• Select and clean a workspace surface (eg, tabletop).
• Gather the necessary equipment.
• Open the packages (swabs, syringes, needles, filter needles, tubing) without touching the inner contents so that they remain clean.
• Check that the new tubing is not damaged.
• Check that the protective cover (often blue) is present over the cassette.

This step ensures safety and allows the subsequent procedure.

• Remove the bag from its black envelope.
• Check on the label that:
  • your child’s name appears,
  • the date of the solution has not expired,
  • the composition of the solution, the amount and duration of administration are the same as those prescribed for your child.
• Inspect the bag thoroughly. It should not leak. If particles are visible in the bag or there are more air bubbles than usual, put the bag aside and contact your pharmacy or healthcare team; repeat the check with a new bag.
• Check if the solution in the upper chamber of the bag (fat) is milky white and well blended. There should be no trace of fat droplets.
• Check if the solution in the lower chamber of the bag (amino acids) is transparent. It generally has a consistency of egg white but it can vary according to the different additions made by the pharmacist.
• Check that there are no small particles (precipitates or crystals) in the two chambers of the bag; a few bubbles may be apparent.
• From one bag to another, the solution should always have the same color and consistency (unless the prescription has been changed). Notify your pharmacy or healthcare team if this is not the case.
• Do not give solution if bag has been frozen.

This step ensures the safety of the procedure.

Check on the labels on the box or the bag to verify that:

• your child’s name appears,
• the date of the solution has not expired (this information is also written on each vial and on each ampoule),
• the name of each additive and the dose are the same as those prescribed for your child.

This step ensures the safety of the procedure.

• If syringes and needles are separated: without touching the syringe tip, screw the needle (with the protective cap still on) into it by turning clockwise about ¼ turn.
• If you need to remove an additive from an ampoule, use the same procedure but with a filter needle.
• Prepare the required number of syringes, one per each additive.
• Keep the protective caps on the needles.

This step allows the rest of the procedure.

If you do not have an additive to add from a vial, go to step 8.

• Remove the protective cap from each additive vial.
• Use a disinfectant swab to vigorously scrub the septum (rubber cap) of each vial. Use a new swab for each vial.
• Let the rubber cap dry completely.
• Do not blow on the cleaned cap of the vials.
• Make sure that nothing touches the cap in order to avoid contamination.

The rubber cap of the vial is not sterile. Disinfection is necessary to prevent bacteria or particles from entering the additive.

• Place the vial on the table.
• Remove the protective cap from the needle of a syringe.
• Pull the plunger of the syringe back to aspirate an amount of air equal to the amount of liquid to be drawn out of the vial.
• Hold the syringe like a pencil with one hand and hold the vial on the table with your other hand.
• Push the needle through the center of the rubber cap of the vial with the needle of the syringe held at a 45⁰ angle and with the bevel of the needle (open part of the needle at the tip) pointing upwards.

• Straighten the needle quickly to a 90⁰angle.

• Push the air contained in the syringe into the vial by pushing on the plunger of the syringe.
• Holding the tip of the needle in the solution, turn the vial upside down and upright. Make sure the tip of the needle remains in the solution.
• Withdraw the amount of additive required.
• Remove the needle from the vial.

This way of piercing the vial reduces the possibility that small pieces of rubber will fall into the solution in the vial.

• Hold the syringe vertically with the needle up.
• Pull the plunger of the syringe down slightly so that all of the liquid in the needle collects in the syringe.
• Tap the side of the syringe vigorously with your thumb and forefinger so that the air bubbles rise to the top.
• Gently press the plunger of the syringe to release the bubbles.
• Push gently on the plunger of they syringe until there is no air in the syringe and a drop of liquid appears on the tip of the needle.
• Withdraw solution again from the vial if necessary until the quantity in the syringe is correct.
• Replace the protective cap securely on the needle of the syringe.
• Place the prepared syringe in front of the vial.

Additive to be taken from another vial: repeat steps 6 and 7 with a new syringe and a new needle.

Additive to be taken from an ampoule: go to the next step.

No other additives needed: go to step 13.

This step is necessary to remove excess air from the syringe.

Placing the prepared syringe in front of the vial makes it possible to keep track of each syringe and know which additive is in each one.

If you do not have an additive to add from a ampoule, go to step 13.

• Holding the ampoule upright, gently move it in a circular motion on the table top surface so that any liquid in the top of the ampoule collects in the lower portion.
• Using a disinfectant swab, thoroughly clean the narrow portion of the ampoule (neck) including the breakout level which is where the ampoule is designed to break open. Keep the empty envelope of the disinfectant swab for the next step. Let the ampoule dry completely.

Disinfection is necessary to prevent bacteria or particles on the ampoule neck from entering the additive solution.

• Using the inside of the empty envelope which previously contained the disinfectant swab, hold the top of the ampoule and break the neck of the ampoule at the breakout level by pointing it away from you.
• Throw the top of the ampoule into the sharps container.

This prevents you from cutting yourself accidentally and prevents small pieces of glass from injuring your eyes.

• Remove the protective cap from the filter needle of a syringe, taking care not to touch the needle tip.
• Hold the ampoule with one hand flat on the table.
• Insert the tip of the filter needle into the ampoule
• Keeping the bevel (open portion of the needle tip) inside the centre of the ampoule, pull back on the plunger of the syringe to withdraw the additive into the syringe. Make sure that you have withdrawn all of the contents of the ampoule.
• Once all of the additive has been withdrawn from the ampoule, remove the needle from the ampoule.
• Replace the protective cap securely on the filter needle of the syringe.

When the ampoule is broken open, small particles of glass may fall into the additive solution. The use of the special filter needle ensures that no glass particles enter the syringe.

• Pull the plunger of the syringe down slightly so that all of the liquid in the filter needle collects in the syringe.
• Unscrew the needle from the syringe by turning it counterclockwise.
• Dispose of it in the sharps container.
• Without touching the tip, screw a new needle onto the syringe by turning clockwise about ¼ turn.

The filter needle may contain glass particles so must be discarded and exchanged for a clean regular needle in preparation for injection of the additive to the parenteral nutrition bag.

• Hold the syringe vertically with the needle up.
• Tap the side of the syringe vigorously with your thumb and forefinger so that the air bubbles rise to the top.
• Gently press the plunger of the syringe to release the bubbles.
• Push gently on the plunger of the syringe until there is no air in the syringe and a drop of liquid appears on the tip of the needle.
• Continue to push gently on the plunger of the syringe until the correct amount of the additive remains in the syringe.
• Place the prepared syringe in front of the ampoule.

Additive to be taken from another ampoule: repeat steps 9 to 12 with a new syringe and a new filter needle.

This step is necessary for the to avoid the injection of air and to prepare the correct amount of additive safely.

By keeping the prepared syringe in front of the ampoule in question, you can keep track of which additive is in each syringe.

• Use a disinfectant swab to vigorously scrub the injection port of the lower chamber of the parenteral nutrition bag.
• Let it dry completely.
• Make sure that nothing touches the injection port to avoid contamination.

Disinfection is necessary to prevent bacteria or particles present on the injection site of the bag from entering the bag during injection of the additives.

• Place the bag flat on the table.
• Remove the protective cap from the needle of the syringe.
• Insert the entire needle into the centre of the bag injection port carefully.
• Inject the additive by pushing on the plunger of the syringe.
• Remove the needle from the injection port.
• Replace the protective cap securely on the needle of the syringe.
• Unscrew the needle from the syringe by turning it counterclockwise and place it in the sharps container.
• Repeat steps 13 and 14 for each additive syringe to be injected into the bag.
• Throw all used needles and ampoule bulbs into the sharps container.
• Dispose of syringes and vials in the trash.

This step allows you to add the elements necessary to complete the content of your child’s parenteral nutrient solution.

• Mix the contents of the lower chamber of the bag by gently massaging it.
• Remove the bar (partition device) between the upper and lower chambers of the bag.

• Gently massage the entire bag.
• Check the appearance and consistency of the solution; it should be homogeneous, milky and free of particles. It is yellowish in color if vitamins have been added.
• If the solution does not have the usual color and appearance, do not administer it and contact your pharmacy or healthcare team.

This stage finalizes the preparation of the solution and ensures the safety before its administration.

• Make sure the tubing clamp is securely closed.
• Use a disinfectant swab to vigorously scrub the bag insertion port.
• Let dry completely.
• Open the insertion port by unscrewing the protective cap.
• Remove the protective cap from the tubing spike with a rotating motion, as explained by your healthcare team.
• Holding the bag insertion port with one hand, insert the spike with the other hand by turning it about a quarter turn clockwise until the connection is tight.

