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A critical essay involves evaluating information, theories or situations and is an important way of analysing information, posing questions and challenging information.

The critical essay is an important academic tool that allows your knowledge to develop, because rather than being a personal opinion, the critical essay requires an indepth analysis of a topic.

Distraction Techniques for Managing Pain

Evidence based practice can be considered as the integration of the best available clinical evidence of each of the patients from systematic research. It can be considered as the integration of the patient values, clinical expertise and research evidences in the decision making method for the care of the patient. EBP helps to improve the patient outcome and helps in reducing the hospital readmissions. EBP in pediatrics ward have been found to be useful in many aspects such as reduction of hospital acquired infections and management of pain in the painful procedures that are common in the pediatric surgery. Intravenous cannula insertions and the venipuncture are the two common sources of the pain in the hospitalized children (Darby & Cardwell, 2011). Children have stated that their worst fear during the hospitalization is related to the nursing interventions, especially the invasive procedures that involve the needles and the syringes. Being exposed to syringes and needles develops a strong negative feeling among the children.  According to Katende & Mugabi, (2015), pain relief is the fundamental rights and requires a multidisciplinary approach as well as an evidence based care approach. This paper would discuss about the probable evidence based approach that can be taken for the pain management in pediatric patients suffering from IV cannula insertion.

In this paper a nursing practice has been described about a painful procedure- intravenous cannulation in a 2 year old boy. This was performed in the pediatric ward of an X hospital. The two years old child needed an insertion of the venous cannula for continuing an antibiotic therapy. Initially the procedure was explained to the parents, who were a bit perturbed about the fact, whether their baby will be able to bear the pain at the time of the insertion. All the information regarding the past medical history of the child was noted, or if the child suffers from needle phobia. The child was not informed of the procedure as any incisional procedure can be traumatic to a child. However the child was told that he will be experiencing a" little bit" of pain but he is "stronger" than the other boys to bear such a little pain. After that all the equipment were assembled before for the treatment. The child provided with a toy prior to the procedure and was brought to the treatment room. The child was told to sit on the bed but the child looked nervous and the doctor asked the mother to remain in the room and take the child on her lap. The child's arm was placed underneath a pillow with the ino pad and a tourniquet was applied for selecting a suitable vein. While checking the vein the child looked distress and started to cry but the doctor assured that "he would surely not hurt him". After choosing the appropriate site the tourniquet was removed and was carries on with the procedure. The child was laid in a supine position on the bed and all the hands were held by the assisting nurses. At this point of time the child started to cry and tried to get up pushing against the hands of the nurses. The mother was standing beside the bed and proactively took the initiative to hold the hands of the child. This assured the child to some extent and the he was distracted for a while. Finally the cannula was inserted with the bevel up at an angle of 30 degree in the punctured site.  The child was crying loudly and the mother looked distressed at this yet tried her best to minimize the movement of the child. Finally after the procedure the child was made to sit up in the bed close to his mother.

Role of Family Involvement

Hence it can be seen that the insertion of a venous cannula can be painful for a child and can bring about considerable distress to the child and the parents. It is important that information about the procedure in not given to the child beforehand about the incident and are told with the progression of the processes (Stevens et al., 2012). It is essential that to distract the concentration of the children from such painful procedures such as engaging them with some toys (Garg, Gupta &Ramalakshmi, 2016). Other distraction techniques such as administration of oral sucrose solution, breastfeeding and reduction of the external stimuli have been found to be useful in distracting the patient (Uman et al., 2012). Innovative activities such as “ bubble  making” can be used to distract the child (Coyne & Scott,2014). Distraction can act as a counter conditoning function. Counter conditioning is a behavioral therapy which is mainly based on the respondent conditioning theory. It is used to substitute one conditioned response to a stimulus such as fear and escape with another such as relaxation and approach, by a planned stimulus pairing (Slifer et al., 2011).

It has to be remembered that the preschooler's like this child are learning autonomy vs shame and hence should be given the opportunity to take some decisions. Erikson has stated that the preschoolers should be allowed to walk to the treatment room all by themselves. Procedural restraint is common in clinical procedures. In the process of restraint has long been contested and procedural restraint has been found to be acceptable for the nurse working in a child care setting (Hull & Clarke, 2010). The negative effects of the restraints on the child have been studied in several literatures, yet many literatures have suggested that restraint is not the last resort (Jeffery, 2010). While focusing on the procedural restraints a variety of terms are used in nursing interchangeably, such as clinical holding and immobilization (Cramton & Gruchala, 2012). However it has been found that in most of the cases involving the patient and the child in the assisting plan can prove as beneficial for the child, particularly when used in collaboration with the play therapists and the distraction technique (Fein et al., 2012). Most of the studies have supported the notion of the clinical holding defining it as positioning the child out in a manner with the consent of the child or the family (Hull & Clarke, 2010). This approach would ensure greater partnership and should be adopted between those providing the care and the family and the child. Shared decision making has been found to be useful in reducing the psychological trauma in both the parents and the child (Czarnecki et al., 2012). It should be mentioned that there are certain procedures where restraint is required in small kids. Any type of restraint should be discussed with the family (Katende & Mugabi, 2015). The provision of comprehensive information would ultimately reach a situation where informed consent is reached. In this scenario it can be seen that the involvement of the mother alongside the child led to a successful insertion of the IV cannula.

