journal club presentation
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Journal Club Presentation
Bonnie Sawyer-Banda, RN, BSN
What is a journal club?
It is a group of nurses that meet regularly to discuss and critique research articles appearing in scientific journals.
A journal club is a good way to get started using evidence based practice (Beyea and Slattery, (2009).
Today’s Article:
Pain Reduction During Pediatric Immunizations: Evidence Based Review and RecommendationsJournal: PediatricsAuthors: Schechter, N., Zempsky, W., Cohen, L., McGrath, P., McMurty, M., and Bright, N.Published: May, 2007A literature review
Background
Children receive between 14 and 20 separate injections before the age of 2Immunizations are the most frequently occurring painful procedures performed in pediatric patientsPain of injections causes stress and anxiety in the patients, their parents and in the nurses that must administer the injections.All children have a pain memory and react more intensely if they have had previous painful experiences without analgesia.
Background (cont)
There are many variables that can heighten or lessen the response to injections.Parents – concern about injection pain can affect compliance with medical carePhysicians – have strong concerns about giving 3-4 injections per visitPhysicians and nurses are 6 times less likely to administer all immunizations at one visit if the child is scheduled for ≥3 injections than if the child were schedule for ≤2 injections.
PICOT question:
(Population, Intervention, Control, Outcome, Time)
In pediatric patients, what effects do pain reduction techniques have compared to no pain reduction interventions during routine immunizations?
Before the injections
Preparation for ImmunizationStudies have shown that preparation for procedural pain can reduce the anxiety and pain of many medical events, such asVenipunctureDental proceduresSurgeryVCUGHowever, there are few studies that look at preparation for immunizations. 2 studies were inconclusive (Vapo-coolant and training video).
Recommendations based on preparation for other painful procedures
For Parents:
Reason for the vaccineEmphasis on benefits
Realistic information about he pain that is to be expected
Provide parent with coaching and coping techniques – breathing, story telling
Recommendations based on preparation for other painful procedures (cont)
For Children:Preparation is guided by age. More relevant >2Preparation should consist ofWhat will happen (where, how long, what will be done)How it will feel (pressure, temperature, level of discomfort to be expected)Strategies to cope – (Give choices of strategies)Optimal timing for particular age ranges:Toddlers and pre-schoolers – as close to actual administration as possibleOlder children – depends on their coping stylesThere are no clear guidelines because there are limitations specific to pediatric immunizations
Injection site selection
Anterolateral thigh – large muscle mass and lack of vital structuresWhen to shift to arm?At 18 months, more severe pain, decreased movement and limping when given in thigh. Option: ventrogluteal Lower rates of systemic reaction and local reactions
Needle length
Longer needles cause less pain and fewer adverse reactions
Studies indicate that there is greater redness and swelling when immunizations are administered with smaller needle rather than a longer needle.
Conclusion: Individualization of needle length based on patient size and injection technique.
Injectate Properties
Temperature – in patients >16, no difference in pain scores whether the vaccine was cold, rubbed or warmed.
Injectate formulation – Vaccines with higher pH cause less pain. If there is a choice
During the injection
Parental behavior
Parental behavior during the immunization significantly influences the amount of pain and distress children experience
Parental behaviors that increase coping:
Commands to use coping strategies
Distraction techniquesHumor
Non procedural talk
Parental behaviors that increase child distress:
Empathy
Criticism
Apologies
Giving control to the child
Reassurance – most common adult vocalization during immunizations - it is counter intuitive that reassurance causes more distress, but fathers believe “comforting encourages more crying”
Educate the parents
Teaching parents techniques to promote coping can reduce their sense of helplessness and benefit the child by reducing distress and increasing mastery.
Securing the child
Young children:
Parent holds the child in his or her lap
Older children:
Sit in parent’s lap facing forward or face the parent with legs wrapped around the parent (big-hug)
Distraction
Recognized as a key interventionPossible explanations:Gate control theory – cognitive attention might affect processing and perception of pain. If some attention is allocated to a distracting task, then there are fewer resources available to attend to the pain
Examples of distraction stimuli
MoviesParty blowersNon procedural talkVirtual reality gogglesKaleidoscopesBubble blowingShort storiesMusic
Distraction
A meta analysis showed that distraction decreased distress behavior but had minimal impact on self-reported pain. Most effective in children <7.Interactive distraction decreased children’s pain more effectively. The more the children are engaged in the distraction (regardless of the type) the lower the pain. Most research has been done in pre-school age children. More research is needed in non pre school aged children.
Things to consider when choosing a distraction stimulus
Age and cognitive maturity of the patient
Age appropriate and engaging stimuli
Cost
Time
Space
Children’s natural coping tendencies and temperament
Patient preferences
Clinicians should routinely use distraction for pediatric
immunizationsEase of use
Growing body of evidence
Lack of negative consequences
Use of Sucrose
Sucrose water (1 packet of sugar mixed in 10ml of water) has been shown to decrease pain in neonates.It has been suggested that Sucrose interacts with opioid pathways to accomplish this phenomenon. Can be administer with a pacifier or instilled directly into the mouth. Loses efficacy by 4-6 months. Nonnutritive sucking also has analgesic properties.Combination of direct parental contact and sucrose have an additive effectBreastfeeding also provides analgesiaThere seems to be sufficient data to recommend sucrose use as a routine part of immunization administration for infants ≤6 months of age.
Topical anesthetics
Should be
Safe
Inexpensive
Should have rapid onset
Should have effect on vaccine immunogenicity
Examples
EMLADecreases pain as needle penetrates the skinReduction of underlying muscle spasmOnset of action – 1 hour
Vapo-coolant spraysProvides anesthesia in 30 seconds and are inexpensiveSome studies show them to be no better than placeboUniversal use of local anesthetics can not be endorsed as there is lack of availability of one that is rapid acting.
Technical Variables
Injection techniqueFor Intramuscular InjectionsHold skin tauntInject dart-like at 90°Do not pull back on the plungerInject vaccine at steady pressureWithdraw needle at the same angle
For SubcutaneousPinch or bunch the skinInsert needle at 45°
Site Pressure
10 seconds of direct pressure at the injection site - reduction of immediate pain
Simultaneous injections
No decrease in discomfort, but parents preferred
References
Beyea, S and Slattery, M.J. (2009). Ask the expert: What is a journal club? Retrieved 07/02/2012 from http://www.hcpro.com/NRS-243376-975/Ask-the-expert-What-is-a-journal-club.html Grady, D. (n.d.) a recommended journal club format Retrieved 07/02/2012 from http://www.unmc.edu/intmed/geriatrics/docs/journalclubformat.pdfRed Book (2010) Site and needle length by age for intramuscular injections. Retrieved 07/02/2012 from http://www.unboundmedicine.com/redbook/ub/view/RedBook/187027/all/Table_1_4__Site_and_Needle_Length_by_Age_for_Intramuscular_Immunization?q=needle%20length Schechter, N., Zempsky, W., Cohen, L., McGrath, P., McMurty, M.,
and Bright, N. (2007). Pain reduction during pediatric Immunizations: Evidence based review and recommendations. Pediatrics. 119(5). e1184-e1198.
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