35 Key Pediatric Nursing Interventions Notes

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IV Fluid Administration

Administering IV fluids to an infant or child requires close attention to the child's fluid status. Typically, the amount of fluid to be administered in a day (24 hours) is determined by the child's weight (in kilograms) using the following formula: 100 mL per kg of body weight for the first 10 kg 50 mL per kg of body weight for the next 10 kg 20 mL per kg of body weight for the remainder of body weight in kilograms A. IV house over the IV site on a child's hand. B. IV house over the site on an infant's foot.

TAKE NOTE!

Administering ear drops. A. For the child younger than 3 years of age, the nurse pulls the pinna of the ear down and back. B. For a child older than age 3 years, the nurse pulls the pinna of the affected ear up and back.

Peripheral Parenteral Nutrition

Child's status Nutritional status usually within acceptable parameters Oral intake decreased or absent

MEDICATION ADMINISTRATION

At one time or another, every child will need to receive medication. As with adults, pediatric medication administration is a critical component of safe and effective nursing care. The pediatric nurse must adapt administration principles and techniques to meet the child's needs. Medication administration, regardless of the route, requires a solid knowledge base about the drug and its action. As with medication administration to any person, the nurse must adhere to the "rights" of medication administration (Box 35.1). These rights were developed to ensure patient safety by decreasing the occurrence of medication errors. Some experts have added additional rights, such as right documentation, right to be educated, right to refuse, and right form. These additional rights are important to consider to increase patient safety and satisfaction.

Peripheral Parenteral Nutrition

Components Fluid, electrolytes, and carbohydrates (dextrose); usually no protein or fats Carbohydrate concentration usually limited to 10% or less and osmolarity of <600 mOsma

TAKE NOTE!

Do not rotate a jejunal or gastrojejunal tube because it can cause kinking

Growth and Development Issues Related to Pediatric Medication Administration for a toddler

Issue/Concern Development of autonomy with displays of negativism; rituals, routines, and choices necessary to maintain some sense of control Nursing Interventions Follow routines and rituals from home in giving medications if these are safe and positive approaches Involve parents in medication administration Offer simple choices (e.g., "Do you want Mom or me to give you your medicine?") Allow child to touch or handle equipment as appropriate

Growth and Development Issues Related to Pediatric Medication Administration for an adolescent

Issue/Concern Development of identity, benefiting from much more control over their care Nursing Interventions Approach in same manner as adults, with respect and sensitivity to their needs Maintain the adolescent's privacy as much as possible

Preventing Complications

IV therapy is an invasive procedure that is associated with numerous complications. Strict aseptic technique is necessary when inserting the device and caring for the site. Adherence to standard precautions is key. Inspect the insertion site every 1 to 2 hours for inflammation or infiltration (inadvertent infusion of a nonirritant solution or medication into the surrounding tissue). Note signs of inflammation such as warmth, redness, induration, or tender skin. Check closely for signs of infiltration such as cool, blanched, or puffy skin. Use of a transparent dressing or IV house dressing provides easy access for assessing the IV insertion site. These types of dressings also help to prevent movement of the catheter hub, thus minimizing the risk of mechanical irritation, dislodgement, and complications such as phlebitis or infection (Fig. 35.10). Typically, in adults, an IV site is changed every 72 to 96 hours and at any time when the integrity of the system has been compromised or contamination is suspected (CDC, 2017). However, with children, the 72- to 96-hour time frame may need to be adjusted to minimize the child's exposure to the repeated trauma of insertion. Current recommendations include replacement in children only when clinically indicated (CDC, 2017). Follow the agency's policies and procedures related to site changes. Consider an alternative route for fluid and medication administration or the insertion of an alternative IV device, such as a PICC line. Catheter-related bloodstream infections often can occur with the use of central venous lines. These infections result in increased morbidity and health care costs (CDC, 2016). Prevention is paramount. Nurses need to practice proper hand hygiene, use maximal barrier protection during insertion, assess the site frequently, provide proper site care using strict sterile technique, and ensure that the child's central venous catheter is removed as soon as it is no longer needed. In children, it is important also to prevent the child from touching and playing with the central venous line site or dressing. The CDC and Healthcare Infection Control Practices Advisory Committee (HICPAC) currently recommend changing administration sets that are continuously used no more frequently than 96 hours but at least every 7 days, except if fluids that increase microbial growth, such as blood, blood products, or parenteral nutrition, have been administered (CDC, 2017). In these cases, changing the administration sets every 24 hours is recommended (CDC, 2017). Replace administration sets per agency policy. Ensure proper disinfecting of all catheter hubs, needleless connectors, and injection ports before accessing them to minimize contamination. TAKE NOTE! Chlorhexidine-impregnated sponge (Biopatch) dressings may be used to help prevent infection in children older than 2 months of age (Gorski et al., 2016). Always follow agency or institution policy and procedures regarding site care. Discontinuing the IV Device Prepare the child for removal of the IV device in much the same manner as for insertion. Many children may fear the removal of the device to the same extent that they feared its insertion. Explain what is to occur and enlist the child's help in the removal.

CLINICAL REASONING ALERT!

If the child vomits during the feeding, stop the feeding immediately and turn the child onto his or her side or sit him or her up.

