In this section
Note: This guideline is currently under review.
Definition of terms
Who to contact?
Before, during and after considerations
Paediatric patients in hospital may experience many different medical procedures (i.e. having observations conducted, blood taking etc). It is our responsibility as healthcare professionals to ensure that every step is taken to protect children from unnecessary healthcare-induced trauma and
distress, especially those who will be needing ongoing care . The goal of procedural management at RCH is to minimise anxiety associated with these procedures, particularly in light of potential future procedures (See Figure 1). Planning for procedures is essential for ensuring
that the patient’s experience with procedures is a positive one, as poorly managed procedural distress and pain can have long-term negative effects on children and young people . This is best achieved through a multimodal approach incorporating pharmacological and non-pharmacological approaches to reduce
distress and improve patient coping with procedures .
The aim of this guideline is to provide guidance as well as adequately prepare clinical staff with the knowledge and effective interventions to support the management of procedure-related distress for children and young people receiving health care.
Assent: the act of agreeing to or approving of something post thoughtful consideration. This is given by someone who is not of the age to give legal consent
Behaviour Support Profile (BSP): the behavioural support profile is a documentation tool for the non-medical needs of our patients, including their communication preferences/abilities, sensory needs, behaviours of concerns and triggers to name a few. It can be used for any patient with any diagnosis, but is aimed for patients with communication difficulties, behaviours of concern or severe anxiety. For more info click here https://www.rch.org.au/emr-project/learning-resources/Behaviour_Support_Profile/
Consent: to give assent or approval given by someone of legal age or considered a mature minor
Procedural Support: Procedural support is a process of preparing and coaching patients and their families before, during and after medical procedures to promote positive coping skills during any interventions
Procedural Support Plan (PSP): the procedural support plan documents a patient’s preferences for procedures. A general plan can be completed for all procedures, or individual plans for specific procedures can be created. Please refer to the following - Pain / Procedural Support Plan EPIC
Procedural Support Team: A multidisciplinary health professional team working in conjunction with the child’s caregivers form the basis of a procedural support team. The aim of the procedural support team is to promote coping and mastery of medical procedures for the child receiving healthcare.
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ED until 8pm M,T, TH
A guide to conducing a procedure on a paediatric patient.
3. Assess procedural experience
5. Prepare the child
referrals to Child Life Therapy, Comfort Kids and Comfort First can be
generated through Nursing Admission navigator on EMR in the wellbeing screening
section. Please refer to the following - https://www.rch.org.au/emr-project/learning-resources/Nursing_Admission/
with additional needs
13. Pharmacological strategies
should not be viewed as a last resort and the patient should not be seen to
have failed because they need sedation. However sedation is not an alternative
to non-pharmacological techniques. They are used in conjunction. Sedation
should be considered if :
Refer to the procedure on procedural
sedation in ambulatory areas for further information -http://www.rch.org.au /policy/policies/
Procedural _sedation_%E2%80%93 _ward_and _ambulatory_areas_%E2%80%93_at_RCH/
Distraction can provide
patients with a positive alternative focus which can help to reduce perceptions
of pain during an intervention . Distraction should be engaging,
interactive and suit the developmental level of the patient. Distraction is
best done by one person in the room to help create a calm environment.
breathing techniques can be used as a coping strategy to help a patient
regulate their anxiety and perceptions of pain during an intervention [12, 13].
the supply of oxygen to the brain can reduce the sympathetic nervous system
response (fight or flight) and help to calm anxiety by activating the
parasympathetic nervous system (relaxation and calm) .
These techniques will be more effective if the patient has had time to
briefly practice these ideas before the intervention
imagery can be used and taught to patients to help them deal with a painful or
anxiety provoking situation . Guided imagery involves drawing a picture of
a place in the patient’s mind that relaxes them. Guided imagery may be
elaborate or a simple visualisation.
These techniques will be more
effective if the patient has had time to practise these ideas before the intervention.
Procedures and the medical
environments in which they occur can be frightening for paediatric patients. A
quiet and low stimulus room will reduce the potential for the patient to become
The treatment room is recommended for
procedures to help maintain the patient’s bed and room as a safe space. This is
especially true for infants and toddlers who might otherwise begin to perceive
a threat every time a staff member enters their room.
The use of
age-appropriate and positive language when supporting patients is integral in
aiding coping and cooperation. Communication that creates negative expectations
of the procedure will increase reported levels of pain .
Assigning the patient a role can help a patient feel in control
and helps them build a sense of mastery. Give the patient controlled
choices to help engage them as active participants in their medical treatment
. For example:
Some patients may want a very simple step by step explanation about what is happening during the procedure. Asking a patient if they want to know what is happening or if they prefer to look at something else can help to give the patient control of how they might want to be involved in the procedure.
Visual schedules are a set of pictures which show the steps of an activity or intervention. They can help break an intervention down into smaller achievable stages that the patient can see themselves progressing through, which may otherwise seem overwhelming and difficult to begin . Visual schedules are frequently used with patients with Autism Spectrum Disorder and developmental disabilities, but they may also be useful with many other children or CALD patients.
Visual schedules could be used for many different interventions including nursing observations or IV access.
RCH Child Life Therapy have a license to use Boardmaker software to create visual schedules for common procedures
Buzzy is a vibration device that can help to dull or eliminate the pain by confusing the body’s nerves and distracting away from a painful stimulus . Buzzy is recommended to be used in combination with an ice pack if the patient can tolerate the cold sensation (Buzzy® Device PowerPoint Presentation).
Buzzy is best introduced to the patient prior to the intervention to see if the patient will tolerate the strong vibration sensation. Ice packs may also be used without Buzzy if a child prefers for interventions such as immunisations or injections if the patient has found this to be helpful.
Breastfeeding is preferable when available as parent contact, especially skin to skin provides comfort. Sucrose is safe and effective at reducing pain during procedures, such as heal lance. Although most effective in neonates less than 28 days, the RCH recommends use for infants up to 18 months. Sucrose is most effective when used in combination of supportive measures, such as swaddling and containment (refer to sucrose guideline). Although EBM is not as effective at reducing pain when compared to sucrose or breastfeeding, it can be considered as an alternative intervention.
Procedural holding or ‘Positioning for comfort’ promotes the use of upright positioning and close contact to the parent/guardian. Positioning for comfort facilitates safe access to the part of the body required for the medical procedure without removing the child’s right to freedom of movement. Swaddling and facilitated tucking for young infants (0-3 months) may provide comfort . For infants older than 3 months more upright positioning and close contact with parent/carer is recommended.Sitting upright during a procedure has been demonstrated to reduce fear and distress during medical procedures  and enhances the patient’s sense of control over the medical procedure. The patient can engage in distraction, monitor the progress of the procedure or look away.
Children’s memories of painful experiences are strong
predictors of subsequent reports of pain intensity . Therefore it is
integral that any medical procedure
is ended in a positive manner for the patient by:
The evidence table for this procedure management nursing guideline can be accessed here.
Please remember to read the disclaimer.
The development of this nursing guideline was coordinated by Charmaine Cini, CSN, Koala Wards, and approved by the Nursing Clinical Effectiveness Committee. Updated December 2020.