Peadiatric Health Nursing

SKILLS BOOK

Year III, SEMESTER V

PREPARED BY: SUBIA NAZ

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 Index page

S.NO CONTENT PAGE #

01 Physical assessment 3-5
 Newborn assessment (A Review)
 Child head to toe assessment

02 Tub bath to an infant 6-8

03 Care of an infant in incubator 9-10

04 Care of an infant under phototherapy 11-13

05 Care of an infant / neonate receiving oxygen therapy 14-16

06 Oral/SC/ Rectal Intravenous Medication administration in children 17-21

07 Naso gastric and Oro gastric tube interventions 23-26

 N/G or O/G tube insertion
 N/G or O/G tube feeding and removal

08 Oro/naso- pharyngeal suctioning/ Tracheostomy suctioning 27-30

09 New born/ Infant CPR 31-35

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 SKILL # 01

Physical assessment  Newborn assessment (A Review)  Child head to toe assessment

1. Objective :

To establish a standard procedure for BScN students to perform skills and to know:
 Demonstrate the proper technique of baby assessment
 Verbalized the purpose of health assessment

2. Scope :
This procedure applies to nursing students for the Utilization of nursing knowledge
through the application of critical thinking, judgment and skill. It is stranded in the
principles of nursing education.

3. Purpose
 To perform an assessment of a newborn, using history, physical exam and routine
screening procedures
 To identify normal parameters assessment of: RR, HR, BP, temperature
 To recognize the physical findings seen in a sick infant: poor perfusion, lethargy,
hypotonic, cyanosis, plethora, poor feeding, weak cry,
4. Important Requirements :

 Tape Measure
 Digital Scale
 Examination Form
 Stethoscope for auscultation (listening) to the heart and lungs
 Small Mattress

5. Procedure :
S# Procedure Rationales U US
1. Before starting the exam, always wash your Prevent cross infection
Hands
2. Tell the mother that you will be examining the It will reduce the anxiety
baby and take the baby to the examination area level of the mother and
her involvement
3. General Appearance To identify any
Briefly describe baby’s appearance (hair, color, and abnormalities
posture)
4. Some of the measurements will be To observe Small for
recorded onto the gestation, Large for
‘Newborn examination sheet’, such as: gestation & Appropriate
 Date and time of examination for gestation
 Weight (grams)

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  Head Circumference (HC) (cm)
 Length (cm)
5. Assess the skin for discoloration, Texture, Turgor, To identify any
Pigmentation, jaundice and normal variations congenial skin
example rashes, Mongolian spots, birth marks, anomalies)
bruises, and petechiae.
6. Head to Toe Assessment
 Head Assessment (General appearance, Size, To identify any
Common Variations (Caput Succedaneum congenital abnormality/
and Cephalohematoma),Fontanels (Pulsation, anomaly
Bulging, Sunken), Hairs (Texture,
Distribution)
 Face (Symmetry, Spacing of features,
movement)
 Eyes (General placement. color, any tears,
pupils react to light, sub Conjunctival
hemorrhage)
 Nose (General appearance, Any sneezing,
Occlude one nostril, Coanal Atresia)
 Mouth (Symmetry, cleft palate, cleft lip,
Tongue)
 Ears (Position, symmetry pre-auricular skin
tag )

 Neck (appearance and mobility)

 Clavicles (appearance and size, expansion and
retraction, breast tissues, auscultate breath
sounds, breathing movement, RR )
 Heart (palpate, auscultate, any murmur, thrill,
HR)
 Abdomen (appearance, palpate)
 Umbilicus (protrusions and herniation,
number of vessels, auscultate bowel sounds,
voiding)
7. Genitals
Male: General appearance ,Penis (placement of To identify any
urinary meatus, scrotum, testis, congenital abnormality/
Female :General appearance, vaginal tag, discharge) anomaly

8. Buttocks (symmetry , pattern of stool, pilonidal To identify any

dimple,) congenital abnormality/
anomaly
9. Extremity and trunk

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 General appearance , symmetry, ROM, polydactyl, To identify any
syndactyly , simian crease, spine, hip, legs and feet) congenital abnormality/
anomaly
10. Reflexes (Moro, Rooting , Sucking, Palmer grasp, To observe the motor
Planter grasp, Stepping, Babinski, Tonic neck, Trunk responses
incurvation)
11. Activity ( cry (check for pitch) Weak cry indicate
abnormal brain
development
12. Sensory (vision, auditory, tactile, olfactory, To observe the sensory
gustatory) responses
13. Remember to properly wrap the baby after To regulate the body
the exam temperature and prevent
from hypothermia
14. Document all the findings according to the institution To report any alteration
policy and findings

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 SKILL # 02

Tub bath to an infant

1. Objective :

To establish a standard procedure for nursing students to be competent and confident in

the baby bath/tub bath of an infant.

 List equipment necessary for baby bath.

 Demonstrate setting up of equipment for baby bath.
 Discuss the purposes of giving tub bath.
 Understand and demonstrate care of equipment and an infant after the procedure.

2. Scope :
This procedure applies to nursing students for the Utilization of nursing knowledge through
the Application of critical thinking, judgment and skill. It is stranded in the principles of
nursing Education.
3. Purposes
• Understand the importance of checking of infant’s and water temperature before bath.
• Perform neonate / infant bath

4. Important Requirements :
 One tray (medium size),
 baby soap,
 2 gallipots,
 I kidney tray,
cotton balls,
 baby lotion.
 1 clinical thermometer,
 1 bath thermometer (if available),
 1 big towel,
 1 small towel,
 baby wrappers,
 baby clothes,
 distilled water,

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  baby bath tub,
 baby weighing scale,
 1 stethoscope, spirit s
 2 Bason
 Baby