Proper Site Selection to Mitigate Pain

Performing painful processes in already anxious children can be distressing and challenging at the same time. The nurses may suffer from ethical dilemma while applying restraints on small kids (Karlsson et al.,2014) . All these problems led to the research of some evidence based techniques to reduce the pain in the preschool children like this kid. However the techniques to hold the child should be such that the child is not hurt. Katende and Mugabi, (2015), have found that involving a family member during the procedural restraint helps to reduce anxiety in the child. Although there are reports that have shown that the management of pain is an important duty of the nurses and the physicians caring for children, there are studies that have shown that parent participation through their presence can significantly reduce the distress in children, while initiating an IV cannulation (Czarnecki et al., 2012). 

Many of the studies have proved that skin -to- skin contact with the mother have or breastfeeding has found to be soothing for the child (Czarnecki et al., 2012). Similarly, the positioning the child on the mother's lap in an upright position, ensuring that the chosen position was comfortable, after obtaining consent from the child and the mother has proven to be useful (Fein et al., 2012). Similarly tucking or swaddling the child can be efficient in reducing the pain in children. Presence Of a family member during the procedure not only increases the trust between the therapist and the child, also the parents gets relief by seeing it being performed in front of their eyes, as many parents have also complained that they were often not given with any choice to stay with the kid (Wente, 2013).

Pain during the insertion of the intravenous cannula can be painful for the patients and can cause considerable anxiety on the patient during the nasal cannula insertion. It is often regarded as an unpleasant experience among the pediatric patients visiting an ambulatory care surgical setting. The site of the insertion of the venous cannula also affects the intensity of the pain during the venous cannula insertion in child (Goudra et al., 2012). Normally the dorsum of the hand (DOH) and the antecubital fossa (ACF) are the commonly used sites for the venous cannulation. The sensory innervation density of the skin depends upon the choice of the site, and hence the pain associated at various sites are also different.Difference in the pain perception in two different sites can be explained by the fact that sites having tougher skin and more density of the pain receptors are the sites of more pain. As per most of the reports, IV cannulation in the ACF has been found to be less painful than compared to DOH. Hence the proper choice for the selection of the sites such as ACF can be simple and effective process of pain mitigation at the time of IV cannulation in the pedriatics patients. Again Goudra et al., (2016), have suggested that ACF vein may overlie the median cutanous nerve present in the forearm and hence can be injured. Hence choice of site is another evidence based approach to manage pain.

Topical Anesthesia for Active Pain Management

According to Chandler et al. (2013) under emergency set-up, it a standard practice for the children to undergo cannulation under topical anaesthesia. Sheta, AlSarheed & Abdelhalim (2014) are of the opinion that providing local or topical anaesthesia help in active pain management. Two most commonly used agents in paediatric anaesthesia before cannulation include  EMLA (eutectic mixture of local anaesthetics dilute in 1:1 ratio with the aqueous emulsion of lidocaine and prilocaine) and AnGEL (4% amethocaine gel). Schreiber et al. (2013). Numerous studies have highlighted that EMLA cream is useful in reducing pain associated with venipuncture and venous cannulation. Amethocaine has also been found to be effective as a topical anaesthetia in various studies and its efficacy is found to be as effective as EMLA. However, Lidocaine/prilocaine and amethocaine varies in their vasoactive function. In EMLA, biphasic vasoactive response is produced with initial vasoconstriction. In case of topical use of amethocaine, intrinsic vasodilatory effects are generated and thereby resulting in erythema as the principal side-effects (Baxter et al., 2013). Larson et al. (2013) are of the opinion that vasoconstriction after the application of EMLA might hinder the process of cannulation and as a substitute of this; an anaesthetic agent with vasodilatory property will be more advantageous. In order to ascertain the choice and type of anaesthetic towards influencing the likelihood of the successful i.v. cannulation under paediatric population, Schreiber et al. (2013) conducted a randomised control double blinded trail over patients between the age group of 12 to 24 months in tertiary hospital emergency department. The results highlighted that there is no difference in the rate of success of cannulation between two anaesthetics (AnGEL and EMLA). Schreiber et al. (2013) performed a comparative study in order to ascertain the effect of topical anaesthesia in paediatric i.v cannulation. Schreiber et al. (2013) mainly used randomised control trial study and two comparative anaesthetic agent used were iontophoresis of a 2% topical solution of lidocaine diluted with epinephrine and 2.5% of lidocaine diluted in 2.%% of prilocaine (EMLA cream). The results highlighted that less pain was reported among the children who received iontophoresis in comparison to EMLA cream. Moreover, time of accomplish topical anaesthesia was less with iontophoresis (13 minutes) than that of EMLA cream (60 minutes) Moreover, application of iontophoresis cause on dermal burn in children. Thus overall it can be said that in order generate successful i.v cannulation of a child of 1 to 2 years old under topical anaesthesia, iontophoresis can be regarded as the best possible agent Schreiber et al. (2013). However, anaesthetic must also be guided by other factors like cost, total time of anaesthesia, efficacy of the anaesthetic agent and adverse effect profile and training of the healthcare professional giving anaesthesia (Buchsbaum et al., 2013).