Nontunneled central venous catheter (CVC)

Nontunneled central venous catheter (CVC) Usually used short term One or more lumens Percutaneous insertion most commonly via the subclavian, internal jugular, or femoral vein with the tip of the catheter at the top of the superior vena cava just above the right atrium Useful for emergency situations Catheter sutured in place at the exit site Increased rate of central line associated blood stream infection than tunneled CVC

Central Access Devices

Numerous devices for central venous access are available. The type chosen depends on several factors, including the duration of the therapy, the child's diagnosis, the risks to the child from insertion, and the ability of the child and family to care for the device. The device may have one or multiple lumens. Although central venous access devices can be used short term, the majority are used for moderate- to long-term therapy. Central venous access devices are indicated when the child lacks suitable peripheral access, requires IV fluid or medication for a prolonged period of time, or is to receive specific treatments, such as the administration of highly concentrated solutions or irritating drugs like chemotherapeutic agents, parenteral nutrition or blood and blood products. Child preference is also a consideration. Central venous access is advantageous because it provides vascular access without the need for multiple IV starts, thus decreasing discomfort and fear. However, central venous access devices are associated with complications such as infection at the site, sepsis due to the direct access to the central circulation, and thrombosis due to partial occlusion of the vessel. Typically, a chest radiograph is performed after a central venous access device is inserted to verify proper placement. No fluids are administered until correct placement is confirmed. Table 35.3 describes the major types of central venous access devices.

Parenteral Nutrition

Nutritional support can be administered IV through a peripheral or central venous catheter. The concentration and components of the solution determine the type of parenteral nutrition. Parenteral nutrition given via a central venous access device is termed total parenteral nutrition (TPN). Comparison Chart 35.1 gives information about peripheral and central parenteral nutrition.

TAKE NOTE!

Parental involvement in medication administration when possible helps decrease stress on the child and provides an opportunity for teaching and evaluating parental techniques.

TAKE NOTE!

Pay close attention to ensure if the safe range dose is for 24 hours (mg/day) or a single dose period (mg/dose).

Inserting Peripheral IV Access Devices

Peripheral IV devices are used for most IV therapies. Prior to insertion, review the child's diagnosis and medical history for information that may affect therapy, such as site selection or insertion. For example, a child who has a history of chronic illness may have heightened fears and anxieties related to insertion due to his or her previous experiences or difficulty in accessing IV sites. Typically, the nondominant extremity should be used for insertion, but this may not be possible in certain situations, such as if a right-handed child has a cast on his left arm. Check the orders for the prescribed therapy. Determine the purpose and length of the IV therapy and the type of fluid or medication that is to be administered. This information aids in selecting the best device and insertion site. For example, the device needs to be of an adequate gauge to allow the solution or medication to infuse into the vein while at the same time allowing enough blood flow around the device to promote dilution of the infusion. Establish rapport with the child and parents. Inform them about IV therapy and what to expect. Be honest with the child. Explain that the venipuncture will hurt but only for a short time. Provide the child with a time frame that he or she can understand, such as the time it takes to brush his or her teeth or eat a snack.

TAKE NOTE!

Position the infant or young child with head elevated for safe medication administration. Holding the child or having a parent hold the child is preferred unless contraindicated.

TAKE NOTE!

Prior to administration of any medication, wash hands and don gloves if necessary. Adhere to the rights of medication administration.

Total Parenteral Nutrition

Provides all nutrients to meet child's needs Enough calories supplied to maintain a positive nitrogen balance.

Focus on Safety GOAL: Safely Use Medications

Steps: Label all medications that are removed from the manufacturers package and that are not being given immediately to the child, with pertinent information such as name, dose, and volume.

Providing Skin and Insertion Site Care

Skin around the gastrostomy or jejunostomy insertion site may become irritated from movement of the tube, moisture, leakage of stomach or intestinal contents, or the adhesive device holding the tube in place. Keeping the skin clean and dry is important and will help prevent most of these problems. The skin around a gastrostomy or jejunostomy tube requires cleaning at least once a day. Routine site care includes gentle cleansing with sterile water or saline for newly placed tubes, or for established tubes, soap and water followed by rinsing or cleaning with water alone. To clean under an external disc or bumper, a cotton-tipped applicator may be used. During insertion site care, rotate the gastrostomy tube or button a quarter-turn to prevent skin adherence and irritation. Always follow agency or institution policies and procedures. Assess the insertion site and condition of the surrounding skin for signs and symptoms of infection, such as erythema, induration, foul drainage, or pain. A small amount of clear or tan drainage is normal. If any drainage is present, a dressing can be placed. Use a presplit 2 × 2 gauze and place it loosely around the site. Change this dressing when it is soiled. If no drainage is present, do not place a dressing as it can cause undue pressure and trap moisture, leading to skin irritation. Preventing movement of the tube also helps reduce skin irritation. Check the volume of the balloon with a balloon-tipped device about once or twice a week and reinflate the balloon to the initial volume if needed. The tube should be able to move slightly in and out of the child's stomach. The plastic disc should be snug against the skin but not tight enough to cause pressure. Tube stabilization methods help prevent the tube from moving around and sliding further into the stomach or jejunum. Stabilize the tube by pulling gently on the tubing and sliding the stabilizer bar or disc snugly against the abdomen. Measure and record the length of the tube from the exit site of the abdominal wall to the end of the tube. All future measurements should be the same unless the tube length is changed. For tubes without a stabilizer bar or disc or for additional stabilization needs, several other methods may be used, including cut baby bottle nipples, taping methods, and commercially available stabilizers (Fig. 35.12). It is always important to follow agency policy.

