Steps

Rationale/Points of Emphasis

1 Gather the necessary supplies.

Promotes efficient time management and provides an organized approach to the procedure.

2 Perform hand hygiene.

Reduces transmission of microorganisms.

3 Identify the infant using two different patient identifiers.

Reduces incidence of procedure being completed on wrong infant.

4 Prepare infant.

4a If topical analgesia is used, apply in enough time before circumcision to allow efficacy.

Provides adequate time for skin penetration of anesthetic.

4b Administer acetaminophen 30 minutes before procedure, as ordered.

Augments analgesia; provides time for adequate blood levels of medication.

4c Verify the infant’s identification band and presence of signed consent with the healthcare prescriber.

Ensures that correct infant has procedure performed and consent has been obtained.

caREminder

To detect potential for complications, assess infant for signs of blood dyscrasia, such as ecchymotic spots or prolonged bleeding, and report presence to healthcare prescriber.

5 Place infant under radiant warmer or heat lamp on circumcision restraining board. Remove diaper and, if clean, place under the buttocks.

Prevents hypothermia and controls infant movement. Allows for complete visualization of the penis. The diaper provides area to collect drainage.

6 Dip pacifier in sucrose and offer to infant. Throughout procedure, check frequently to keep pacifier in infant’s mouth.

Sucrose may be mediated through opioid receptors and used to help manage procedural pain in infants. Initiates some analgesia before procedure to augment, not replace, more potent pain prevention measures (e.g., dorsal penile nerve block, topical anesthetic).

7 Don gloves.

Standard precaution to reduce transmission of micro organisms.

8 Cleanse penis, scrotal area, and groin with chlorhexidine. Remove gloves and perform hand hygiene.

Reduces transmission of microorganisms.

9 Assist in administration of subcutaneous ring block or dorsal penile nerve block. Wait for 4-5 minutes.

Prevents pain. Subcutaneous ring block may be more effective than dorsal penile nerve block, which is more effective than EMLA, a topical analgesic. Waiting allows analgesia to occur.

10 Prepare equipment using aseptic technique.

Reduces chances of equipment contamination and transfer of microorganisms.

10a Open circumcision tray and sterile gloves.

10b Place proper size of sterile clamp or Plastibell requested by healthcare prescriber on tray; have several sizes available.

Infants require different sizes of clamps or Plastibells.

10c Have bulb syringe readily accessible.

Prepares for suctioning in case of vomiting.

10d Dressing supplies (e.g., petroleum jelly and gauze) should be immediately accessible.

Dressing applied to site immediately after procedure prevents bleeding. Petroleum prevents gauze from sticking to wound and may promote healing.

11 Position light on groin area.

Enhances visualization of area.

12a Monitor child’s response and assist healthcare prescriber during procedure.

Ensures procedure is progressing without untoward effects.

12b Provide soothing measures/pad restraint board if distress due to restraint; if distress is due to being exposed, cover with blanket or provide support by placing hands on infant to provide sense of containment.

Promotes atraumatic care.

caREminder

If infant cries, evaluate cause. If due to pain, ensure that adequate time has elapsed for analgesia to take effect; recoat pacifier with liquid sucrose solution and reposition in infant’s mouth.

13 If foreskin tissue is being sent for evaluation, collect and handle tissue using aseptic technique. Place tissue in a sterile container labeled with infant’s name, date, and time. Place specimen in biohazard bag and send to laboratory.

Ensures safe collection of tissue and that correct infant tissue is tested.

14a At completion of procedure, don gloves and immediately apply dressing to penis using sterile petroleum jelly liberally applied around penis and then cover with sterile gauze, or use petroleum gauze packet if Gomco-type circumcision. If Plastibell type, apply antibiotic ointment as ordered by healthcare prescriber. Completely remove chlorhexidine solution with sterile water.

Controls bleeding and prevents diaper from adhering to surgical site.

Chlorhexidine may cause tissue damage if left in contact with infant’s skin.

Do not apply dressing if circumcision was performed using a Plastibell. In all cases, semipermeable dressings or large amounts of tape should not be used. Petroleum may cause Plastibell to loosen, and gauze may snag on Plastibell. Removing a semipermeable dressing or large amounts of tape can cause pain and irritation or can damage the infant’s fragile skin.

14b Assess site for bleeding, and then loosely apply diaper. Comfort infant.

Detects complications. Circumcised area may ooze blood, but no frank bleeding should occur. Bleeding is the most common complication and usually is controlled well using local hemostatic measures.

If frank bleeding occurs, apply sterile pressure dressing using sterile gauze. Notify healthcare prescriber immediately.

15 Wrap infant in blanket. Position infant on back.

Reduces risk of hypothermia. Decreases risk for sudden infant death syndrome and prevents placement of pressure on circumcision area.

16 Dispose of equipment and waste in appropriate receptacle. Remove gloves and perform hand hygiene.

Standard precautions. Reduces transmission of microorganisms.