multiple punctures - use intermittent infusion device with saline, coordinate care, have "2-try only" policy (Catudal, 1999); sequential vs simultaneous injections (Horn & McCarthy, 1999); consider central venous access device EARLY (Santolucito, 2001), know amount of blood needed for tests, have lab save blood for future tests
Painful injections - use smallest gauge needle; venipuncture (not heel puncture for >1.5ml; also leave arterial catheters in longer, warm heels before lancing, automatic lancet devices (Tenderfoot, One Touch), slow infusion, LAT (not TAC),EMLA, buffered lidocaine, iontophoresis (Numby Stuff), vapocoolants (ethyl chloride or Fluori-Methane spray), sucrose for newborn, tissue adhesive for sutures (Dermabond).
Intramuscular injections - use IV route, especially for pain control; EMLA for 2.5 hr.; ventrogluteal (hip, not buttock) site.
see Guidelines For Atraumatic Skin/Vessel Punctures

Avoid or reduce other kinds of physical distress

Restraints - consider absolute need, i.e., armboards, and alternatives, such as "therapeutic hugging" for procedures, i.e., child sitting in parent's lap instead of being held down
Shivering - avoid sponging or hypothermia blanket to reduce fever unless absolutely necessary, ex. seizures or hyperthermia
Sleeplessness - organize care to provide 60 - 120 minute sleep cycles
Smells - eliminate when possible, i.e., uncover food tray cover outside of room, do not make popcorn or wear perfume, eliminate body or mouth odor
NPO - allow clear liquids 2 hours before surgery or conscious sedation; 4 hr. for breastmilk or 6 hr. for formula (American Society of Anesthesiology, 1999.)
Noise - reduce; can lower intracranial pressure; prevent ear damage; use ear muffs; have "quiet hour"
Suctioning - use premeasured technique; insert catheter to tip or no more than 0.5 cm below tip of ET or trach tube; reconsider use of saline lavage
See related article on suctioning technique.
Skin trauma - avoid tape; use skin barriers; hydro gel electrodes; promote moist wound healing; assess frequenly to prevent injury

Control pain

Assess frequently using multidimensional approach and document findings
See a pain assessment record
See the FACES pain rating scale
Use pharmacologic interventions
See related article on the pharmacologic management of pain.
See bibliography on pharmacologic pain management.
Use nonpharmacologic interventions as an adjunct to analgesics

PREVENT OR MINIMIZE PARENT/CHILD SEPARATION

Promote family-centered care — THE FAMILY IS THE PATIENT

Use core primary nursing — same group of nurses and assistants with RN managing care

Consider research findings on parents' and children's preferences:

All children ages 4 to 18 years wanted their parents to accompany them during a bone marrow test (Hamner and Miles, 1988)
Over 80% of children ages 5 to 11 years wanted parents at the time of anesthesia induction and over 90% wanted them to be in the post anesthesia care unit (Hanna and Sherlock, 1983)
70% of adolescents ages 14 to 19 years preferred their parents to be present during cancer-related procedures (Weekes and Savedra, 1988)
When school-age children were asked what would help most if in pain, 99.2% answered having parents present, even though most realized that parent could only be there (Ross and Ross, 1984)
Family member opinions of presence during procedures in ED: Good idea 101 (91%), bad idea 6 (5%), and did not care 4 (4%); ED staff opinions good idea 92 (93%), bad idea 2 (2%), and did not care 4 (5%); family member presence made 4 (5%) members of the ED staff nervous (Sacchetti and others, 1996)
When parents who stayed with their child during CPR were asked about experience, 100% stated they would do it again (Villarreal, P., University of Texas, Austin, personal communication, 1991; for further information, contact Jan Zimmer, RN, MSN, Director of Patient Care Services, Santa Rosa Children's Hospital, 519 W. Houston St., San Antonio, TX 78207-3198; 210-704-2530)
Of family members who stayed during CPR and invasive procedures, 100% felt their presence was beneficial for them and caused no negative psychologic effects and said they would do it again. Of the staff, 96% of nurses, 79% of attending physicians, and 19% of residents were satisfied with family presence (Meyers and others, 2000).
Emergency Nurses Association (1994) supports the option of family presence during invasive procedures and/or resuscitation efforts.

To be or not to be together:

Offer children and parents an informed choice if they choose or not choose to be together
Prepare children and parents for the experience if they choose to be together
Help parents support child during procedure, i.e., be near child's face, sing, touch

PROMOTE A SENSE OF CONTROL

Respect and elicit family's knowledge about child and health condition

Promote parent-professional partnerships
Promote empowerment and enabling

Reduce fear of unknown

Educate about environment, diagnosis, treatments; use nonthreatening models (i.e., Legacy dolls)
Make environment less threatening (concept of animism — out of sight -out of mind, "safe" areas)
Keep familiar article with child

Provide opportunities for control

Participate in care, i.e. admission menu
Use time structuring to maintain consistent and normalized daily schedule
· provide direct suggestion (ex. GI motility post-op, Disbrow, et al, 1993): compared the return of intestinal function after intra-abdominal operations in 2 groups of patients: the suggestion group received specific instructions for the early return of gastrointestinal motility, and the control group received an equal-length interview offering reassurance and nonspecific instructions. The suggestion group had a significantly shorter average time to the return of intestinal motility, 2.6 versus 4.1 days. Time to discharge was 6.5 versus 8.1 days.

References

Selected Bibliography and Notes: Atraumatic Care

Additional Information

March 15, 2002