Dosage Calculation Using Body Weight

• After converting the child's weight in pounds to kilograms and checking the safe dose range: • Calculate the low safe dose range (e.g., 10 to 20 mg/kg and the child weighs 30 kg): • Set up a proportion using the low safe dose range • 10 mg/1 kg = x mg/30 kg • Solve for x by cross-multiplying: • 1 × x = 10 × 30 • x = 300 mg • Calculate the high safe dose range: • Set up a proportion using the high safe dose range • 20 mg/1 kg = x mg/30 kg • Solve for x by cross-multiplying: • 1 × x = 20 × 30 • x = 600 mg • Compare the safe dose range (for this example, 300 to 600 mg) with the ordered dose. If the dose falls within the range, the dose is safe. If the dose falls outside the range, notify the prescriber.

Guidelines for Administering Medications via Gastrostomy or Jejunostomy Tubes

• Verify correct placement (refer to Box 35.4). • Give liquid medications directly into the medication port. Draw appropriate amount into syringe and clear air. • Mix powdered medications well with warm water first. • If medication is in pill or capsule form, verify it is OK to crush or open. Then, crush tablets or open capsules and mix with warm water to prevent tube occlusion. • Label each syringe appropriately. • Give medications one at a time. Flush the tube with water after administering each medication unless contraindicated to ensure that the entire amount of medication has been given and to prevent tube occlusion. When the child has a nasogastric, orogastric, nasojejunal, nasoduodenal, gastrostomy (opening into the stomach), or jejunostomy tube, oral medications may be given via these devices. The tube allows for the medication to be placed directly into the stomach or small intestine area. Be aware that not all medications can be placed directly into the duodenum or jejunum. Medication for administration via a tube must be supplied in a liquid form, or a crushed tablet or opened capsule can be mixed with a liquid (Box 35.3). Always check tube placement before administering the medication. After administration, flush the tube to maintain patency.

Intravenous Maintenance Fluid Calculations by Body Weight

<10 kg in weight 100 mL per kg of weight = # mL for 24 hours Example: A child weighs 7.4 kg 7.4 × 100 = 740 mL (daily requirement) 740/24 = 30.8 or 31 mL/hour 11-20 kg in weight 100 mL per kg of weight for the first 10 kg + 50 mL/kg for the next 10 kg = # mL for 24 hours Example: A child weighs 16 kg (10 × 100 = 1,000) plus (6 × 50 = 300) Total = 1,300 mL (daily requirement) 1,300/24 = 54 mL/hour >20 kg in weight 100 mL/kg for the first 10 kg + 50 mL/kg for the next 10 kg + 20 mL/kg for each kg >20 kg = # mL for 24 hours Example: A child weighs 30 kg (10 × 100 = 1,000) plus (10 × 50 = 500) plus (10 × 20 = 200) Total = 1,700 mL (daily requirement) 1,700/24 = 70.8 or 71 mL/hour

TAKE NOTE!

In young infants, instill the medication in one naris at a time, since they are obligate nose breathers.

Providing Nutritional Support

Adequate nutrition is important for all individuals but especially for children. During the growing years, the quality of a child's nutrition affects his or her overall health and development. The presence of a chronic illness, disease, or trauma can increase the child's nutritional demands; if the child cannot meet these even with oral supplementation, other measures may be necessary to provide nutritional support. Such measures may include enteral nutrition (delivery of nutrition into the gastrointestinal tract via a tube) and parenteral nutrition (IV delivery of nutritional substances). The nutritional plan is determined by the child's age, developmental level, and health status.

Determination of Correct Dose

Administering the correct dose is a key component of medication administration. Children are more vulnerable to medication errors due to the individual dosing necessary for proper medication administration. Improper dosing is a common medication error reported in the pediatric population (Zimlich, 2018). Many drug references list recommended pediatric dosages, and nurses are responsible for checking doses to ensure that they are appropriate for the child. Two common methods for determining pediatric doses are based on the unit of drug per kilogram of body weight or BSA.

CLINICAL REASONING ALERT!

If for any reason the TPN infusion is interrupted or stops, be prepared to begin an infusion of a 5% to 10% dextrose solution at the same infusion rate as the TPN (Bowden & Greenberg, 2016). This helps to prevent rebound hypoglycemia that may occur due to the increased insulin secretion by the child's body in response to the use of the highly concentrated TPN solution.

Differences in Pharmacodynamics and Pharmacokinetics

Although a drug's mechanism of action is the same in any individual, the physiologic immaturity of some body systems in a child can affect a drug's pharmacodynamics (behavior of the medication at the cellular level). As a result, the body may not respond to the drug as intended. The intended effect may be enhanced or diminished, necessitating a change in the dosage to ensure optimal effectiveness without increasing the child's risk for toxicity. The child's age, weight, body surface area (BSA), and body composition also can affect the drug's pharmacokinetics (movement of drugs throughout the body via absorption, distribution, metabolism, and excretion). Drugs are administered to children via many of the same routes that are used for adults. However, this similarity ends once the drug is administered. During the absorption process, drugs move from the administration site into the bloodstream. In infants and young children, the absorption of orally administered medications is affected by slower gastric emptying, increased intestinal motility, a proportionately larger small intestine surface area, higher gastric pH, and decreased lipase and amylase secretion compared with adults. Intramuscular (IM) absorption in infants and young children is affected by the amount of muscle mass, muscle tone and perfusion, and vasomotor instability. Similarly, decreased perfusion alters subcutaneous (SQ) absorption. Absorption by these routes is erratic and may be decreased. In contrast, topical absorption of medications is increased in infants and young children, which can result in adverse effects not seen in adults. Infants and young children have a greater BSA, leading to increased absorption of topical medications. Absorption in infants is also increased due to greater permeability of the infant's skin. The distribution (movement of a drug from the blood to interstitial spaces and then into cells) of medications is also altered in infants and young children. Medication distribution in children is affected by: higher percentage of body water than adults. more rapid extracellular fluid exchange. decreased body fat. liver immaturity, altering first-pass elimination. decreased amounts of plasma proteins available for drug binding. immature blood-brain barrier, especially in neonates, allowing permeation by certain medications. Metabolism of medications in children is altered because of differences in hepatic enzyme production and the child's increased metabolic rate. Biotransformation (the alteration of chemical structures from their original form, which allows for the eventual excretion of the substance) is affected by the same variations affecting distribution in children. In addition, the immaturity of the kidneys until the age of 1 to 2 years affects renal blood flow, glomerular filtration, and active tubular secretion. This results in a longer half-life and increases the potential for toxicity of drugs primarily excreted by the kidneys.

