Ahmed
Ahmed, Samya's son is due his Measles Mumps and Rubella Vaccine (MMR).
He was sent an appointment just after his 1st birthday but because of Samya's needle phobia she did not take him to the appointment. She has spoken to the GP surgery and has now agreed to attend with Ahmed so that he can receive his MMR but has requested that she is not with him during the injection due to her needle phobia.
On arrival to the GP surgery Samya is obviously very anxious and Ahmed is crying. Using the table below describe how you would assess and plan the safe delivery of Ahmed's MMR vaccine and the clinical holding technique you would adopt. You may want to use the comments section for any additional information that you would like to include.
Patient/Parent preference
To wait outside the room and if possible offer to support Samya with her needle phobia which will help with future vaccines/potential medical interventions.
Comments
- Use of distraction i.e. bubbles, story book, electonic device, use of rewards, such as bravery stickers.
- MMR vaccination crucial to prevent the spread of communicable diseases.
- Significant potential health risks to Ahmed if vaccine not given.
Framework
Intro and approach including consent.
Any concerns?
Non-threatening approach, establish a rapport. Gain consent from Samya. Find out what Ahmed likes, consider distraction techniques. Check for allergies.
Concerns - Ahmed is already upset and Samya does not want to stay with Ahmed. This is a 2 person technique, as Samya is not able to hold Ahmed - one to deliver vaccine and one to hold Ahmed
Procedure being performed
IM injection to administer MMR vaccine
Purpose and benefit of hold
To keep Ahmed still so that the vaccine can be given/to keep Ahmed’s arm /leg secure to enable vaccine to be given. This action restricts movement and allows for immobilisation of the limb
Characteristics of hold
In this section you would document:
Actions the person holding Ahmed will take.
The action should allow immobilisation of limb.
Allow Ahmed to kick his feet if vaccine given in deltoid Ahmed could be sitting on the lap of the person holding him, or lying in their arms
Refer to the clinical holding website for further advice on documentation.
Actions of person giving vaccine. Are they helping to immobilise limb? - if yes how?
The holder secures the child's legs by placing their other arm over the child's legs, on top of the child's thighs - close to knee.
Evaluation of Risk factors and action taken
There are no obvious risk factors except that Ahmed can wriggle and become hot and sweaty - but you may wish to identify that Mum has a needle phobia/don't want Ahmed to have same phobia.
Number of people required to apply this technique and their roles
Two - nurse to hold child (and distract) and nurse to give vaccination.
If possible a third member of staff to comfort and reassure mum and provide distraction, or the person holding Ahmed to offer distraction
How many attempts will be made
One attempt, however currently there are no guidelines - but many authors identify three attempts as being custom and practice.
When and why would you stop the procedure
If Ahmed becomes unduly distressed.
If Ahmed's vital signs become outside the normal range for him ie tachycardia, tachypnoea and hypertension.
If there is a danger that force needs to be applied to immobilise (i.e. the people doing the holding are struggling to do so safely).
If there is a potential for harm to Ahmed and/or the people involved in the holding.
If there are not enough people available to perform the hold safely.
Reflection
For all holding episodes, consider the following questions:
- Do I feel satisfied with my care delivery?
- Could I justify my decisions to a 3rd party
- If I were giving this care again, what would I do differently and how would I have achieved this
- How flexible have I been in my decision making?
To support your practice decisions refer to the Clinical Holding Flowchart to Support Decision Making.
