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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. - PowerPoint PPT Presentation

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  • Journal Club PresentationBonnie 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).

  • Todays 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

  • BackgroundChildren 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 injectionsPreparation 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 proceduresFor Parents:Reason for the vaccineEmphasis on benefitsRealistic information about he pain that is to be expectedProvide 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 selectionAnterolateral 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 lengthLonger needles cause less pain and fewer adverse reactionsStudies 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 PropertiesTemperature 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 injectionParental behaviorParental behavior during the immunization significantly influences the amount of pain and distress children experience

  • Parental behaviors that increase coping:Commands to use coping strategiesDistraction techniquesHumorNon procedural talk

  • Parental behaviors that increase child distress:EmpathyCriticismApologiesGiving control to the childReassurance most common adult vocalization during immunizations - it is counter intuitive that reassurance causes more distress, but fathers believe comforting encourages more crying

  • Educate the parentsTeaching parents techniques to promote coping can reduce their sense of helplessness and benefit the child by reducing distress and increasing mastery.

  • Securing the childYoung children:Parent holds the child in his or her lapOlder children:Sit in parents lap facing forward or face the parent with legs wrapped around the parent (big-hug)

  • DistractionRecognized 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 stimuliMoviesParty blowersNon procedural talkVirtual reality gogglesKaleidoscopesBubble blowingShort storiesMusic

  • DistractionA meta analysis showed that distraction decreased distress behavior but had minimal impact on self-reported pain. Most effective in children
  • Things to consider when choosing a distraction stimulusAge and cognitive maturity of the patientAge appropriate and engaging stimuliCost TimeSpaceChildrens natural coping tendencies and temperamentPatient preferences

  • Clinicians should routinely use distraction for pediatric immunizationsEase of useGrowing body of evidenceLack of negative consequences

  • Use of SucroseSucrose 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 anestheticsShould beSafeInexpensiveShould have rapid onsetShould have effect on vaccine immunogenicity

  • ExamplesEMLADecreases 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 VariablesInjection techniqueFor Intramuscular InjectionsHold skin tauntInject dart-like at 90Do 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 Pressure10 seconds of direct pressure at the injection site - reduction of immediate pain

  • Simultaneous injectionsNo decrease in discomfort, but parents preferred

  • ReferencesBeyea, 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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