TAKE NOTE!

Always administer medications promptly, assist the child in holding still using a comforting position for the child, and reward positive behavior.

Administering Oral Medications

Be firm when telling your child that it is time for his or her medication. State, "It's time for your medicine" instead of asking, "Will you take your medicine?" or "Can you take your medicine for me?" • Allow your child to choose an appropriate liquid to help swallow the medication or drink after taking it. Limit the choices to two or three. • Never bribe or threaten your child to take his or her medication. • Never refer to the medication as "candy." • Be honest about the taste of the medication. If necessary, mix it with another food such as apple sauce, yogurt, or syrup to help mask the taste. • Do not mix the medication with formula or baby food. • Always check with your physician or nurse practitioner and pharmacy about opening capsules or crushing tablets and mixing them with food. Some medications should not be opened or crushed. • If you are giving a liquid using an oral syringe or dropper, place the medication slowly along the inside of the cheek. Never squirt the medication forcibly to the back of the child's throat. It may cause the child to gag and spit out the medication or aspirate it into his or her lungs. • Always praise the child after taking the medication and provide comfort and cuddling.

Dose Determination by Body Surface Area

Calculating the dosage based on BSA takes into account the child's metabolic rate and growth. It is commonly used for chemotherapeutic agents. Some recommended medication doses may read "mg/BSA/dose." To determine the dose using BSA, you will need to know the child's height and weight, which will be plotted on a nomogram (Fig. 35.1). A nomogram is a graph divided into three columns: height (left column), surface area (middle column), and weight (right column). Use these guidelines to determine BSA: Measure the child's height. Determine the child's weight. Using the nomogram, draw a line to connect the height measurement in the left column and the weight measurement in the right column. Determine the point where this line intersects the line in the surface area column. This is the BSA, expressed in meters squared (m2). Once you have determined the BSA, use the recommended dosage range to calculate the safe dosage.

TAKE NOTE!

Certain drug formulations should not be crushed. Before crushing a pill or opening a capsule, always check that this will not alter the intended effects of the drug. Crushing a time-release medication allows immediate absorption of the entire dose of the medication and can have lethal consequences.

Total Parenteral Nutrition

Child's status Child with a nonfunctioning gastrointestinal (GI) tract, such as a congenital or acquired GI disorder Severe failure to thrive Multisystem trauma or organ involvement Preterm newborns

Developmental Issues and Concerns

Children are constantly growing and developing. The specific psychosocial, cognitive, physical, and motor developmental levels of children are important. Nurses need a solid understanding of growth and development to ensure safe administration of medications to children. Table 35.1 details some growth and development issues related to administering medications to children. Always give developmentally appropriate, truthful explanations before administering medications to children, including: Why the drug is needed What the child will experience What is expected of the child How the parents can participate and support their child The child's past experiences with taking medications and the approaches that may have been used will often affect how the child reacts. Always approach children positively; let your manner convey the belief that they can accomplish this needed behavior. Never label the child as "bad" if he or she did not fully cooperate in taking medication. When medications must be administered with a needle (intramuscularly or subcutaneously), assure the child that this method is not a consequence of the child's behavior. Help parents to work through the feelings of frustration that may result from the child's refusal to cooperate with medication administration. Provide parents with facts about growth and developmental issues and children's fears and anxiety related to medication administration. Model alternative ways for the parents to deal with undesirable behavior.

Growth and Development Issues Related to Pediatric Medication Administration for a school-aged child

Issue/Concern Development of industry, benefiting from being a part of their care; generally very cooperative Nursing Interventions Explain to child in simple terms the purpose of the medication Seek their assistance, such as putting pills in cup or opening the packet, and allow a broader range of choices Establish a reward system to enhance their cooperation, if necessary

Peripheral Access Devices

Devices used for peripheral venous access in a child include over-the-needle catheters or winged-infusion sets, commonly referred to as "butterflies" or scalp vein needles. These devices are inserted into the vein and then connected to the IV solution via tubing to provide a continuous infusion of fluid. These devices can also be inserted for intermittent use if the child does not require a continuous fluid infusion. Typically, the hub of the device is capped or plugged to allow intermittent access, such as for administering medications or obtaining blood specimens. When used in this manner, these devices are termed peripheral intermittent infusion devices or saline or heparin locks. Needle size on the device also varies. Typically, the needle ranges from 21- to 25-gauge, depending on the child's size. The rule of thumb is to use the smallest-gauge catheter with the shortest length possible to prevent traumatizing the child's fragile veins. Typically, peripheral IV devices are used for short-term therapy, usually averaging 3 to 5 days (O'Grady et al., 2011). Midline catheters or peripherally inserted central catheter (PICC) are also available, and recommended for use if therapy is to exceed 6 days (CDC, 2017). These catheters are longer than peripheral catheters but still remain outside the central veins and can stay in for up to 2 months (Bowden & Greenberg, 2016). They are seated deep in the cephalic or basilic veins, but the tip does not extend past the axilla.

Educating the Child and Family

Educate children receiving enteral feedings and their parents thoroughly about this method of nutritional support. Reinforce the reason for the therapy and provide the child and parents with opportunities to verbalize their concerns and ask questions. Ensure that the parents understand the risks and benefits of the therapy and the expected duration. Provide the child, if developmentally appropriate, and parents with opportunities to participate in the feeding sessions. This helps allay some of their fears and anxieties and promotes a sense of control over the situation. They will also gain valuable practice in learning the skill should the feedings be required at home. Teaching Guidelines 35.3 identifies important topics to include in the teaching plan for a child receiving enteral nutrition at home. Troubleshooting problems at home is an important topic to cover. Refer to Teaching Guidelines 35.4. Education also involves helping the family develop appropriate coping strategies to adapt, solve problems, and access the support and services they will need after discharge.

Administering Enteral Feedings

Enteral feedings can be given continuously or intermittently, regardless of the type of tube used. Intermittent feedings are commonly called bolus feedings. With a bolus feeding, a specified amount of feeding solution is given at specific intervals, usually over a short period of time such as 15 to 30 minutes. Given via a syringe, feeding bag, or infusion pump, bolus feedings most closely resemble regular meals. Continuous feedings are given at a slower rate over a longer period of time. In some cases, the feeding may be given during the night so that the child can be free to move about and participate in activities during the day. For continuous feedings, an enteral feeding pump is used to administer the solution at a prescribed rate. Checking for tube placement is a priority before administering any intermittent tube feeding and periodically during continuous tube feedings, regardless of the type of tube being used. (Refer to Box 35.4.) For gastrostomy and jejunostomy tubes, ensure that the calibration, if present, has not changed. Measure the length of the tube daily from the exit site on the stomach to the end of the tube. Assess the abdomen for distension and bowel sounds. Also, measure the gastric residual (the amount remaining in the stomach; indicates gastric emptying time) by aspirating the gastric contents with a syringe, measuring it, and then replacing the contents. Check the residuals periodically, according to the facility's policy, such as every 4 to 6 hours, and before each intermittent feeding. If the residual volume exceeds the amount specified by the physician's order, hold the feeding and notify the physician or nurse practitioner. Begin the feeding by placing the child in a supine position with the head and shoulders elevated approximately 30 degrees so that the feeding will remain in the stomach area (Bowden & Greenberg, 2016). Flush the tube with a small amount of water to clear it and prevent occlusion. This is not necessary for a gavage feeding if the tube is being inserted each time a feeding is given. Ensure that the feeding solution is at room temperature. Administer the feeding per the facility's policy. Feeding solutions may be placed into the barrel of a syringe or into a feeding bag attached to the feeding tube and allowed to flow by gravity. The rate of flow for gravity-assisted feedings can be increased or decreased by raising or lowering the feeding solution container, respectively. Typically, intermittent feedings last from 15 to 30 minutes. A feeding bag also may be attached to a pump to control the rate of flow. Monitor the child's tolerance to the feeding. Once the feeding is complete, but before the formula completely empties from the container, flush the tube with water. As the water leaves the syringe or tubing, clamp the tube to prevent air from entering the stomach. Then disconnect the syringe or tube-feeding bag from the tube. If the child has a gastrostomy button, open the cap and connect an adaptor or insert extension tubing through the one-way valve. This allows access to the gastric conduit. The feeding solution container is connected to the extension tubing or adaptor and the feeding is given as described previously. After the feeding is completed, the extension tubing or adaptor is flushed with water and the flip-top opening is closed. Burp the infant during and after any type of tube feeding in the same manner as for an infant who is bottle- or breastfed. Also, position the child on his or her right side with the head slightly elevated, approximately 30 degrees, for about 1 hour after the feeding to facilitate gastric emptying and reduce the risk of aspiration and regurgitation. Some children have a difficult time with gas and burping on their own after tube placement. Venting, which helps relieve gas, may be ordered by the physician or nurse practitioner. It removes excess air and can be helpful if the child is bloated or the abdomen is distended. Use a catheter-tip syringe with the plunger removed and attach to the end of the tube. Hold the syringe above the child's stomach for a few minutes. Once the air or gas is removed, allow any stomach contents or formula to flow back into the stomach. Weigh the child daily throughout enteral nutrition therapy to determine the effectiveness of the therapy.

Enteral Nutrition

Enteral nutrition, commonly called tube feedings, involves the insertion of a tube, so that feedings can be delivered directly into the child's gastrointestinal tract. The tube may be inserted via the nose or mouth or through an opening in the abdominal area, with the tube ending in the stomach or small intestine. Nasogastric or orogastric tube feedings, a tube from the nose to the stomach or from the mouth to the stomach, respectively, are commonly referred to as gavage feedings. Nasoduodenal or nasojejunal feedings involve a tube that is inserted through the nose and ends in either the duodenum or jejunum. Gastrostomy feedings involve the insertion of a gastrostomy tube through an opening in the abdominal wall and into the stomach. Jejunostomy feedings are similar to gastrostomy feedings except that the tube lies in the jejunum. Enteral nutrition is indicated for children who have a functioning gastrointestinal tract but cannot ingest enough nutrients orally. The child may be unconscious or have a severely debilitating condition that interferes with his or her ability to consume adequate food and fluids. Other conditions that may warrant the use of enteral nutrition include: Failure to thrive Inability to suck or tiring easily during sucking Abnormalities of the throat or esophagus Swallowing difficulties or risk for aspiration Respiratory distress Metabolic conditions Severe gastroesophageal reflux disease (GERD) Surgery Severe trauma Enteral feedings may be given via nasogastric, orogastric, nasojejunal, nasoduodenal, gastrostomy, or jejunostomy tubes (Fig. 35.11). Table 35.5 provides additional information about these types of feeding tubes. Enteral feedings cost less, are associated with fewer complications, and are considered safer than parenteral feedings. However, tube misplacement is a serious complication.