5. Procedure :
S# Procedure S US

01. Assess the baby's general condition.

02. Explain the procedure to mother.
03. Check baby’s temperature. If below 97.6 F (Ax) don't give
Bath to infant.
04. Assemble the clothes, towels and other bathing supplies.
Wash hands. Make sure everything you need is with arm’s
Reach.
05 Close all the windows because the baby is extremely
Delicate and a draft could cause her/him to catch a chill.
Make sure the room is warm.
06 Undress the infant except the diaper and place the baby
(Preferably on a flat surface).
07 Wrap the infant in baby sheet / wrapper (mummy restrain).
Clean eyes with boil water (room temp). Clean eyes
From inner to outer can thus, using one stroke only
And discard it. Use a separate cotton ball for the
08 Other eye, clean nares and ears with wet cotton balls
Check water temperature with elbow or wrist or bath
thermometer.(use a water temperature of 100.4 degrees
09 Fahrenheit)
Wash the face with clean water without using any soap.
10 Wash and dry face with clean towel/cotton.
Hold the infant in a football hold, plug ears with thumb and
11 Fingers for safety.
12 Wash hair and dry it properly.
Unwrap and remove the diaper of the infant. Talk to your
infant in a soothing voice and tell her/him what’s going to
Happening while you’re removing the clothes.
Soap him/ her using both hands from top to bottom and back
and do not forget behind the ears, neck and under the arms—
13 all places where stuff can accumulate.
Clean the genitalia last and always wipe from front to back
to keep the bacteria from the bowel from spreading to the
Genital area. Dry your hands with corner of the towel (for
14 Safety.)
Immerse the infant in the tub and support the head and neck
15 With your arm. Put your hand in baby's axilla which is

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 Further away from you and rinse the soap off.
Remove infant from the tub and place on clean side of towel,
16 dry the infant immediately and gently pat dry.
Give cord care (if applicable). Apply lotion (if skin is dry)
and dress up the infant, keep diaper folded away from area
and wash hands prior to handling infant’s umbilical cord
17 area.
Store reusable items. Empty, rinse and dry wash basin.
18 Dispose soiled linen in the hamper bag.
19 Wash hand
20 Document response of baby

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 SKILL # 03

Care of an infant in incubator

1. Objective :

To establish a standard procedure for BScN students to perform skills and to know:

 Discuss the purposes and indications of keeping a neonate / infant an incubator.

 Demonstrate proper utilization of an incubator.

2. Scope :
This procedure applies to nursing students for the Utilization of nursing knowledge
through the application of critical thinking, judgment and skill. It is stranded in the
principles of nursing education.

3. Purposes
 To provide nursing care to a neonate / infant placed in an incubator.
 To provide save and warm environment to neonate.

4. Important Requirements :

 Incubator
 Incubator Sleeves
 Linen

5. Procedure :
S.No Procedure S UN
1. Ensure incubator has been disinfected and labeled with date and time.
(Incubator must have been disinfected within the last 7 days). For
detailed incubator cleaning
2. Wash hands before doing anything.
3. The incubator should always be pre-warmed before placing an infant
in it. The use of double-walled incubators significantly improves the
infant’s ability to maintain a desirable temperature and
4. Set the incubator temperature as follows according to
weight of the neonate:
Under 1000g 35 – 360C
1000 – 1500g 34 – 350C
1500 – 2000g 33 – 340C
2000 – 3000g 32 – 340C
Over 3000g 31 – 330C
Note: Modification in the ranges can be made according to Infant’s

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 requirement.
5. Lock dial at appropriate level.
6. Label incubator with date and time initiated.
7. Explain to the family.
8. Place infant in pre heated incubator.
9. Cover port holes completely.
10. Put mittens on infant according to infants’ condition.
11. Ensure that IV tubing’s, cardiac monitor wires and other wiring is
passed through appropriate holes located in hood of incubator.
12. Monitor infant’s temperature q 2-3 hrs / or according to the policy and
record incubator temperature simultaneously.
13. Notify physician if infant’s skin temperature is below or above 36 –
370C / 96.7 0F.
14. Dress and wrap infant warmly when taking out of incubator e.g. for
feed, I/V samples.
15. Plan all care at one time i.e.
vital signs ,changing, weighing ,feeding and position changing etc.
16. Place the infant with head side of incubator elevated.
17. Position q2 hourly with appropriate support.
18. Encourage parents to participate in care i.e. to touch, hold and feed
infant (as per hospital policy)
19. Clean incubator q 24hours with 70% alcohol solution. Wipe inside &
outside mattress and tray after removing the infant. Change incubator
sleeves at the same time
20. When incubator is to be discontinued ensure the following:
 Switch temperatures dial to off.
 infant temperature remains stable
 Wrap infant in blanket and shift to cot.
 Monitor infants temperature q2 hourly for 6 hrs and then
according to neonate’s condition
21. When incubator is changed / discontinued transfer the incubator to
designated place as soon as possible
22. Document the nursing care been provided.

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 SKILL # 04

Care of an infant under phototherapy

1. Objective :

To establish a standard procedure for BScN students to perform skills and to know:

 Review the path physiology of Hyperbilirubinemia

 Understand the phototherapy unit.
 Discuss the purpose of phototherapy.
 Demonstrate care of a neonate under phototherapy
2. Scope :
This procedure applies to nursing students for the Utilization of nursing knowledge
through the application of critical thinking, judgment and skill. It is stranded in the
principles of nursing education:

3. Purposes:
 To assess the need of the baby
 To cover the baby eye for further irritation
 To prevent from burn

4. Important Requirements :

 Phototherapy lamp (single or double)

 Eye pads / Green eye protectors
 Tape
 Baby cot/ warmer/ incubator

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5. Procedure :
S U
Care of a Neonate under Phototherapy S S

S.No Procedure s
Check doctor’s order for starting of phototherapy single or double
1. Assemble equipment
2. Make sure all tube lights are working.

3. Wash hands before handling infant.( medical asepsis)

4. Explain procedure to the family.

5. Undress infant completely, in order to have maximum

Exposure to light, which will help in decreasing the bilirubin level.
6. Cover infant's eyes with eye pads and secure firmly, Make
sure that eyes are closed properly because the cornea may
become excoriated if the dressing comes in contact with the
Dressing.
Asses eyes for the evidence of discharge, excessive pressure
On the eyelids or any corneal irritation.
Prevent any occlusion of the nares because infants are
obligatory nose breathers; blockage due to eye pads will
Produce apnea.
7. Set up the phototherapy light distance between the surface of
Lamps and the infant. It should not be less than 18 inches(46
cm)
If the neonate is in an incubator, place the phototherapy light
At least 3 inches (7.6 cm) above the incubator.
Lights closure to infant will cause the burn; light on far
Distant will not give any effect or benefit.
8. Infant should be placed in incubator, if kept in cot or bed
Then place the sheet over the light; To prevent hypothermia.
9. Change position of infant every 2 hours during therapy from
Supine to prone and side lying.
10. Do not apply petroleum jelly, lotion or oil to skin,
Oily skin is burnt easily with phototherapy light. Oily
products can absorb health and cause burn, as well as serves
As barrier to effective phototherapy.
11. Monitor body temperature every 2-4 hours. Heat from light
will produce dehydration, which will be manifested by
increase in temperature
12. During therapy observe skin condition for:
a. Dryness
b. Eruption of skin rashes
c. Alteration in color
d. Dehydration

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13. Monitor stool for frequency and consistency and give good
Skin care after each stool and voiding. Loose stools may
Indicate accelerated bilirubin removal.
14. Maintain intake and output record during therapy in order to
Monitor the hydration status.
15. Observe following signs of kernicterus: it is produced from
the injury to the brain cells due to excessive bilirubin in
Blood reaching to brain cells.
a. Poor feeding d. Apneic spells
b. Lethargy e. Irritability
c. High pitched cry f. Jitteriness or Seizures
16. Turn off the phototherapy unit before drawing blood sample,
direct exposure of blood to light will increase the
Isomerization of blood sample and will give the false result.
17. Ensure bilirubin results are obtained as prescribed or as per
Routine. Inform results to physician.
18. Encourage mother to handle and feed infant during
phototherapy to prevent dehydration and maintain the mother
infant bond, but discourage to much handling outside
Phototherapy.
19. Remove eye pads if the infant is being fed outside the
Incubator / cot.
20. Check eyes and then clean with normal saline, before replacing eye pads
In every shift to prevent eye infection.
Document the Following:
a. Feeding f Urinary Output
b. Condition of Skin g Intensity of Phototherapy
c. Body Temperature h Time that phototherapy is started or Stopped
d. Bilirubin Levels i. Number and consistency of Stool
e. Occurrence of Side effects

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 SKILL # 05

Care of an infant / neonate receiving oxygen therapy

1. Objective :

At the end of the session, students will be able to:

 Discuss briefly the physiology of respiration.

 Describe clinical signs of respiratory distress.

 Discuss purposes and indications of oxygen therapy.
 Demonstrate correct documentation and client’s response.

2. Scope :
This procedure applies to nursing students for the Utilization of nursing knowledge through the
application of critical thinking, judgment and skill. It is stranded in the principles of nursing
education

3. Purposes
 To assesses the client before and after therapy
 To prevent from respiratory distress
 To perform the procedure of giving oxygen therapy using different devices.

4. Important Requirements :

 Oxygen (cylinder or wall fixed) with flow meter.

 Humidifier with water.
 Oxygen device and tubing (Infant/child mask or nasal prongs)
 Gauze pieces, Torch, and Applicator.
5. Procedure :

SNO STEPS S US
1 Identify the client.

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2 Determine the need for oxygenation
3 Check Physician’s order.
4 Wash hands.
5 Collect equipment
6 Explain the procedure to the client/attendant and allow them to feel the
equipment.
7 Explain the safety measures to family members and follow them.
8 Assist the client to assume semi Fowler’s position or left lateral if
possible.
9 Assess nares for nasal discharge. Clean if required
10 Apply the appropriate oxygen delivery device as per physician’s order.
Documentation as per policy
Oxygen Tent / Mistent:
11 Select the appropriate tent that will achieve the desired concentration of
oxygen and maintain patient comfort.
12 Pad the metal frame that supports the tent.
13 Check the functioning of the device.
14 Place the client in the tent.
15 Analyze and record the tent atmosphere every 1-2 hours. Concentrations
of 30% -50% can be achieved in well-maintained tents.
16 Maintain a tight-fitting tent. Regularly provide organized nursing care
through the sleeves or pockets of the tent.
17 Documentation as per policy
Oxygen by Nasal Cannula or Nasal Prongs
18 Attach the connecting tube from the nasal cannula to the humidifier
outlet and check the tubing for kinks and leakage.
19 Place the tip of the cannula in client’s nose and adjust straps around ears.
20 Periodically inspect nares and skin behind ears.
21 Documentation as per policy
Oxygen by Mask:
22 Choose an appropriate mask that covers the mouth and nose but not the
eyes
23 Place the mask over the client’s mouth and nose. Secure the mask with a
elastic head grip. Do not allow the oxygen to blow in client eyes
24 Remove the oxygen mask at hourly intervals; wash the face and dry.
(According to client’s condition)
25 For comatose infants or children, use the masks with caution.
25 Documentation as per policy
OXY Hood

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26 Warmed, humidified oxygen is supplied through a plastic box that fits
over the child’s head
27 Oxygen should not be allowed to blow directly into the infant’s face
28 Continuously monitor the oxygen concentration, Temperature and
humidity inside the hood
29 Open the hood or remove the baby from it as infrequently as possible
30 Document the following findings Record in nurses’ notes. Child’s
respiratory status. Child’s response to oxygen therapy

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 SKILL # 06

Oral/SC/ Rectal Intravenous Medication administration in children

1. Objective :

 Demonstrate safety precautions in administering medications and follow

rights of medication.
 Demonstrate skin preparation technique

2. Scope :
This procedure applies to nursing students for the Utilization of nursing knowledge
through the application of critical thinking, judgment and skill. It is stranded in the
principles of nursing education.
3. Purposes
 Prepare medication using aseptic technique.
 Explain the side effects of each drug.
 Determine site of injection properly.

4. Important Requirements :
 Medication(Tab, Cap, Syp, aOint)
 Medication Administration record (MAR) sheet
 Physician order / Active Profile sheet
 Ampule of sterile medication.
 Filer (if ampoule is not scored).
 Small size gauze piece
 Sprit swabs.
 Needle and syringe of appropriate size
 Danger box.
 Kidney dish.
 Medication ticket.

5. Procedure :

SNO Steps S US
1 Check medication order and compare it with active profile sheet.
2 Prepare medication ticket follow the ten rights
3 Wash hands
4 Collect equipment
5 Select proper ampoule from bin (read label first time) and compare with
MAR sheet.
6 Check for expiry date and any changes in color, consistency etc.
7 Calculate the dosage.
8 Tap top of ampoule lightly with finger until fluid leaves neck.

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9 Partially file the neck of an ampoule (if necessary).
10 Wrap small gauze piece/ tissue paper around the neck of ampoule.
11 Snap neck of ampoule bending it towards you.
12 Clean tip of the ampule with alcohol swab, waiting for dry then Insert
syringe needle tip or shaft to touch rim of ampoule).
13 Draw medication into syringe by gently pulling back on plunger.
(Read label second time).
14 To expel excess air bubbles, remove needle from ampoule. Hold Syringe
with needle pointing up. Tap side of syringe to cause bubbles to rise
toward needle. Draw back slightly on plunger and then push the plunger
upward to eject air. Do not eject fluid.
15 If syringe contains excess fluid, use kidney dish. Hold syringe vertically
with needle tip up and slanted slightly towards kidney Dish. Slowly
eject excess fluid into the kidney. Recheck fluid level in syringe by
holding it vertically.
16 Cover needle with cap.
17 Change needle on syringe (if required)
18 Discard the ampoule and its top into sharp container. (Read label third
time before discarding).
19 Replace equipment and wash hands.
20 Document properly

Medication through IV chamber

6. Check Doctor’s Orders. Check both MAR sheet & Patient’s
7. Active profile.
8. Identify the patient.
Wash hands.
9. Prepare medication and normal saline using the ten rights of
Medication administration and aseptic technique.
10. Determine the patency of hep-lock. Assess for signs of Phlebitis.

. Clean hep-lock with spirit swab.

. Cannula must be flushed with normal saline before and after
the medication administration
Neonates – 0.5 – 1ml of normal saline
Children – 1 – 2 ml of normal saline

11. Fill burette with 10-50 cc of IV solution (as per child’s age and
Weight) and prime the tubing. Also, check compatibility of IV fluid
with the drug being administered.
NOTE: Administer medication within 60 minutes of preparation.
Also, ensure that IV solution used is compatible with the medication,
and flow rate is maintained according to the Physician order.

12. Clean port of burette and add medication

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13. Clean the hep-lock with spirit swab and insert needle through
Hep-lock / or open the hep-lock by applying pressure above the
cannula to prevent blood drop, remove the needle from the drip set
and directly attached to the cannula. Start I.V, secure tubing and
monitor flow rate.
14. Label the bag/ burette with date, time, name and dose of drug, and
15. your initials. Ensure that the medication finishes in the given time.
Flush tubing with 10 CC of IV fluid after completion of each I/V
medication. Flush cannula with 3-5 ml of normal saline after the
medication.
(Patients identification, concept of asepsis and protocols of
drug administration to be followed throughout whenever necessary
Note: All I/V medication administration set and burette should be
change in 72 hours
16. Document in the medication file.
17. Oral Medication
18. Check Doctor’s Orders. Check both MAR sheet & Patient’s
Active profile.
19. Identify hands
20. Wash hands
21. Prepare medication and normal saline using the ten rights of
Medication administration and aseptic technique.
22. Read the label to make certain you have the right drug and to check
the right amount of medicine to give the child. Shake the bottle well
to mix the medicine if the label says to do this.
23. Pour out the exact amount of the drug into the measuring spoon Or
Fill the syringe or dropper with the drug to the right amount. Read the
amount at the bottom of the semicircular line around the top of the
liquid.
24. Give the medicine to the child in a quiet place so that you will not be
disturbed.
25. Tell the child what you are going to do.
26. If needed, hold the infant or young child in your lap. Place her
Arm closest to you behind your back. Firmly hug her other arm
and hand with your arm and hand; snuggle her head between your
body and your arm. Sometimes you may also want to grasp her legs
between yours. Your other hand remains free to give the drug to the
child.
27. Allow the child to sip the drug from the spoon. If it is a large amount
of medicine, and the child can drink from a cup, you can measure the
drug into a small cup. Make sure that the child takes the entire drug.
You may have to add a small amount of water to rinse the drug from
the sides of the cup.
Or
Gently place the dropper or syringe in the child’s mouth along the
inside of the cheek. Allow the child to suck the liquid from dropper or
syringe. If the child does not suck, squeeze a small amount of the
drug at a time. This takes longer but the child will swallow the

