Case Study

When children experience pain or discomfort, during nursing interventions, cause distress for all involved. This may lead to fear, anxiety and potential long term problems. We sought to reduce these issues by introducing the use of 50% Nitrous Oxide 50% Oxygen (Entonox) when undertaking invasive nursing procedures in children in the community. On investigation we found that this is not done by any other children’s community nursing team in the country.

The initiatives objectives were therefore clearly identified from the start: Our aim was to find a solution which could be utilised in all invasive treatments, preventing pain, discomfort and distress for patients, families and team members. The outcome would be person centred, subjective and qualitative, with the experience of the child, family and team members determining if the initiative had been a success or not. It is envisioned that the initiative would make a sustainable difference as Entonox could be used for many children with varying nursing requirements on a long term basis.� All competencies, and guidelines developed are easily transferable to other teams and organisations and can be easily disseminated.

The ‘Eureka’ moment in regards to the use of Entonox in the community was during the insertion of a nasogastric tube (NG) to one child known as Joe. Joe has undergone dialysis, he required twice weekly injections and found that the NG experience was one procedure too many. Joe is 5 years old. Joe became so upset and distressed, he was inconsolable. This caused mistrust towards the professional, breaking down an established relationship.

Following a staff supervision session we analysed the situation and sought potential solutions. We considered sedation but felt this was too risky within the community.� We acknowledged we have the use of Entonox in the hospital therefore our initial plan was to meet Joe and his Mum in hospital. He self-administered Entonox and was given distraction whilst the tube was inserted much more easily. Joe was given 10 minutes to play following the procedure and was then allowed to go home. His mum commented she wished that could be done at home where he could watch his TV and feel more comfortable. Hospitals still scare Joe. This became the challenge for our team.

The process began by consulting the expertise of the pain control specialist nurse within the Trust. Through joint working and training we (the two teams) decided to look into the pros and cons of using Entonox on children in their own homes for any distressing procedure.

The use of Entonox is a universally established practice within community midwifery services and within our trust has been used for over 30 years. It has been found to be a safe and effective method of pain relief with a low incidence of adverse effects and a quick recovery time (Kanagasundaram S, Lane L, Cavalletto B, Keneally J and Cooper M 2001).

We carried out a risk analysis and the team underwent training and completed competencies, whilst being supervised and supported by our specialist colleagues. We contacted, by post, the entire directory of Community children’s nurses in the United Kingdom to ask of their experiences, in this regard. 98% of respondents stated they did not routinely use Entonox in the Community, but were greatly interested to learn from our experiences.

Practical problems we envisaged included:

• The cost of equipment
• Storage of equipment
• Car insurance & transportation
• Prescribing, patient group directives and consent
• Staff training
• On-going costs

The cost of the equipment was £400 which included 2 cylinders, the release valve, a carry bag and a box of disposable masks. The child keeps their own mask and this can be reused, for on-going painful dressings or procedures. The cylinders are stored in our clean utility storage cupboard which is locked and accessed by the CCN team only.

All staff have business use for work on their car insurance and as long we notified our insurers of the potential of carriage of medical gases, no one incurred any additional cost. We were asked to display a sign in our cars when carrying medical gases.

The senior nurses within the team can all prescribe so this is prescribed as either a once only or as required dose; however, a Patient Group Directives (PGD) was also developed in collaboration with the pharmacy department to enable Staff Nurses to still use entonox on the rare occasion a nurse prescriber is unavailable. Staff training was completed through multiagency working with the pain nurse specialists and the use of the medical representative. Hand-outs, written materials and competency sheets were undertaken by all staff. Consent of the family and\ or child is documented within the nursing notes.

On-going costs will be monitored, but are felt to be minimal and cost effective in regards to patient comfort, compliance, prevention of re-admission/re-attendance at hospital and long term outcomes of trust for the child. On-going audit will be more of a comparison of the child’s previous experience and patient satisfaction is gauged both formally and informally. We observe comments made by the child and family and also issue patient satisfaction questionnaires on a rotational sequence. Since we have started this process we have discussed this with the tissue viability team and they are considering introducing this method of pain relief throughout their clinics and home calls for painful procedures. The population of CCN’s are interested in using our experiences to inform their practice.

Our aim is for children not to ever experience pain, or distress!

The types of nursing action which will require consideration for the use of Entonox include but not exclusively limited to:

• The insertion of nasogastric tubes or gastrostomy button
• The insertion of a port-a-cath needle
• Painful burns, or dressing changes
• Injections or Venepuncture for a terrified child
• Removal of clips or sutures

If the child has a good experience they are less likely to develop phobias or anxieties which can be carried through to adulthood.

Children do not have to experience any painful procedures without adequate pain relief and distraction. This should make the parents more relaxed and in turn the children may not have preconceived fears when faced with a nursing intervention in the future. The results are monitored formally by the use of patient and family satisfaction questionnaires and informally in verbal feedback from children and their families. So far, families have been very positive about the use of Entonox and children seen to be a lot less anxious about nurses visiting them at home.

• Collaborative working
• Reflecting upon experiences and identifying areas for improvement within our practice
• Identifying drawbacks
• Risk assessment
• Seeking solutions
• Sharing experiences
• Identifying a good practice
• Problem solving