Types of Enteral Feeding Tubes

Gastrostomy (surgically inserted through the abdominal wall into the stomach) Jejunostomy (surgically inserted through the abdominal wall into the jejunum) Long-term enteral feeding or when esophageal atresia or stricture is present. Jejunostomy tubes are indicated when gastric feeding is not tolerated. • The inner section of the tube is below the skin surface with the tip located in the stomach or jejunum (may be balloon, winged, or mushroom shaped). The outer section appears above the skin surface at the insertion site and has an opening or feeding port to which the feeding solution is attached. • Low-profile gastrostomy device (gastrostomy button) is flush with the abdominal surface. The flip-top opening is anchored by a dome that fits against the stomach wall. Less conspicuous, it allows the child to be more active and mobile. • After initial insertion, the tube length is measured from the insertion site to the far end of the tube and recorded. This measurement is checked at least daily to ensure that the tube has not moved. • There are many different devices available. For any gastrostomy or jejunostomy tube, the type and size of tube inserted as well as the amount required to fill the balloon, if present, should be known.

Intramuscular Administration

IM administration delivers medication to the muscle. In children, this method of medication administration is used as infrequently as possible because it is painful and children often lack adequate muscle mass for medication absorption. However, IM administration is used to administer certain medications, such as many immunizations. Muscle development and the amount of fluid to be injected determine IM injection sites in children. Needle size (gauge and length) is determined by the size of the muscle and the viscosity of the medication. For example, more viscous medications often require a larger-gauge needle. In addition, the needle must be long enough to ensure that the medication reaches the muscle. The preferred injection site for infants 12 months or less is the vastus lateralis or anterolateral thigh muscle, in certain circumstances (such as physical obstruction of the anterolateral thigh) the gluteal muscle can be considered (Centers for Disease Control and Prevention [CDC], 2018; Immunization Action Coalition, 2018). In infants and children greater than 12 months, the vastus lateralis or anterolateral thigh muscle remains the preferred site but the deltoid can be considered if sufficient mass is present The deltoid muscle is used as an IM injection site in children older than 3 years of age and may be used in toddlers if the muscle mass is sufficient (CDC, 2018; Immunization Action Coalition, 2018). Figure 35.7 illustrates IM injection sites. Select the needle size and gauge based on the size of the child's muscle. The goal is to use the smallest length and gauge that will deposit the medication in the muscle. Table 35.2 provides general guidelines for solution amount, needle size, and needle gauge when administering IM medications. Insert the needle into the skin at a 90-degree angle. Aspirating and, if no blood was present, injecting the medication was the traditional procedure. However, recent research has shown decreased discomfort and no associated complications with rapid injection of IM immunizations without aspiration (CDC, 2015). In addition, there are no large blood vessels present in the currently recommended injection sites, the vastus lateralis and deltoid muscles (CDC, 2015). Therefore, the CDC and the Advisory Committee on Immunization Practices (ACIP) no longer recommend aspiration before injection of vaccines (CDC, 2015; Kroger et al., 2018).

INTRAVENOUS THERAPY

IV access provides a route for the administration of medications and fluids. It is commonly used for children because it is the quickest, and often the most effective, method of administration. As with adults, numerous sites and various devices and equipment may be used to provide IV therapy over a short or long period of time. When administering IV therapy, safety is crucial. The nurse must have a solid knowledge base about the fluids or medications to be given as well as a thorough understanding of the child's physical and emotional development. Venipuncture can be a terrifying and painful experience for children and their families. Nurses play a crucial role in providing support and education to the child and family before, during, and after the procedure (refer to Chapter 30 for additional information related to provision of atraumatic care with procedures).

Implanted ports (e.g., Port-a-Cath, Infuse-a-Port, Mediport)

Implanted ports (e.g., Port-a-Cath, Infuse-a-Port, Mediport) Surgically inserted by a physician Stainless steel port with a polyurethane or silicone catheter attached Catheter tip lying in subclavian or jugular vein; port implanted under skin in a subcutaneous pocket, usually on the upper chest wall Port covered completely by skin and visible only as a slight bulging on the chest; possibly more appealing to the older child and adolescent because there are no visible parts or dressings Access to port via a specially angled, noncoring needle (Huber needle) Site preparation and pain relief measures necessary before accessing the port Lowest risk for central line-associated blood stream infection

Intravenous Administration

IV medication administration is commonly used with children, especially when a rapid response to a drug is desired or when absorption via other routes is difficult due to the child's illness or condition. In some cases, the IV route is the only effective method for administering a medication. Use of the IV route requires that the child have an IV device inserted, peripherally or centrally. Although insertion of this device is invasive and traumatic for the child, IV medication administration is considered to be less traumatic when compared to the trauma associated with multiple injections. Unfortunately, the veins of a child are small and easily irritated. Most medications given by the IV route must be given at a specified rate and diluted properly to prevent overdose or toxicity due to the rapid onset of action that occurs with this route. Therefore, when administering medications via the IV route, knowledge of the drug, the amount of drug to be administered, the minimum dilution of the drug, the type of solution for dilution or infusion, the compatibility or various solutions and medications, the length of time for infusion, and the rate of infusion is required. Careful maintenance of the IV site is required to prevent complications. The primary method for IV medication administration is a syringe pump. This method provides a highly precise rate of infusion. Nursing Procedure 35.1 gives the steps for administering medication via a syringe pump. If a pump is unavailable, the medication may be administered via a volume control device. The medication is added to the device with a specified amount of compatible fluid and then infused at the ordered rate. Direct IV push medication is typically reserved for emergency situations and when therapeutic blood levels must be reached quickly to achieve the desired effect. Direct IV push administration requires that the drug be diluted appropriately and given at a specified rate, such as over 2 to 3 minutes. Care must be taken to prevent fluid overload, which may occur due to flushing needed to maintain IV patency and prevent drug incompatibilities, and from the administration of multiple drug therapies.

Sites

IV therapy may be administered via a peripheral vein or a central vein. Peripheral IV therapy sites commonly include the hands, feet, and forearms (Fig. 35.8). In neonates and young infants, the scalp veins may be used (CDC, 2017; Doyle & Edens, 2018). The scalp veins are easily visualized, being covered only by a thin layer of SQ tissue. These veins do not have valves, so the device may be inserted in either direction, although the preference would be in the direction of blood flow. However, use of a scalp vein requires that that area of the infant's head be cleared of hair to enhance visualization. In addition, use of the scalp veins can be frightening to parents, who may think the fluid is infusing into the infant's brain. Thus, scalp veins are usually used only if other sites are assessed to be inferior or attempts at other sites have been unsuccessful (Bergvall & Sawyer, 2018). When used, ensure appropriate education of the parents prior to insertion and, if shaving the child's hair is needed, inquire if parents would like to keep the child's hair. Central IV therapy usually is administered through a large vein, such as the subclavian, femoral, or jugular vein or the vena cava. The tip of the device lies in the superior vena cava just at the entrance to the right atrium. The device is inserted surgically or percutaneously and exits the body typically in the chest area, just below the clavicle. A device can be inserted via a peripheral vein, such as the median, cephalic, or basilic vein, and then threaded into the superior vena cava.

TAKE NOTE!

If a parent, caregiver, or child questions whether a medication should be given, listen attentively, answer their questions, and double-check the order.

Troubleshooting Complications at Home

If a tube becomes clogged, instruct caregivers to slowly push warm water into the tube. Amount and size of syringe will vary based on child's size and facility policy. Repeat if necessary. Instruct caregivers to never use an object or put anything into the tube. They should call the doctor or nurse if they are unable to unclog the tube. Declogging medications may be prescribed. • If a tube is inadvertently removed, instruct the caregiver to cover the site with a small clean dressing tape, then to call the physician or nurse immediately; the tube needs to be replaced as soon as possible or the tract will close. Some institutions may instruct the family on how to replace the tube once the tube is more than 6 weeks old and has formed an established G-tube tract. • If the site is red or irritated, instruct caregivers to continue with routine cleaning and call the physician. An antibiotic or skin barrier cream may be ordered. Assess for leakage and try to minimize, if possible. Check the tube's position and ensure tube is stabilized and secure and not dangling. • If the tube is leaking, the caregiver needs to keep the dressing clean and dry. Assess tube position and secure the tube to avoid dangling. Assess if leaking is from stoma area or tube valve, if applicable. More frequent venting may help and the physician should be notified. Always teach following the instructions per agency policy and procedure regarding home care.

ATRAUMATIC CARE

If appropriate, allow the child to assist in removing the tape or dressing. This gives the child a sense of control over the situation and also encourages his or her cooperation. In addition, practice atraumatic care by doing the following: Use water or adhesive remover to help loosen the tape. If a transparent dressing is in place, gently lift off the dressing by pulling up opposite corners using a motion parallel to the skin surface. Avoid using scissors to cut the tape, but if cutting the tape is necessary, be sure that the child's fingers are clear of the tape and scissors. Turn off the infusion solution and pump. Once all tape and dressings are removed, gently slide the IV device out using a motion opposite to that used for the insertion. Apply pressure to the site with a dry gauze dressing and then cover with a small adhesive bandage. If possible, allow the child to choose the bandage. TAKE NOTE! If the IV site was in the arm at or near the antecubital space, apply pressure until the bleeding stops. Do not have the child bend his or her arm after removal of the device as this is not sufficient pressure to prevent hematoma formation.

TAKE NOTE!