Once the bag is spiked, the tubing can be connected to the pump which will be connected to the catheter.

• Press and hold the “Power switch” on the right side of the pump.
• The pump does various self-tests and beeps six times after the tests are completed.
• After the beeps, the home screen should appear.

This step allows the rest of the procedure.

• Remove the small protective cover over the cassette (often blue in colour).
• Attach the cassette to the bottom of the pump by first inserting the two hooks at one end of the cassette into the pump. This creates a lever.
• Pull the entire cassette up towards the pump until it snaps into place.

This step ensures the safe holding of the cassette at the pump and ensures the precision of the perfusion.

• Lift the cassette latch lever in the closed position.
• If you have strong resistance when fixing the cassette, it means that it is misplaced; try again.

This step ensures that the cassette is securely attached to the pump.

• The pump displays a question “Reset reservoir to XX ml?” (XX ml is the total volume of solution prescribed for your child and that must be received).
• Select YES to reset the volume.

This step allows the rest of the procedure.

• Place the bag on the work table.
• Raise the top of the bag about 30° or hang the bag.
• Open the bag clamp.
• Keep the protective cap on the end of the tubing to prevent contamination.
• Let the tubing hang vertically with the filter perpendicular to the ground.

• The pump display displays the message “Prime tubing?“.
• Select Yes.
• Select Prime.
• Continue purging as required by selecting Yes or selecting No to complete the purge.
• Ensure air bubbles are released from the filter by tilting or tapping it before continuing priming.
• Do the same with the Y-port when the liquid is being returned to this level.

• You must stop the priming after removing air from the tubing.
• Check that a drop appears at the end of the tubing.
• When the air is removed, close the tubing clamp.

This step ensures the security of the administration of the solution.

The high position of the top of the bag allows the air bubbles present in the solution not to drop and to interfere with the proper functioning of the filter. It must first be moistened with the solution to do its job well (prevent air and particles from accessing your child’s catheter).

If you administer the solution immediately:

• Irrigate catheter and give the parenteral nutrition solution.

If you administer the solution later:

• Press and hold the “Power switch” on the right side of the pump.
• When the message “Power down?” appears on the display, select “Yes“. The pump will then go out.
• Keep the bag away from bright light until it is used (eg, put it in its black envelope or in the backpack).

See the full description here

Summary:

Collaborate and form a team with your child. When you invest the time to form a strong team, children feel more comfortable and less anxious – this will help you complete the care with less stress – for you and your child.

Use these tips, from the start, to set the stage for a positive care procedure:

• Create the right moment: integrate the care in a routine.
• Alert your child to the needed care and communicate together.
• Form a team with your child: Encourage autonomy by offering realistic choices such as the method of distraction. Stay tuned to your child. Manage pain and anxiety, using distraction and positioning for comfort.

See the full description here

Summary:

• Prepare the environment: Identify a routine place for care. Close windows, doors and fans. Wash and dry the work surface and gather the needed materials for the care and to distract your child.
• Prepare your child: Get help if needed. Position your child for comfort to receive the care and start to use the selected distraction method.
• Prepare yourself: Find the right time when you are ready to provide the care safely. Review the list of care steps. Wash your hands.

Now that you are ready to start the care procedure, take the opportunity to encourage and praise your child.

See the full description here

Summary 3 key concepts:

• Safety: Carefully follow the care practice steps as you have been taught.
• Flexibility: Be ready to adjust according to your child’s reactions during the procedure. As needed, reposition or select an alternative distraction strategy. Follow your child’s pace and rhythm.
• Collaboration: Reassure your child, verbally and non-verbally. Acknowledge your child’s emotions and reactions. Help your child differentiate between the different sensations during a procedure.

Position your child:

• to easily reach the catheter entry site,
• in one of the positions discussed with your healthcare team,
• consider your child’s age and ability to collaborate.

This step allows you to more easily view the catheter entry site and keeps your child comfortable.

