Use these tips to make pediatric procedures easier

Do you often encounter frightened, squirming children when attempting to start intravenous lines or care for lacerations? Their fright and movement can make care difficult to deliver, says Teri Howick, RN, nurse educator for the ED at McKay Dee Hospital in Ogden, UT.

For example, infants or young children can loosen dressings or laceration repairs, she notes. "Sometimes, you are just short of putting them in one of those veterinary collars that look like a lampshade to keep them from gnawing the stitches out," says Howick.

To make children more comfortable and facilitate procedures, use these tips:

• Lessen pain of intramuscular (IM) shots.

If children are getting IM shots in the deltoid, have the patients place their arms behind their backs with their elbows bent at a 90-degree angle or less, says Howick. "This makes it difficult to tighten the deltoid, and the shot will be less painful going into a relaxed muscle," she says.

• Use the "hand elephant" to divert children’s attention.

If a painful procedure has to be performed, Howick suggests drawing an elephant on a child’s hand with a marker, using the index finger as the trunk, and the web space between the index and the thumb for the mouth. The head of the elephant covers most of the side of the hand, with the ear extending up to the wrist, she explains.

"I have them name the elephant and practice grasping things, like a pencil, with the index-finger trunk, and opening and closing the mouth by extending their thumb," she says. "I’ve even drawn elephants on both hands so they can interact’ with each other."

• Use "the Pickens Sling" for elevation.

This sling is for patients who need to have a hand elevated, as in the case of finger lacerations, or nerve or tendon repairs, to reduce swelling, says Howick. Follow these steps, she recommends:

Measure a length of muslin stockinet 1½ the length of the patient’s arm.

Fold it in the middle, and make a cut halfway through.

Slide the patient’s arm through the cut so the arm is covered and the cut opening just covers the elbow.

Have the patients cross their covered arms across their chests so that their hand is up on their shoulders. Bring the other end of the stockinet around their backs, and tie both ends high on the scapula.

"The arm will be elevated, and it nestles nicely in the stockinet cradle," says Howick.

• Use the "boxing-glove" dressing.

To prevent children from removing dressing for a hand laceration, do the following, says Howlick:

Cut a piece of stockinet then length of the patient’s arm from elbow to fingertip, and slide it onto the forearm so it goes from elbow to wrist. Take a ½- to 1-inch piece of nonstretchy cloth tape, wrap it around the stockinetted wrist at the narrowest part, and circle it twice, she says.

"Do not stretch or make it constrictive in any way," Howick says. "Just lay it on the stockinet."

Next, dress your wound as necessary, applying ointments and nonadherent gauze dressing, says Howick. Place 2x2s between the second, third, and fourth digits, and place a large, rolled gauze in the palm of the hand so the thumb reaches around it, says Howick. "Wrap it all with a gauze bandage so the patient maintains the position of function. No tape is necessary," she says. "Now pull the stockinet over the entire ball of wax."

Tie a knot in the end to enclose the dressing and cut off any excess, says Howick. This dressing is absorbent and should be rechecked every day to check for signs and symptoms of infection, she advises.

"It is not occlusive in any way, and the patient can’t pull it off," she says. "Most children can’t loosen the knot with one hand or their mouth."

• Calm children when starting an intravenous line.

When starting an intravenous line (IV) in a frightened child, explain to the child that this is a straw to give their body a drink, suggests Deby Campbell, RN, MSN, clinical nurse specialist for the pediatric ED at Banner Desert Medical Center in Mesa, AZ. "This is especially effective when the child has been vomiting," she says.

Next, explain that there is a little needle in the straw, but you will take it out and make a big bandage when it is all done, she says. "During the procedure, I always make a loud comment when my catheter is advanced and in place that the needle’ is gone," she says. "Now, it is time for the bandage."

Compliment the child on how well he did, she says. "Children always need recognition, so a sticker or a decorated bandage is now in order," she says.

Never blame children for problems with insertion or expect young children to hold perfectly still, she stresses. "Don’t say things like, Since you moved, I have to do it again," she says. "They are too scared. We are the grownups, and we can take the blame. Say, I’m sorry, this one didn’t work,’ or It wasn’t your fault, but I have to do it again.’" 


For more information on pediatric procedures, contact:

Deby Campbell, RN, MSN, Clinical Nurse Specialist, Pediatric Emergency Department, Banner Desert Medical Center, 1400 S. Dobson Road, Mesa, AZ 85202. Telephone: (480) 512-3349. Fax: (480) 512-5312. E-mail:

Teri Howick, RN, Nurse Educator, Emergency Department, McKay Dee Hospital, 4401 Harrison Blvd., Ogden, UT 84403. Telephone: (801) 387-2286. Fax: (801) 387-2244. E-mail: