Calculate - Sci up ralio bel ween dosage on hand and

desired dosage

Arroont rn hrrrl XArrrurt dsired

• Fonnula

D (desired) . _.:....__~xQ (quanllty) = X (amount)

H (have)

3 yr old wt: 36 lbs

Dx. Meningitis

• MD order: Ampici llin 500 mg IVPB q 6 hr

Drug research-

mild-mod. Infection- 50 to1 00 mg/kg/24 hr

severe infection- 200 to 400 mg/kg/24 hr

• Infant wt is 9 kg

Dx - sepsis

MD order- Gentamycin 32 mg IVPB q 12 hrs

Drug Research - 7.5 mglkg/24hrs

• 12 year old; wt 90.5 lbs

• MD order - Cefotaxime 600 mg po q 4 hrs

• Drug research- 50 - 200 mg/kg/day

• mL per hour example: - Order: 0 5\V 250 mL IV during next 2 h by

infusion pum11

Use formula

250 mL = 125 mL/h 2 h

Set pump at 125 ml per hour

How many 30 minutes in 60? Multiply rate by 2.

• For 20 minutes? Multiply by 3

• For 15 minutes? Multiply by 4

mL per hour with infusion rate of less than one hour example:

Total mL ordered X mL/h ....:....::..:.:::..:.:.:::...:;=:._:;:_ =---Total min ordered 60 minlh

X=mL/ h

ll'ml

• mL per hour with infusion rate of less than one hour example:

- O rder: Ampicillin 500 mg IV in 50 mL

0 5 NS in 30 minute5 by IV pump

I. Think - Controller set by rate of mL per hour - If 50 mL is to be in fused in 30 minute5:

• 100 mL will be infused in 60 minutes

• Set rate of controller at I 00 mL per hour to infuse 50 mL in 30 minutes

2. Use ratio-proponion

50 mL v X mL! h

30 min ' ' 60 min/h

30X = 3,000

30 X = 3,000

30 30 X = 100 mL/ h

• Nurse may not arbitrarily speed up or slow down now rate to catch up IV

Check for institutional policy regarding correcting o ff-schedule IV rates and percentage of variation a llowed - Normally should not exceed 25 percent

,• {

«{

r:-!: E '

-

• When adding medication to metriset, do not count added med if under 5ml.

Do not lower infusion rates ever. If need more fluid, dilute medication in more fluid in metriset. - Ex. You have to give 4ml medication over

half an hour and the IV is running at 50mUhr.

• You would place the medication in the metriset and bring fluid level up to 25ml. because at a rate of SOmUhr, 25ml will run in half an hour.

• If you have 50ml to run over 30 minutes and the IV is at 10mUhr, you would have to increase the rate to 100mUhr.

If you have 1 OOmL to run over 1 hour and the IV is at 30mUhr, you would have to increase the rate to 100mUhr.

If you have 1 Oml to run over 30 minutes, and the IV is at 60mUhr, you would have to further dilute the medicine for a total of 30ml.

~~~.~"

Less than 1 ml , solve for 3 places, round to 2. Ex: 0.894 becomes 0.89

More than 1 ml, solve for 2 places, round to 1. Ex: 1.36 becomes 1.4

5 or over rounds up 4 or less the number stays the same

Questions?

• Children< 18 are more than 23% of population.

Cultural group sizes are changing. - Divers ity is increasing.

Family-centered care - Famil ies are partners in care.

.<S years

• !t 10 13 years

• 14 to 17 yaHrs

• 18 <o&< yenrs

.65· yecus

The~ o l Chkten unde1 age 1& yeass w;n ~KtJm•Led 1r1 201 .C io ~counllor 23 1"4 of the ~lllOI"'-. lht UMed StAtes Note dle companiOn of tM ~<btut

poP'btJOn we Wl:h other poptqtiOn •oe groups :.;,..e. ~"-U$ ~ ..... -.. ~()~QOI~ ~ • ........,..,., ... ,......,~b .-...: p~e, .. ,,., ... ~:... ~J ~ ~A...r»RcoC' .... ~ei'C....._.,.oc.

~:11 ,.,, I :01 4 ~ll<do"IQt t.ld!"'W'(-~_.. ~ :-"I~ r: .• ••• ... I• .. -. ... ._.-._. ~-

• Role of nurse - Interact effectively with children and family. - Modify physical assessment techniques to

age. - Identify strategies to reduce pain and stress. - Ca lculate accurate medication dosages. - Provide safety for child's developmental

status. -Adapt procedures to chi ld's age and

development.

Education Role - May be challenging because of range of

understanding of ch ildren and parents. - Goals in helping chi ld and

parents/guard ians: • Make informed choices. • Adapt to heallhcare settings.

Prepare for procedures.

Advocacy Role - Enable child and family to adjust to changes

in chi ld's health.

• In their own way and time

• Needs of both children and adults

• Awareness of resources • Psychosocial needs

• Cultural awareness

• Importance of coordinated interprofessional team.

Nurse is often aware of family's desires. Spends more time with child/family then any other team member.

Continuity of care.

Ask and clearly describe specific clinical question.

• Collect most relevant and best evidence from well-designed studies.

Review, synthesize, analyze evidence using critical thinking.

• Integrate evidence with clinical experience. - Develop practice guideline.

• Evaluate change in practice for effect on quality care.

T

• Parents are usually asked to give consent for the child. - Must be clear that child or parents can

refuse consent at any t ime - Divorced and joint custody - Divorced and one parent has custody - Proxy custody - Emancipated minors - Mature minors -Assent

Informed consent

Child's versus parent's rights • Confidentiality

.... . . , ft...A.: .. ,c

- Legal reporting - Insurance In parent's name

·•..:: ' .. ,..,. .·

Limiting or withdrawing life-sustaining treatment -Ability to maintain life - Quality of l ife - Family's wishes

• Form therapeutic alliance • Help resolve conflicts

- Choosing among treatment options

- Religious and cultural differences

~ . ..:. . . . ileF.Ti':·

Philosophy of care with mutually beneficial partnership between family and healthcare team.

Each party respect what other brings to interactions. - Versus fami ly-focused care, in which health

professional is the expert

• Collaboration brings optimal outcome.

Parent' perspective can be critical to quality care.

Make communication developmentally appropriate

Get on child's eye level

Approach child gently and quietly

Always be truthful

Give child choices as appropriate __ ....,.. __

Communicating with Chil

Avoid analogies and metaphors

Give instructions clearly

Give instructions in positive manner

Avoid long sentences, medical jargon; think about "scary words"

Give older child opportunity to talk withou t parents present

A young child may take the C)(pression "a l1ttle slick m the arm~ literally,

Build a relationship.

Create a comfortable and accepting environment.

Make parents an ally. Ask for their help and input.

• Always address their issue. Don't just say you' ll ca ll the doctor.

Try to answer their questions as honestly as possible. If you don't know, find out.

• Do not feed into the emotion of the situation. Try and diffuse anger.

• Make communication accommodative and interpersonal.

Concept of Det\th Toddlers are very egocentric, can not comprehend

the absence of life

Preschoolers have magical thinking • May think they caused illness or death

School Age • May personify as the devil or god, ghosts or spirits

9- 10 years • know that 1t's irreversible

• attitudes influenced by adults around them

• need a lot of explanations

• cunous about funeral and wakes

Concept of Death (Contbt·~:-

Adolescents have a hard time coping with death because they have adult understanding

· Feel alienated when sick

• Worried about physical appearance: losing hair with cancer

• Reaction to death varies

• How do you tell them they are terminally ill? - Tell them the truth

.;,e l'!u..l...., L' ·~

Psychosocial Issues lnfan~:~;~_!o'

~a ration Anxiety

No separation seen tt l I approx 4 months as long as patient rece1vmg CONSISTENT CARE

!rul12!illl ·4-6 mo begms to recogmze stgntftcant caretakers • 4-6 mo -cease acllvtty • 6 mo -aymg

Protest- cnes. screams. searches for parents wtth eyes. cling to parent, or avotds & reJeCts contact with strangers

Despatr- tnacttve. withdrawn, dtsinterested m envtronment

Detachment- denial. resignation (nol contentment), appears I ' Interested 1n surround•ngs, appears happy & fnendly

' "" 1'11.-U-.i:

Psychosocial Issues Infant.~"';~~

Loss or Control

Unusuallo see tn mfams- until meel tng aulonomy needs

Fear or Bodily in jury & Pain

Most consistent 1ndicator of dtstress 1s a facial express1on of diScomfort with sqwmtng writhtng. Jerking & flatltng

Temperamenl or personality may come tn espectally after 4 mo-(eas•ly consoled? conlinues lo cry?)

· Less than 6 mo - no memory of prevtous pa1nful expenence (per lileralure)

• Older !han 6 mo - recalls & affecls response

· Anuctpatory prep tends to tncrease rear & reststance

· Neonate- total body reaction to patn easily distracted

• Later tnfancy- localized reaction, uncooperauve, offers phystcal res•stance

F!u.J:.~'I

Psychosocial Issues Toddler .,; .. :1

Separation Anxiety

Protesl - cnes for parent pleads wtlh parent 10 stay; clings to parent, physical fightmg; appears not to be happy to see parent, avoids strangers. temper tantrums

Despatr- passtve depressed: dtsmterested· loss of newly acqu•red skills won't eat or sleep

Detachment - restgnation superftctal adJUStment

Psychosocial Issues To~dle~;_">;

Loss o r Control

Rtgtd schedules. altered care gtvtng activttles, separation from parents, unfam1liar surroundmgs and med1cal procedures usurp toddlers control over the world

NegatiVISm, regresston. uncooperative

Fear o r Bodily injury & Pain

React wtth Intense emot1onal upset and physical res1stance to actual or perceived pa1nful expenence; fights dunng tnvas1ve procedures: can communicate pain

Psychosocial Issues Pre!phOoler ~J!\ . ,"

Separation Anxiety

Protest -less d~rect and aggress1ve than toddler, may break toys, h1t other chtldren, uncooperat ~ve

Oespa1r- refuse to eat refuse to sleep. quietly cries for parents. contmues to ask for mommy, wtlhdraws from others

Detachment stmllar to toddler

Psychosocial Issues PreschQoler , ,

Loss of Control

Egocemnc and mag,calth,rkmg cause preschooler to feel powerlul, omnipotent- hosp,tal,zatlon 1ncreases feelings or loss of control Feels hospttahzatton ts a pumshment May react with uncooperattveness. cry1ng

Fear of Bodily inju ry & Pain

Fear 1ntrustve procedures- espectally those involvtng genttals (Castrat,on Mublat1on)

Reacts w1th phys1cal and verbal aggress1on

Regress1on- 1ncreased dependency; withdrawn. reel1ngs of fear . anx1ety; gu1lt; shame

Psychosocial Issues School A~~-·:,.;

!)~paration Anxiety

Young School age - hosptlaltzatton tncreases need for parental secunty

M1ddle and Late School age - react more to separation from peers and usual acllvilles. no su1table outlet for mental and physical activittes. mtss routine. worry wont be able to compete Behavtors- lonettness. boredom, isolation depresston

May be reluctant to ask for support. cultural stigma to "act hke a man' or ·be brave·. reacts with stOICism: Withdrawal: or passivo acceptance

May show negat1ve feehngs by irntab1l11y, rejecllon of peers, aggress1on; Withdrawal from parents, inab1hty to relate to peers

Psychosocial Issues School Age .... .!.'.:.,~~

Loss of Control

Can occur with· aHered family roles, physical disability; fears of death. abandonment or permanent injury; loss of peer acceptance. increased dependent hospital activities - enforced BR; lack of privacy; forced to use bedpan; inability to choose menu; restrictions

React by telling nurse what to do; boredom; depression; making many demands; hostility; uncooperative

Psychosocial Issues Schoo

Fear of Bodily injury & Pain

Begin to show concern for reasons for procedure- "What's this for?" "How ~ovill this help?"

Behaviors: Young child- same as preschool- crying name calling BY 9 or 10- show less fnght and overt resistance Passive methods-Reacts by holding rigidly still: clench fists; "acting brave"; verbally communicates about pain; stalling; postponing; wanting explanations

Gi~s express more and stronger fears than boys

Psychosocial Issues Adolesc~ce !:,:...~

Sej;!aration Anxiety

May welcome a separation from home and parents

Severe emotional threat to loss of peer/group contact, results in loss of group status. inabil ity to exert group control or leadership foss of group acceptance

Behaviors- Depression, withdrawal, uncommunicative

Psychosocial Issues Adolescenc~,::~~-,~

Loss of Control

The patient role fosters dependency and depersonalization_ This is a major threat to teenager searching for identity

Behaviors - respond with rejection, uncooperativeness, isolate self from peers, reject staff, seeks information about condition, questions nurses' ability

Psychosocial Issues Adolescence . .:_ .....

Fear of Bod ily injury & Pain

React to pain with much self-control

Fear of bodily injury more than pain

Behaviors- asking numerous questions, withdrawing, rejecting others, questions adequacy of care, overconfidence, conceit or "know it all" attitude

More concerned over scar or bodily appearance than procedures or illness- looks more toward immediate body changes

Interventions for Psychosociallssue~Ge]!~@l . ,

Separation Anxiety

Consistency of NSG personnel

Arrange work schedule (parents) for more personal contact

Encourage rooming-in

Recognize child's behavior as normal- allow to cry

Help parents understand reasons and behaviors of separation

Convey expected time of parental return m terms of events (after lunch. after bath, etc.) clock for older child

Interventions for Toddler and Pr~~h~I&J-,

Separation Anxiety Visit for short but frequent rather than one long visit

Favorite home articles at bedside (blanket. toy, cup)

Provide sensory stimulation and diversion for G & 0

Assign foster grandparent or volunteer

Allow siblings to visit

Use language consistent w~h G & 0

Interventions for Toddler and PreSJ:'l9P.Il~ . Loss of Cont ro l

Determine from parents customary roulifles - lry to keep similar routines (same cup, own pajamas, etc.)

Use terms familiar to child

Allow choices when possible

Allow freedom within safety limits

Fear of Pain and BodilyJ!ti!!!Y

Provide age appropriate explanations for procedures, especially Uwse involving genitals

Provide pnvacy

Use terms that don't convey misunderstanding (lake a• out "draw blood") use "fix"

. • ,l!lia Use bandaids l'tu...:..,.,.: ·r

Separation Anxiety

Familiar articles from home- pictures. radio. usual pajamas, favorite toy (over Y, of school age children have treasured items). videos

Help mamtain usual outs1de contacts- schoolwork. phone calls, cards. letters, call teacher, cub scouts

Interventions for Schoo!_A.s_~.~~ :v!~.t Loss of Control

Sense of control increased when feels useful and productive

Allow to help on ward- make bed, help care for younger children, make arm boards

Owet activities- models. collecting objects. art, schoolwork

Give anticipatory preparation and information

Give choices- joint planning, wear street clothes, choices in bedtime, food selection, ADL's

•• 1'!>.4.l~i'l Allow to assist with procedures

Interventions for School A9Q.:::~~~< '·,

Fear of Pain and Bodil y Injury

Explanation based on cognitive development

Distraction- ·ouch·, counting, squeeze nurse's hand, deep breathing

Relaxation

Gu1ded Imagery- Th1nk of a pleasant event or place

Behavioral contracting

Posit1ve statements

Allow to help wilh procedure- SL Flush. holding dressings

Interventions Adolescents -.. '~' :;:;i~~,~~.~

Separation Anxiety

0 Benefits from group associations with other hospitalized age-mates

0 Keep in contact with friends - visits, calls

0 Keep up with lessons

Interventions for Adolecence _..1_~, '. Loss of Control

G1ve choices Give information about procedures; illness

Fear of Pain and Bodily Injury Same as adult

Show acceptance

. . , . . . : •

Eye Drops • Never g1ve directly over cornea • Drops before ointment • About 3 minutes apart for multiple eye drops

Recta l Suppositories · Tylenol or Aspirin • 5-10 minutes to absorb ·Use lubricant

Administration of Medic

' 4 llfo...A.:-..1.:

Ear Drops

1. Drops should be at room temperature

2 Restra1n an 1nfant or uncooperative young child as needed.

3 Turn head so affected s1de 1s up.

c W1pe outer ear. clean dra1nage from outer ear

5 <3 years old- pull pmna down and back >3 years old- pull ptnna \JP and back Insert drops be1ng careful not to let dropper touch ear canal

7 Rub ontenor pon1on of ear to enhance absorption unless ot1t1S externa (SWJmmer"s ear)

-. 1!111 8 Keep chen! 1n pos111on for several mmutes If> ..

Vital Si

Count respirations first (before disturbing the child)

Count for full minute

Count ap1cal heart rate second

Measure blood pressure (BP) (if applicable) third

. Measure temperature last

Vital Signs

Blood Pressure • Somelimes do on calves or thighs

• If BP cuff too small; false high

• If BP cuff too big; false low

• If you can't find the right size cuff. b etter to find a little too b ig than too small

Vital Signs

Vital Signs

Temperature • Oral temperature- arouna 4 years old

• 1f unable, do ax1llary temps

• Ax1llary- always done on bab1es under 30 days

•Tympamc- no longer felt to be accurate and rarely used

·Rectal

·usually done when you can't do oral or axillary or 1f MD specified

- contra1nd1cated· diarrhea. rectal surgery, 1eukem1a. newborn. neu:ropen1c. oncology patients • lay ch1ldlbaby on s1de

· msert no more than :r, an 1nch (ch1ld) :r. 1nch (Infant)

· Always chart route

Weighing ·Weigh nude

Vital Si

Measurements

• Wnte the number on scale paper if you won·t remember · Weigh before feeding

Head Circumference · Over occiput directly above eyebrows. 3 times

~M

ChestCircumference ~~~ • Nipple line ,

Abdominal Circumference 1

_ 1

• "' _ .. 1 . Belly butlon ~cw~~~,_,._~ . ... ...

Length ~~~~

· Lay the down on a paper or bed sheet. mark it. then , , measure the markings

~.:.~'

Pain Assessme

Children are under medicated by health care providers • Underestimation of pain in children

Lack of information on pain management

Facial grimacing is most reliable and consistent indicator of patn in infants

Use simple terminology when assessing pain

Tell them to point and locate the pain

Pain Assessment

Use pain rating scale • Chart the name of tool used

Numerical rating scale from 0-10 Have to understand VALUE of

numbers (usually age 7 or older)

.::. ..... - -­- ·-··--

Pain Assessment : Wong Baker Faces,_-~'"·,:,.

Wong-Ba..er FACES Pain Rt~I IOQ SClllle

0 l <1 6 I 10 NO ....,.._t ..,.f\ ~ .... n ..... , -n

Ul'TUWI' un\t w.o-.1 C'\IOIWOII '"'tOUtOt 'I\IOinl

Pain Assessment

FLACC Pain Scale

; Fact I: · Nt.o~···~ .. - ·IJ"'A 1·0«:-....-.:• .. -- --·oo<'\· .. - ·,•M<t

~ ~~...,......--t ... ..... -""9- ~~··­o-......,. r>Q\_,~~<~•.u-.c

OATI!/TtMf

~~~~~~~~ -------------, ~~~::.-t'l __ ,_...,._.~

, .~ ......... --~­:r-~. f't~ CIO joiV'I9

! ~? ... ..,., .... .._, "' ....... , I ~!11::~=~~::;:.::_.,_" · -~ .........

ll •lt."'-"'.U.O~_,_ ~-~.,_. ... Oit.tll'tnOit J -~IOOV.Nooc~

TOTAL SCORE I

Pain Management

Non-pharmacological · Repos1t1on

· Massage

• Drstraction

• Role-ptay1ng

• Gu1ded 1magery

Pharmacologic • Oral meds f~rst . IV next. if appropnate

• PCA pump after age 6

• Morphme drug of cho1ce

• If switching f rom IV to o ral mods, your dose wi ll increase

1&0

Weigh diapers • 1 gm = 1ml

• weigh dry diaper. then weigh wet diaper then subtract

Check every time they void

Record feedings in ml • 30 ml = 1 oz -

PROCEDURES N~rf..eeds.- ·.i.t.:

1= -~ t Nasogastric Feeding _.)/~- . :: 1 ~JP:· I POUt prescnbed amotWII ollormufa 11\IO meastu-.g device

2. PoSition Infant With h(lil tl elmnt led 30~ P(l&l11on c:hitd in seml·foYo'lnr'~~o position.

3 Check lor placement of 1\Jbc by aspubniJ o•:.tr~e corltent& ootng r~mount tmd quantity In ~nfants rf 1/4 ol preVIOUS feedl-.g r~ mU5t hold feeding for 30 to 60 mn.Jtet; and repM to MO U ... than 1/4 o f p~e'nO\JS feeding. may ...-bOlo feeding

4 Pour tornnala .nto bat1CI ol 30 to 60 mt syrm~Je Push to start, Should !low by gra\nfY 3 mVm~n lor ;nlanb and 10 mVm1n lor oldt.'f c:l\lldfen Usu:\lty tAkes IS to 30 minutes lor a bokr& gmvrty teedllg

5 After leedflg flush W'l'lh 1 to 5 ml of water tOt •1lan1s 15 mJ tOt older children Of t.to pre" rlbed or~s for Uh

:o ~-nate on right Side with head of hea up Leave neoMte undisturbed lor 45 to

~ .. -.,t'l'

. _ ...... _ .. _ --

.,. ;~b::: . - ~-· t!u.)sur•I'IV :\IG t.JbC ;ns.:'1.0n

d S.tMI((> .. _ .. ___ ..., ___ .,_ .. -·------.. ., ... _, __ _ ___ .... __ .. __ _ ------------··---.... --...

PROCEDURES Urine Specimen~~ . , OBTAINING A U8)NE SPECIMEN

School Age Md adoltscent can use n bedpan or urinal. For toddler5/preschoolers use teuns thty wil understnnd like ·peepee· ,

GNe o gin" ol water 30 m~nules prior to collecting specimen

BAGGING FOR A URINE SPECIMEN

C!etln$1! pet11~1\! aru gertty With t.Oap l'tnd water Remove l'tl diaper olfltment. Dry thmouQIIty Adhesrve W\1 not sttck unless sbl cleM and dsy Don't use \~f

Fm Femrtltta- Spread pmrnealtuea Remove lowtH p~tJon of adhesive from specimen bag Stan at the b•idge or skm 1Jepareting the vag1na and the anua

Fat r.lntes- Spread perineun1 Start etnanow btidge ol slon • epnratlng the anus from scrotum If a smal bab( ccrorum may fLt n bag Work outward Don't C:O\'er

the anus

Pu:!'S adhe'SIVe fr"mty agall'l$1 sk.KI AVOID -wmkles When bottom par1 m plle~J. remo11e paper from upper portion ol odh~e W Ofk ~ward.

Cut ll sl1t in dmpe1 PuH tJ~u thmugh. Can VtSut~llze wh~n ~nlanUioddle, ':i& v01c:ts Check f1equr.n1!y.

~.:. ~.,.

Collect equipment- Sten!e water, sterile glo-ves, correct Size catheter Infant- 8 Fr Toddler· 10 Fr Preschool- 12 Fr Schoolage- 12·14 Fr

1 Posttton older child in semt·fow1ers posthon lnlanl- Restratn With head up

2 Use low pressure- 100 to 120 mm Hg for older ch1ld Use 60 to 100 mm Hg for mfants

3 Pour stenle H20 •nto stenle contamer

4 Apply stenle glove to domtnant hand

5 Ustng gtoved hand, attach catheter to suet on machtne

Suction in

OROPHARYNGEAUNASOPHARNGEAL SUCTIONING (con1)

6 ApproJttmate dtstance between pfs ear lobe and ltp of nose and pace gloved forefinger and thumb at that po1n1

7 MOtston end of catheter wrth stente solutton and appry suct•on Thts checks equ•pment

8 Sucbontng·Orophamgeal Gently msen mto s•de cf mouth and gltde catheter 1010 oropharynx Don t oppty suction durang insen1on To asp11ate left bronchus tum head to nght and ttlt chest to the leU Reverse pl's pos•t•on for a5Pir3110n of oppostte bronchus.

Suchontng-Nas opharyngeal Gently 1nsert catheter mto one nostnl Gu•Ce catheter med1ally along the floor of nasal cav1ty Do not force catheter 1f one nostnl not patent

Suct ioning

OROPHARYNGEAUNASOPHARNGEAL SUCT!ONING (= l

9 Apply suction by oeclud1ng port With thumb. Gently rotate the catheter as you withdraw · Suction no more than 10 to 15 seconds for older child and 5 to 10 seconds for an 1nfant • Avo1d excessive pull on delicate mucosa. Catheter should not obliterate airway

10 Flush catheter With stenle H20

11 Allow child to rest at least 30 to 60 seconds 10 between suct•on•ng

12 SuctiOn secrehons in mouth, under tongue after suchon•ng naso or oropharynx

13 Ots~rd by wrapping around gloved hand and pu!hng glove off ~~ around catheter

~:.i'l

http://wvvw.youtube.com/watch?v=3R31Mwl 1Ja4

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