• The catheter entry site should not change in appearance.
• If the site has ANY of the following features:
  • red, hot, swollen or sensitive to touch,
    
  • redness, sensitivity under the dressing or a cord-like feeling along the length of the vein where the catheter is inserted,
  • the skin is cold around the catheter, the arm is swollen and your child reports burning or pain at the entrance site of the catheter THEN:
• Don’t give the solution or press the “STOP / START” button on the pump in order to stop the infusion, if is running.
• If your child is connected to the pump, then close the clamps of the catheter tubing and the tubing of the pump.
• Contact your healthcare team quickly.

This step allows you to quickly detect problems.

• The dressing should be kept clean and dry at all times.
• If the dressing is wet or blood stained, do not remove the old dressing. The catheter site should always be protected.
• If the dressing is falling off, tape the sides down.
• If the dressing is punctured or torn, install another clear adhesive dressing over the old one.
• Immediately contact your care team.

This step helps you quickly identify complications.

• Tubing should not be pinched or bent.
• Make sure the extension tubing is securely fastened. If necessary, use adhesive tape to keep the tubing in place.

The placement of the tubing must allow good circulation of the medication without  obstruction.

• The outer part of the catheter must remain the same length at all times; it should not move, neither inwards or outwards.
• If you notice a change in length of the external portion of the catheter, DO NOT push the catheter back into the vein; contact your healthcare team immediately.

This step will confirm the catheter has remained in the proper position. Allows quick action if the catheter has moved out of the proper position.

See the full description here

Summary:

The treatment is finished. Wash your hands again.

Be prepared to recognize the challenges faced and to provide positive feedback. Help your child recognize his/her strengths. Acknowledge the collaborative teamwork.

• Listen to what your child says about the parts of the procedure that were difficult or painful.
• Comfort your child and recognize your child’s collaboration with positive feedback.
• Highlight your child’s  specific strengths that helped make the procedure positive.
• Discuss with your child what might be done the same or differently the next time the care is needed.
• Keep your promises if you have promised a reward, follow through.
• Reward yourself too.

See the full description here

Summary:

Collaborate and form a team with your child. When you invest the time to form a strong team, children feel more comfortable and less anxious – this will help you complete the care with less stress – for you and your child.

Use these tips, from the start, to set the stage for a positive care procedure:

• Create the right moment: integrate the care in a routine.
• Alert your child to the needed care and communicate together.
• Form a team with your child: Encourage autonomy by offering realistic choices such as the method of distraction. Stay tuned to your child. Manage pain and anxiety, using distraction and positioning for comfort.

See the full description here

Summary:

• Prepare the environment: Identify a routine place for care. Close windows, doors and fans. Wash and dry the work surface and gather the needed materials for the care and to distract your child.
• Prepare your child: Get help if needed. Position your child for comfort to receive the care and start to use the selected distraction method.
• Prepare yourself: Find the right time when you are ready to provide the care safely. Review the list of care steps. Wash your hands.

Now that you are ready to start the care procedure, take the opportunity to encourage and praise your child.

See the full description here

Summary 3 key concepts:

• Safety: Carefully follow the care practice steps as you have been taught.
• Flexibility: Be ready to adjust according to your child’s reactions during the procedure. As needed, reposition or select an alternative distraction strategy. Follow your child’s pace and rhythm.
• Collaboration: Reassure your child, verbally and non-verbally. Acknowledge your child’s emotions and reactions. Help your child differentiate between the different sensations during a procedure.

• Select and clean a workspace surface (eg, tabletop).
• Gather the necessary equipment.
• Check that the saline syringe is at room temperature.

This step ensures safety and allows the rest of procedure.

• Hold the syringe vertically with the protective cap facing up.
• Push the plunger of the syringe to release it.
• Strike the syringe vigorously with your thumb and forefinger to raise the air bubbles.
• Partially unscrew the protective cap.
• Gently push the plunger until there is no more air in the syringe and a drop of liquid appears at the junction of the protective cap and the end of the syringe.
• Screw the protective cap back onto the syringe tip.
• Place the syringe on your table.

If necessary, refer to the technique taught by your healthcare team, pharmacy or manufacturer’s recommendations.

This step is necessary for the security of the administration of the solution.

Position your child:

• to securely reach the catheter entry site,
• in one of the positions discussed with your healthcare team,
• depending on comfort, age and ability to collaborate.

This step facilitates the work.

Refer to steps 5 through 8 of the care method “Catheter site monitoring”.

This step allows you to quickly detect problems.