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 medicine and be less likely to spit it out or choke on it. Place an
empty bottle nipple in the child’s mouth, add the drug to the nipple,
and allow the child to suck the nipple.
28. Rinse the child’s mouth with plain water to remove any of the
sweetened drugs from the gums and teeth. This can be done by
wrapping a paper towel around your finger, soaking it in plain
Water and then swabbing the gums, cheeks, plate, and tongue.
29. Return the drug to a safe place out of the child’s reach. Place it
In the refrigerator if the label says to do this.
30. Write down the time you gave the child the medicine and check
For the time you need to give the next dose.
31. Praise the child for helping. Documentation as per policy
32. Administration of Intradermal Medication
33. Explain to the patient / parent the reason of medication
Administration .Explain clearly that the drug absorbs very slowly
because it is injected just under the epidermis. This procedure leaves a
small weal under the skin. Use 1.0 ml syringe with a 25 gauge needle
34. Choose appropriate site for injection. Inspect skin surface for bruises,
inflammation and lessons.
NOTE: The inner surface of the forearm and the outer aspect of
the upper arm are the most common sites of injection
35. Assist client to comfortable position.
36. Clean site with an antiseptic swab in a firm circular motion.
37. Remove needle caps or sheath from needle by pulling it straight off.
38. Hold syringe between thumb and forefinger of dominant hand with
bevel of needle pointing up
39. With non-dominant hand, stretch skin over site with forefinger and
thumb.
40. With needle almost against client’s skin, insert it slowly at 5 to 15
degree angle until resistance is felt. Then advance needle though
epidermis to approximately 3 mm (1/8) inch below skin surface.
Needle tip can be seen through skin.
41. Inject medication slowly. Normally, resistance is felt. If not,
Needle is too deep; remove and begin again.
42. While injecting medication, notice that small bleb resembling
mosquito bite appears on skin’s surface Withdraw needle while
applying spirit swab very superficially over the site.
Do not massage site.
43. Encircle injection site 2.5 cm. In case of a test dose observe the
area after 15 minutes if redness develops around the area of injection,
reaction should be recorded and reported to the doctor. Write date,
time, and medication name and nurse initial. Read within 48 to 72
hours of injection.
44. Assist client to comfortable position.
45. Discard uncapped needle in danger box.
46. Wash hands and replace equipment.
47. Observe for any allergic reactions. If allergic reaction to a specific

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 drug is identified then put allergies label on the red folder. Inform
patient regarding the allergies.
48. Record in MAR sheet / medication
49. Subcutaneous Injection
50. Explain procedure to client

51. Choose injection site by assessing size and integrity of muscle. (One
that has not been used frequently).
52. Position the client appropriately for the site selected.
Rectus femoris/Vastus lateralis:
Client lying, on back, or sitting. The preferred site for infant is the
Vastus Lateralis
Ventro gluteal: patient lying on the back or side with the hip and
knee flexed. is relatively free of major nerves and blood vessels, large
muscles ,well defined land marks for safe site location makes it
preferred over the dorsal gluteal muscle and recommendation is that it
should not be used until the child is walking.
Dorso gluteal: patient lying prone or lateral with upper leg flexed at
knee and thigh. It is strongly recommended that children under 6
years of age do not receive injection in this site as the muscles are
very small, poorly developed and located close to sciatic nerve and
major blood supply
Deltoid: - Client sitting or lying flat with upper arm flexed. muscles
are very small and not well developed, so it is not used until the child
is 6 years of age.
Abdomen S/C only). Patient may be side lying or assume. A sitting
position
53. Clean the site with spirit swab in a firm circular motion.
54. Remove needles cap or sheath from needle by pulling it straight off.
55. Use non-dominant hand to stretch/pinch the skin (according to
patient’s body mass)
56. Hold syringe between thumb and forefingers of dominant hand and
insert needle at a 90angle
57. Slowly pull back on plunger to aspirate medication. If blood appears
in syringe, remove needle; dispose of medication and procedure. If no
blood appears, inject medication slowly.
Note:- some institution policies recommend not to aspirate
subcutaneous Heparin injection
58. Withdraw needle quickly while placing antiseptic swab gently above
or over injection.
59. Massage the site gently, using the spirit swab.
Note: Avoid massaging when contraindicated i.e. iron injection, anti-
coagulant, Insulin.
60. Check injection site for bleeding or bruising
61. Do not recap needle. Dispose the syringe and needle into the sharps
container

21
62. Assist patient to comfortable position
63. Record in MAR / Medication sheet
64. Assess client’s response to medication in 30 minutes
65. The Administration of Bronchodilator’s Via Nebulizer
66. Check the medication order and prepare medication as prescribed.
Explain the procedure to the patient.
67. Prepare the dose in the syringe and then instill it into the nebulizer
cup.
(For infants and children dosage should be as
follows:
0-1 yr: 1.25 mg = 0.25 ml + 1.75 ml N/S = 2.0
ml
1-5 yr: 2.50 mg = 0.50 ml + 1.50 ml N/S = 2.0
ml
5–12 yr:3.75 mg = 0.75 ml + 1.25 ml N/S = 2.0
ml
12 yr: 5 mg = 1 ml + 1.5 ml N/S = 2.5 ml).
68. With medication in place, carefully tighten the cup and put it on the
patient’s face in an upright position of the cup.
69. Attach the O2 tubing to the O2 flow and adjust the accordingly.
Children O2 = 4-6 L/min
DON’T USE HUMIDIFER with nebulizer.
Observe for the mist from the nebulizer.
70. When finished, discontinue oxygen immediately and remove the face
mask.. (if applicable) Encourage the patient to expectorate. Observe
and record the amount and color of sputum if any.
71. Leave the patient in a comfortable position and continue to observe
his breathing.
72. Wipe the nebulizer and face mask with a moist tissue and dry it. Keep
the mask in a disposable glove for further use.
73. Document:
Pre-finding: R/R, breath sounds. Therapy: Medication dosage, route,
duration of therapy.
Post finding: R/R, breath sound and child’s Response to therapy.

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 SKILL # 07

Naso gastric and Oro gastric tube interventions  N/G or O/G tube insertion  N/G or
O/G tube feeding and removal

1. Objectives :
By the end of these skills students will be able to
 Apply knowledge of A&P in identifying G.I organs and their
functions related to N.G tube insertion / feeding.
 Discuss briefly the factors influencing diet.
 Identify clinical signs of inadequate nutritional status.
 Perform the procedures.
 Discuss purposes of nasogastric tube insertion, feeding and
removal and gastrostomy 
 Identify different types of formula/supplemental available for 
feeding.
 Discuss purposes of feeding by gastrostomy tube.
 List few nursing diagnoses related to nutritional problems.
 Demonstrate correct documentation.

2. Scope :
This procedure applies to BScN students for the Utilization of nursing knowledge
through the application of critical thinking, judgment and skill. It is stranded in the
principles of nursing education.
3. Purposes:
 Perform assessment of nutritional status before performing feeding.
 Perform the procedures confidently.

4. Important Requirements :

 Tray, (NG tube size 5-12 in children Syringe 5-30cc)

 hypo allergic tape
 Scissors
 Stethoscope
 Bath towel
 wrapper for restraining child
 torch

 Spigot
 clean gloves

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  Lubricant (K-Y jelly or distilled water).
 Prescribed feed / formula
 Nurse’s notes form.
 Fluid balance sheet.

5. Procedure :

S. No. Insertion of nasogastric (NG) tube & Naso/oro Gastric. S US

1. Check doctor’s order for N.G tube insertion.

2. Explain procedure to the client/family
Assess:
Nostrils for patency /obstruction / bleeding etc.
(Note especially history of nasal surgery or deviated septum).
- Abdomen for distension, cramps, and bowel sounds.
- Level of consciousness.
- Presence of gag reflex.
3. - Ability to cope with the procedure
4. Collect equipment.
5. Cut one strip of tape or as required.
6. Wash hands and put on clean gloves.
Place the client in appropriate position:
7. Child: supine with rolled towel under head and neck.
8. Place the towel across the chest.
Measure the tube for approximate length of insertion and mark the
point with a small tape. Measure from the tip of the nose to the earlobe
and to the point midway between the xiphoid process and umbilicus.
9. (Same as for the oro-gastric insertion )
10. Lubricate 1—2 inches of the tube with distilled water / Ky jelly.
Insert the tube into either of nostril with its natural curve towards the
child Ask the client to hyperextend the neck, and gently advance the
11. tube towards the nasopharynx.
If the tube meets resistance, withdraw it, re-lubricate it and insert it in
12. another nostril.
If the client gags, stop passing the tube for a moment, have the client
rest, and take few breaths (if applicable) to calm the gag reflex. While
13. passing the tube check mouth for coiling of tube.
14. Confirm the placement of the tube by:
* Deliver a bolus of air. (0.5-1ml in premature or small infants, 5ml in
older children) through a syringe while listening over stomach for
gurgle and burp. Aspirate air after confirming position.
* Aspirating stomach contents.
15. Secure tube to the upper lip and cheek.
16. Document:
Date and time of insertion / change of the tube, in nurse’s notes and on
the tube as well.
Size of the tube.
17. Client’s response to procedure.

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 Type and amount of aspirated content.
HUB measurement of the outer side of the tube from nostril to the
end of tube.(Indelible mark)

18. Provide Nasogastric tube care daily.

Inspect the nostril for discharge and Irritation.
Clean the nostril and the tube with moistened cotton.
Apply water-soluble lubricant to the nostril, if it is dry or encrusted.
Change the adhesive tape as required.
Give frequent mouth care.

N.G TUBE FEEDING

19. Check the doctor orders
20. Explain procedure to the client / family.
21. Assess the client for:
22. abdominal distension, feeling of fullness,
belching, loose stools, flatus, pain, bowel
Sounds and allergy to food.
23. Gather equipment.
24. Wash hands.
25. Place the client in fowler’s position for the feeding
26. Confirm the placement of the tube by:
* Inject the air into the tube and listen for a "poop" sound. This
Sound will tell you the tube is in the right place. Withdraw the air
You injected to check for placement. If you do not hear this sound,
Remove the tube and repeat the step. (0.5-1ml in premature or small
infants, 5ml in older children) through a syringe while
Listening over stomach for gurgle and burp.
* Aspirating stomach contents.
27. Aspirate all the residual stomach content, measure the amount, and
Check about reinstalling.
28. Test the temperature of the formula by dropping a few drops on the
Inside of your wrist. It should feel warm, not hot.
Or let the formula warm to room temperature, check the expiry date
And administer the feed.
29. Hold your child in fowler’s position while feeding. You may give
Your child a pacifier to suck on during feedings. (This way your
baby will continue to learn feeding skills and will connect the
Sucking with the feeling of being full.)
30. You may need to push gently with the plunger to start the formula
Flowing. Release the tube and let the formula enter the stomach
Slowly. Keep adding more formula as the syringe empties (Picture
3, page 3). Feed your child slowly over 15 to 20 minutes.

31. Flush the tube after feeding with (1-2ml of air / H2O in infant).
Adult (40-60ml) of water in adults.
Pinch the tube before the syringe gets emptied to prevent

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 Introduction of excessive air into the stomach.
32. Clamp the feeding tube before all the water is instilled
33. Instruct the client to remain in fowlers’ or slightly elevated or right
Lateral position for at least 30 minutes.

34. Document: date and time of feeding. type and amount of feeding,
Amount of water used for flushing tube.
- Child’s response to feeding (regurgitation, feeling fullness

N.G Removal Checklist

S US
S.# Procedure

01. Check doctor’s order.

02. Explain procedure to client / family.
03. Collect equipment.
04. Wash hands.
05. Put on clean / disposable gloves.
06. Loosen the tape that is holding the tube.
- disconnect the tube from the suction if it is
Applied.
07. Clamp the tube before removal.
08. Asks the client to take a deep breath and hold it for a second (in
Older children).
09. Pull the tube out quickly and smoothly.
10. Dispose the tube and equipment appropriately.
11. Hold, cuddle and burp the child or provide reassurance in older
Child and adult patient.
12. Document the removal of the tube, with date and time, amount
And appearance of drainage in nursing notes.

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 SKILL # 08

Oro/naso- pharyngeal suctioning/ Tracheostomy suctioning

1. Objective :
At the end of the session, students will be able to:
 Discuss briefly the physiology of respiration.
 Describe clinical signs of hypoxia.
 Explain oropharygeal and nasopharyngeal and tracheal suctioning.
 Discuss purposes and indications of suctioning.
 Demonstrate correct documentation: amount, color, consistency, and odor of
secretions and client’s response.