Moreover, apart from the anaesthetic, the nursing professionals also play an important role while performing paediatric i.v cannulation. The first step include established of the friendly relationship with the child so that he or she might feel relaxed (Karlsson et al.,2014). This will help to reduce the anxiety of the child and thereby helping a streamline the entire process. Developing relationship with the conversation requires an amount of adjustment of the amount of information that is to be disclosed to the child, based on their illness, age, degree of participation, fear, experience and the capacity to focus (Karlsson et al.,2014). Younger children between 2-4 years, the one that has been used in this paper will be receiving limited information about the procedure. “Small talk” has been found to be effective in calming a child during such invasive procedures. In order to support children via conversation it is necessary that right expressions are used so that that the children can understand what is going on and does not experience fear. The experiences of the nurses as well as the age and the experience of the child are helpful while choosing the words and the phrases.  Moreover, it is the duty of the nursing professional to have comprehensive knowledge about the posture and psychology of the child in order to execute the anaesthesia procedure and i.v cannulation in an organised manner (Buchsbaum et al., 2013).   Apart from anaesthesia, evidence-based practice highlights application of external cold and vibration procedure and be used for pain relief during peripheral intravenous cannulation among the children. According to the studies, the afferent pain receptive nerves are blocked by the fast non-noxious motion nerves. Application of cold vibration helps in the stimulation of the C fibers and might block the pain signals. It also increases the pain threshold of the body.  Such procedure is free from any kind of significant side effect and does not demand any form of special skills and can be easily procured by the paediatric nurses (Canbulat, Ayhan & Inal, 2015).

Staff training is another factor that has to be taken of while discussing the pain management strategies. Training should include the normal skill based training such as education about the proper holding technique, how to provide a conducive ambience such that a therapeutic relationship can be established. Clear guidelines should be there about the handling of the equipments. In Michigan Children’s hospital special approach has been undertaken in order to reduce the pain sensation among the paediatric population during i.v cannulation. This procedure is known as specific needle stick pain decreasing program which is popularly known as “The Poke Plan”. This is defined as a well-documented plan and is used as guide to manage procedural pain during i.v cannulation (Koller & Goldman, 2012). According to Koller and Goldman (2012), “The Poke Plan” is known as comprehensive plan for pain reduction and can be easily executed by the nursing professionals. Creative presentation of the plan through posters in the treatment room of the emergency unit helps to get a detailed scenario of the concept underlying the “The Poke Plan” like the postures and the types of procedural restraint. This visual also helps the parents to get a detailed overview of the pain management during i.v cannulation of their child. However, this type of pain management program in paediatric care required specific amount of investment coming from the healthcare organisations (Heinrichs et al., 2013).

In relation to the procedural restrain Heinrichs et al. (2013) highlighted that in iv cannulation though procedural restrain help to reduce the chances of unwanted harm but has certain drawbacks the main drawback include psychological effect of the child arising out of procedural or physical restrain. Evidence based practice highlighted that application of procedural or physical restrain increases anxiety and emotional stress of the child and thus is required to be executed in the presence of parents.

Thus from the above discussion, it can be concluded that intravenous cannulation is a painful process for the children in the emergency department. Hence in order to effectively manage the pain of the child while undergoing intravenous cannulation, it is the duty of the healthcare professionals to perform local anaesthesia. Other effective approaches which can be undertaken in order to effective handle the pain include distraction of the child before the initiation of the procedure, conduction of the cannulation in front of his or her parents so that the child might feel safe and relaxed . Moreover, the child must be placed in proper posture so that the comfort level is heightened and thereby helping to reduce the pain. It is also the duty of the nursing professionals to establish a friendly relationship with the child before initiation f the cannulation procedure this also helps to relax the child and thereby reducing the anxiety and promoting pain management.


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