• Use a disinfectant swab to vigorously scrub the top and sides of the needleless connector.
• Allow the connector to dry completely by holding it in one hand.
• Do not blow on the connector.
• <span style="text-decoration: underline;">Do not touch</span> the connector between the time of disinfection and the syringe connection.

This step is necessary to prevent contamination (transmission of bacteria).

• Take the saline syringe with one hand and remove the protective cap with the other.
• Take care that nothing touches the tip of the syringe to avoid contaminating it.

This step allows the procedure to continue safely.

• Take the needleless connector between the thumb and forefinger of one hand.
• With the other hand, push the syringe into the connector.
• Fasten the syringe by turning it about a quarter turn clockwise until the connection is solid.
• Never use a needle to inject into the needleless connector.

This step allows the rest of the procedure.

• Open the clamp of the catheter tubing.
• Press the plunger of the syringe to push 1 ml at a time: using a brisk start-stop technique with each ml that is pushed (this helps keep the catheter from getting blocked).
• When the entire solution is injected, close the clamp of the catheter tubing.

This step removes deposits that accumulate in the catheter and prevents it from blocking.

• Hold the needleless connector between the thumb and forefinger of one hand.
• With the other hand, disconnect the syringe by turning it counterclockwise.
• Dispose of the syringe in the trash.

This step allows the rest of the procedure.

Using your two hands prevents the needleless connector from unscrewing instead of the syringe.

• Remove the air bubbles from the locking solution syringe.
• Disinfect the needleless connector.
• Take the locking solution syringe with one hand and remove the protective cap with the other.
• Take care that nothing touches the tip of the syringe to avoid contaminating it.
• Screw the syringe onto the needleless connector.
• Open the clamp of the catheter tubing.
• Inject the locking solution, as instructed by your healthcare team.
• Close the clamp of the catheter tubing.
• Disconnect the syringe from the needleless connector of the catheter.
• Dispose of the syringe in the trash.

This step prevents the formation of clots at the tip of the catheter when a prolonged delay is expected before its next use.

Refer to steps 5 through 8 of the catheter site monitoring procedure.

This step allows you to quickly detect problems.

See the full description here

Summary:

The treatment is finished. Wash your hands again.

Be prepared to recognize the challenges faced and to provide positive feedback. Help your child recognize his/her strengths. Acknowledge the collaborative teamwork.

• Listen to what your child says about the parts of the procedure that were difficult or painful.
• Comfort your child and recognize your child’s collaboration with positive feedback.
• Highlight your child’s  specific strengths that helped make the procedure positive.
• Discuss with your child what might be done the same or differently the next time the care is needed.
• Keep your promises if you have promised a reward, follow through.
• Reward yourself too.

See the full description here

Summary:

Collaborate and form a team with your child. When you invest the time to form a strong team, children feel more comfortable and less anxious – this will help you complete the care with less stress – for you and your child.

Use these tips, from the start, to set the stage for a positive care procedure:

• Create the right moment: integrate the care in a routine.
• Alert your child to the needed care and communicate together.
• Form a team with your child: Encourage autonomy by offering realistic choices such as the method of distraction. Stay tuned to your child. Manage pain and anxiety, using distraction and positioning for comfort.

See the full description here

Summary:

• Prepare the environment: Identify a routine place for care. Close windows, doors and fans. Wash and dry the work surface and gather the needed materials for the care and to distract your child.
• Prepare your child: Get help if needed. Position your child for comfort to receive the care and start to use the selected distraction method.
• Prepare yourself: Find the right time when you are ready to provide the care safely. Review the list of care steps. Wash your hands.

Now that you are ready to start the care procedure, take the opportunity to encourage and praise your child.

See the full description here

Summary 3 key concepts:

• Safety: Carefully follow the care practice steps as you have been taught.
• Flexibility: Be ready to adjust according to your child’s reactions during the procedure. As needed, reposition or select an alternative distraction strategy. Follow your child’s pace and rhythm.
• Collaboration: Reassure your child, verbally and non-verbally. Acknowledge your child’s emotions and reactions. Help your child differentiate between the different sensations during a procedure.

Instructions here.

Position your child:

• to securely reach the catheter entry site,
• in one of the positions discussed with your healthcare team,
• depending on comfort, age and ability to collaborate.