2. Scope :
This procedure applies to BScN students for the Utilization of nursing knowledge through
the application of critical thinking, judgment and skill. It is stranded in the principles of
nursing education

3. Purposes
 Assess client’s respiratory status before and after suctioning.
 Maintain asepsis throughout the procedure.
 Perform the procedure of suctioning

4. Important Requirements :
 Oxygen & Suction apparatus,
 Ambu bag,
 Tray,
 Suction catheter: Fr, 5,6,.8, 10 for infant/children.
 T. Connector,
 Sterile water,
 Normal saline 0.9%,
 Syringe (5cc or 10cc),
 Sterile gallipot/sterile container,
 Clean gloves for oro-nasopharyngeal suctioning, and sterile gloves for tracheotomy
suctioning,
 Towel/tissue,
 Mucous extractor – for specimen collection

5. Procedure

SNO Steps S US
1. Assess clients :
 R/R, depth, rhythm, breath sounds.

27
  Ability to swallow and cough (if applicable).
 Oxygen saturation.
 Mouth and nostrils for crusting, ulcers and/debris. (Use torch
and tongue depressor, if necessary).
Treatment.
 Saline nebulizer
 Bronchodilators
 Chest Physiotherapy
 Postural drainage.
Asses the need for suctioning since it can be hazardous
and cause discomfort, it is not recommended in the
absence of apparent need i.e coughing, increased
respiration, excessive secretions through mouth and
nose
2 Explain procedure to the client/family
3 Attach suction apparatus to appropriate unit and check function of
suction machine.
4 Gather equipment.
5 Check that suction pressure is not above 10-15 KPA for infants and
children
6 Make appropriate position:
In conscious client semi fowlers
For unconscious client side lying.
Nasal/tracheotomy hyper extended neck Position.
7 Place towel/tissue on client’s chest.
8 Set up the galipot and pour distilled water/boil water at
Room temperature, aseptically.
9 Wash hands.
10 Put on gloves aseptically on dominant hand
11 Hyper oxygenate client by increasing/giving up to 100% before
suctioning, if not contraindicated.
12 Open the wrapper of catheter from distal end and attach it with
suction unit.
13 Un wrap catheter without touching it to any non-sterile surfaces. Use
dominant/gloved hand to hold the catheter.
14 Measure the tube for distance of insertion. (From tip of the nose to
the ear lobe).
15 Lubricate with distilled water/boil water at room temperature and
check for the patency of the catheter and also check for the pressure
of suction machine

28
16 Insert the catheter in one nostril without applying suction up to the
measured mark distance
17 If one nostril is obstructed, try the other one.
*Never force the catheter against an obstruction
Never apply suction during insertion of catheter
18 Apply intermittent suction for not more than 5 seconds. Rotate and
twist the catheter as you remove it. The total time for suctioning
should not exceed more than 15 seconds. Application of suction
pressure upon insertion increase hypoxia and results in damage to th
nasal mucosa.
19 Look at the mucus for COCA (color, odor, characteristic and
amount). Rinse the catheter in boil water by applying suction and
then repeat for the other nostril.
20 Monitor child’s cardiopulmonary status during and between suction
passes, observe for signs of hypoxemia; dysrhythmias, cyanosis,
anxiety and changes in mental status
21 Use the same catheter for oral suctioning. Insert the catheter the
client’s mouth along one side, until it reaches the back of the throat,
without applying suction.
22 Apply suction for 5 seconds. Rotate and twist the catheter when
removing it.
23 Discard the catheter and save it according to hospital policy
24 Make sure the patient receives O2 during and after procedure too.
Readjust the O2 after few minutes/when client's conditions stabilize
according to doctor’s order.
25 Document in nursing notes, date, time, client’s response,
(Breath sounds, RR, O2 saturation and skin color) secretion obtained
(COCA) and condition of nose and mouth.

TRACHEOSTOMY SUCTIONING
26 Follow the step 1-10
27 Hyper ventilate/oxygenate client before suctioning, if not
contraindicated
-Increase O2 flow rate to 10 liter/min
-Attach ambo bag on the tracheal opening and give 5 breaths.
-If copious amount of secretions are present,
First do the suctioning and then hyperventilate (can be best done by
other Nurse).
28 Open the wrapper of catheter from distal end and attach it with
Suction unit.
29 Lubricate and check for the patency of the catheter in sterile water
And also check for the pressure of suction machine.

29
30 If secretions are thick, instill normal saline 0.9%. 0.5 ml for infants.
(1-2ml for toddler, 2-3rd for older children.)
Be sure to remove needle from the syringe.
31 Gently insert catheter after lubricating the tip of catheter into
Tracheal stoma, about 2-3 inches for infant and child.
-Pull back 1 cm when resistance is met without applying suction.
Catheter is now in the tracheobronchial tree.
Application of suction pressure upon insertion increases hypoxia
And results in damage to the tracheal mucosa.
32 Apply suction for not more than 5 seconds. Rotate and twist the
Catheter as you removes it.
33 Look at the mucus for color, consistency or any other changes
(COCA).
34 Rinse the catheter in sterile water by applying suction.
35 Observe the client’s respiration and skin color between each
suctioning and allow him to rest for 2-3 minutes, Reduce incidence
of hypoxia and atelectasis.
36 Ensure that entire procedure does not exceed 5 minutes duration,
as prolong suctioning can decrease the clients' oxygen level and
Cause distress.
37 Re-apply supplementary oxygen as required during and after
Suctioning.
-Increase O2 flow rate to 10 liters/min.
-Attach ambo bag on the tracheal opening, and give 5 breaths.
38 Discard catheter after suctioning (check hospital policy).
-Use same catheter if required, to do naso-oral suctioning and
Discard after use.
39 Reposition the child. support ventilator effort; promote comfort;
communicates caring attitude
40 Document in nursing notes: Condition of the tracheotomy site,
Date, time, client’s response, and secretions obtained (COCA).
Watch for the potential complications:
Hypoxia ,Atelectasis, Dysrhymias,mucosal trauma with increased
secretions, cardiac arrest

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 SKILL # 09

New born/ Infant CPR

Objective:

To establish a standard procedure for BScN students to perform skills and to know:
 Identify the newborn to acquire CPR
 Demonstrate correct technique
 Demonstrate pertinent behavior key behavior skills to optimize team performance

1. Scope :
This procedure applies to nursing students for the Utilization of nursing knowledge
through the application of critical thinking, judgment and skill. It is stranded in the
principles of nursing education.
2. Purpose
 To prevent any delay in care
 To maintain airway
3. Important Requirements :

 Radiant warmer
 Crash cart trolley
 Intubation trolley
 ABG machine
 Ventilator machine
 Sterile/Latex gloves
 Suctioning machine
 pulse oximetry
 Cardiac monitor
 Gauze piece
 Cotton swabs
 Warm cloth
 CPR form
 Re-breathing bag

31
4. Procedure :
S# Procedure Rationales S US
1. Wash hands and ensure the area is safe To prevent cross infection
and injury
2. Assess infant/child responsiveness gently To ensure consciousness and
stimulate infant/child. Ask child loudly “Are you ensure child response to
alright?” stimuli
3. If child responds by stimulating or answering or To provide care accordingly
moving and to ensure condition
 Leave them in recovery position.
 Check their condition and get help if
needed
 Reassess the situation continuously
4. If child doesn’t responds To provide care accordingly
 Shout for help and to ensure condition
 Carefully turn the child on their back
5. If child is under 1 year old To prevent soft tissue injury
Ensure the head is in neutral position, with head and airway blockage
and neck in line and not tilted
6. If the child is 1 year or above To prevent soft tissue injury
 Open child’s airway by head tilt chin lift and airway blockage
technique
 To do this place your hand on their
forehead and gently tilt their head back
7. Check breathing for rate, rhythm and depth Look listen and feel helps to
 Keeping the airway open look listen and decide normal breathing
feel for normal breathing sound by pattern
putting your face close to the child’s face
and looking along their chest
 Looking for chest movement
 Listen breath sounds
 Listen at the child’s nose and mouth for
breathing sounds
 Feel for air movement on your cheeks
8. a) If child breathing normally It will ensure normal
 turn them on their side breathing pattern and child
 Check for continue breathing send or go safety
for help
 Don’t leave the child alone
b) If child is not breathing or breathing
infrequently or irregularly
 Carefully remove any obvious

32
 obstruction in the mouth
 Give 5 initial rescue breaths (mouth to
mouth resuscitation)
 While doing this , note any gag or cough
response- see the signs of recovery
9. a) Rescue breaths for the baby under 1 year It will ensure effective
 Ensure the head is in neutral position and breathing pattern
lift the chin
 Take a breath then cover baby’s mouth
and nose with your mouth, making sure
it’s sealed.
 Check for chest rise and fall
 Repeat the procedure as needed
b) Rescue breaths for baby above 1 year
 Head tilt chin lift
 Close the soft part of their nose using the
index finger and thumb of the hand that’s
on their forehead.
 Open their mouth a little but the keep the
chin pointing upward
 Take a breath then place your lip around
their mouth, making sure it’s sealed.
 Blow a breath steadily into their mouth
over about 1 second, watch for chest rise
and fall
 Repeat the procedure as needed
10. Obstructed airway To ensure effective breathing
pattern
If the child is having difficulty achieving
effective breathing, the airway may be
obstructed.
Open the child's mouth and remove any visible
obstruction. Don't poke your fingers or any
object blindly into the mouth.

 Ensure there's adequate head tilt and chin

lift, but the neck isn't overextended.
 Make up to five attempts to achieve
effective breaths (enough to make the
chest visibly rise). If this is still
unsuccessful, move on to chest
compressions combined with rescue
breaths.

33
11. Assess the circulation (signs of life) To establish proper breathing
cycle
Look for signs of life. These include any
movement, coughing, or normal breathing – not
abnormal gasps or infrequent, irregular breaths.

Signs of life present

If there are definite signs of life:

 Continue rescue breathing until the child

begins to breathe normally.
 Turn the child on their side into the
recovery position and send for help.

Continue to check for normal breathing and

provide further rescue breaths if necessary

No signs of life present

If there are no signs of life:

 Start chest compressions immediately.

 Combine chest compressions with rescue
breaths, providing two breaths after every
30 compressions.

12. Chest compressions: general guidance To prevent any rib injury and
ensure establishing proper
 To avoid compressing the stomach, find breathing cycle.
the point where the lowest ribs join in the
middle, and then one finger's width
above that. Compress the breastbone.
 Push down 4cm (for a baby or infant) or
5cm (a child), which is approximately
one-third of the chest diameter.
 Release the pressure, then rapidly repeat
at a rate of about 100-120 compressions
a minute.
 After 30 compressions, tilt the head, lift
the chin, and give two effective breaths.
 Continue compressions and breaths in a
ratio of two breaths for every 30
compressions.

Although the rate of compressions will be 100-

120 a minute, the actual number delivered will

34
 be fewer because of the pauses to give breaths.

a) Chest compression in babies less than The quality (depth) of chest

one year compressions is very
important. If the depth of
 Do the compressions on the breastbone 4cm cannot be achieved with
with the tips of two fingers, not the the tips of two fingers, use
whole hand or with two hands. the heel of one hand.

b) Chest compression in children over The quality (depth) of chest

one year compressions is very
important.
 Place the heel of one hand over the lower
third of the breastbone, as described
above.
 Lift the fingers to ensure pressure is not
applied over the ribs.
 Position yourself vertically above the
chest and, with your arm straight,
compress the breastbone so you push it
down 5cm, which is approximately one-
third of the chest diameter.
 In larger children or if you're small, this
may be done more easily by using both
hands with the fingers interlocked,
avoiding pressure on the ribs.

If nobody responded to your shout for help at the

beginning and you're alone, continue
resuscitation for about one minute before trying
to get help.
13. Continue resuscitation until To ensure establishing proper
breathing cycle.
Your child shows signs of life – normal

breathing, coughing, and movement of
arms or legs.
 Further qualified help arrives.
 You become exhausted.
14. Document all findings To maintain the report

References:
 Ball J, Bindler R, Cowen K & Shaw M. (2017). Pediatric Nursing Caring for Children. Julie Lavin
Alexender.USA.
 Wong, D.L. (2015). Whaley and Wong’s nursing care of infants and children, St. Louis: Mosby.

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