This step ensures the safety and allows the rest of the procedure.

Refer to steps 5 through 8 of the care method “Catheter site monitoring”.

This step helps to quickly detect problems.

• Remove the air bubbles from the saline syringe.
• Disinfect the needleless connector.
• Take the saline syringe with one hand and remove the protective cap with the other.
• Take care that nothing touches the tip of the syringe to avoid contaminating it.
• Screw the syringe onto the needleless connector.
• Open the clamp of the catheter tubing.
• Press the plunger of the syringe to inject 1 ml at a time.
• When the entire solution is injected, close the clamp of the catheter tubing.
• Disconnect the syringe from the needleless connector.
• Dispose of the syringe in the trash.

This step removes deposits that accumulate in the catheter and prevents it from blocking.

• Disinfect the needleless  connector.
• Take the tubing with one hand and remove the protective cap with the other.
• Make sure that nothing touches the end of the bag tubing to avoid contaminating it.
• Take the needleless connector between the thumb and forefinger of one hand.
• With the other hand, insert the end of the tubing.
• Turn clockwise, about a quarter turn, until the connection is tight.
• Open all clamps.

This step allows the subsequent procedure and avoids contamination.

• Press and hold the “Power switch” on the right side of the pump.
• The pump does various self-tests and beeps six times after the tests are completed.
• The home screen appears then.
• Press and hold the START/STOP button.
• When “Start Pump?” appears on the home screen, select Yes.

This step allows solution administration.

• Place the parental nutrition bag, tubing and pump in the backpack and keep it close to your child.
• Be careful to place the pump securely.
• Verify that the tubing is not bent or pinched. If available, a hospital style intravenous pole can be used to hang the parenteral nutrition bag overnight.

This step is used to protect the pump and ensure proper flow of the solution.

• Monitor the site of the catheter, dressing, tubing and pump operation, following the frequency recommendations of your child’s healthcare team.
• Check that the parenteral nutrition bag empties gradually.

This step makes it possible to quickly detect problems during the administration of the solution.

When the pump signals the prescribed end of the infusion:

• Press the “STOP / START” button on the pump.
• When “Stop pump?” appears on the screen, select “Yes“.
• Close the clamps of all tubing.
• Press the “Power switch” on the right side of the pump to shut it off.
• When the message “Power down?” appears, select “Yes“. The pump then powers off.

This step allows the rest of the procedure.

• Wash your hands again.
• Hold the needleless connector between the thumb and forefinger of one hand.
• With the other hand, disconnect the tubing from the bag by turning its end counterclockwise.
• Put empty bag, pump and tubing aside.

This step makes it possible to prepare for the irrigation of the catheter.

The use of both your hands prevents the needleless connector from unscrewing instead of the tubing.

• Remove the air bubbles from the saline syringe.
• Disinfect the needleless connector.
• Take the saline syringe with one hand and remove the protective cap with the other.
• Take care that nothing touches the tip of the syringe to avoid contaminating it.
• Screw the syringe onto the needleless connector.
• Open the clamp of the catheter tubing.
• Press the plunger of the syringe to inject 1 ml at a time.
• When the entire solution is injected, close the clamp of the catheter tubing.
• Disconnect the syringe from the needleless connector.
• Dispose of the syringe in the trash.

This step removes deposits that accumulate in the catheter and prevents it from blocking.

Instructions here.

This step prevents the formation of clots at the tip of the catheter when a prolonged delay is expected before its next use.

• Refer to steps 5 through 8 of the care method “Catheter site monitoring”.
• At the end, make sure all the clamps are closed.

This step allows you to quickly detect problems.

• Lower the cassette latch until it comes loose.
• Throw the tubing and empty bag into the trash.

This step prepares the pump for the next use.

See the full description here

Summary:

The treatment is finished. Wash your hands again.

Be prepared to recognize the challenges faced and to provide positive feedback. Help your child recognize his/her strengths. Acknowledge the collaborative teamwork.

• Listen to what your child says about the parts of the procedure that were difficult or painful.
• Comfort your child and recognize your child’s collaboration with positive feedback.
• Highlight your child’s  specific strengths that helped make the procedure positive.
• Discuss with your child what might be done the same or differently the next time the care is needed.
• Keep your promises if you have promised a reward, follow through.
• Reward yourself too.