If bedside methods are conflicting, the NGT was difficult to place or the child is at high risk, such as children with swallowing problems, children with altered levels of consciousness, or children in the intensive care unit, radiologic verification is recommended

Parenteral Nutrition

Indications/use Primarily supplemental Short-term use to supply additional calories and nutrients

Infusion Control Devices

Infants and young children are at increased risk for fluid volume overload compared with adults. Also, malfunction at the IV insertion site, such as infiltration, may result in much greater injury than a similar incident would cause in an adult. Therefore, IV fluids must be carefully administered and monitored. To ensure accurate fluid administration, infusion control devices such as infusion pumps, syringe pumps, and volume control sets may be used. Infusion pumps used for children are similar to those used for adults. In addition, syringe pumps are often used to deliver fluid and medications to children. These pumps can be programmed to deliver minute amounts of fluid over controlled periods of time (syringe pumps are discussed further in the next section). An IV solution bag may be attached to a calibrated volume control set that has been filled with a specified amount of IV solution (Fig. 35.9). The fluid chamber holds a maximum of 100 to 150 mL of fluid that can be infused over a specified period of time as ordered. Usually, a maximum of a 2-hour infusion amount in the chamber avoids accidental fluid overload in the pediatric population. This chamber can be filled every 1 to 2 hours so only small amounts of ordered quantities of fluid can infuse and the child is protected from receiving too much fluid volume. Due to the advances in pump technology and the introduction of "smart pumps" which include dose error reduction systems such as hospital-defined drug libraries (drug lists) with standard drug concentrations, and dose limits, to potentially improve the safety of IV medication administration, the use of volume control devices has been reduced or eliminated in many facilities. Concerns include lack of identifying the medication in the volume control device and the potential for interaction or precipitation that may occur when multiple medications are administered using the same volume control device. However, as a safety device for controlling the volume of fluid administered to children they are still available; therefore, nurses should be familiar with how to use them. Be familiar with your facilities policies and procedures. When using a volume control device, ensure to label the chamber when medications are added and to check for incompatibilities and potential interaction when multiple medications are given.

TAKE NOTE!

Instilling air into the tube and then auscultating for the sound is no longer considered a viable method for checking tube placement as it has consistently proven to be unreliable

Growth and Development Issues Related to Pediatric Medication Administration for a preschooler

Issue/Concern Development of initiative, which is fostered when they sense they are helping Nursing Interventions Provide an opportunity to play with the equipment and respond positively to explanations and comforting Provide choices that are possible and keep them simple (e.g., "Do you want juice or water with your medication?" or "Which medication do you want to take first?") Do not ask, "Will you take your medicine now?" Involve parents in medication administration Be aware that giving suppositories is particularly upsetting to this age group because of their fears of bodily intrusion and mutilation

Growth and Development Issues Related to Pediatric Medication Administration for an Infant

Issue/Concern Development of trust, which is fostered by consistent care; development of stranger anxiety later in infancy Issue/Concern Involve parents in medication administration to reduce stress for infant Ensure that parents hold and comfort infant during intervention

TAKE NOTE!

Many experts no longer recommend use of the dorsogluteal site at any age due to the risk of damaging nerves and vasculature and the possibility of a suboptimal immune response Locating intramuscular injection sites. A. Vastus lateralis: identify the greater trochanter and the lateral femoral condyle; inject in middle third and anterior lateral aspect. B. Deltoid: locate the lateral side of the humerus, one to two finger widths below the acromion process. Inject into upper third of muscle. C. Ventrogluteal: place palm of left hand on right greater trochanter so index finger points toward anterosuperior iliac spine, spread middle finger to form a V, and inject in the middle of the V.

Otic Administration

Medications for otic administration are typically in the form of ear drops. This route of administration can be upsetting to the child because he or she cannot see what is happening. The child often receives otic drugs for an earache and he or she may fear that the ear drops will increase the pain. Explain the procedure to the younger child in terms that he or she can understand to help allay these fears. Gain the older child's cooperation by explaining the purpose of the medication and the procedure for administration. Reinforce the need for the child to keep the head still. Younger children may require assistance to do so. Be sure that the ear drops are at room temperature. If necessary, roll the container between the palms of your hands to help warm the drops. Using cold ear drops can cause pain and possibly vertigo or vomit when they reach the eardrum (Bowden & Greenberg, 2016). Place the child in a supine or side-lying position with the affected ear exposed (Fig. 35.5). Pull the pinna downward and back in children younger than age 3 and upward and back in older children. Instill the prescribed amount of medication using a dropper being careful not to contaminate the tip of the dropper. Then, have the child remain in the same position for several minutes to ensure that the medication stays in the ear canal. Soothe, comfort, and distract the child to allow medication to instill. Massage the area anterior to the affected ear to promote passage of the medication into the ear canal. If necessary, place a piece of cotton or a cotton ball loosely in the ear canal to prevent the medication from leaking.

Oral Administration

Medications to be given via the oral route are supplied in many forms, including liquids (elixirs, syrups, or suspensions), powders, tablets, and capsules. Generally, children younger than the age of 5 to 6 are at risk for aspiration because they have difficulty swallowing tablets or capsules. Therefore, if a tablet or capsule is the only oral form available, it needs to be crushed or opened and mixed with a pleasant-tasting liquid or a small amount (generally no more than a tablespoon) of a nonessential food such as apple sauce. However, never crush or open an enteric-coated or time-release tablet or capsule. The crushed tablet or inside of a capsule may taste bitter, so never mix it with formula or other essential foods. Otherwise, the child may associate the bitter taste with the food and later refuse to eat it. Liquid medications, primarily suspensions, may be less concentrated at the top of the bottle than at the bottom of the bottle. Always shake the liquid to ensure even drug distribution. The key to administering liquid forms of oral medications is to use calibrated equipment such as a medicine cup, spoon, plastic oral syringe, or dropper If a dropper is packaged with a certain medication, never use it to administer another medication, since the drop size may vary from one dropper to another. If using a syringe for oral administration, only use the type intended for oral medications, not the one designed for parenteral administration. When using a dropper or oral syringe (without a needle) for infants or young children, direct the liquid toward the posterior side of the mouth. Give the drug slowly in small amounts (0.2 to 0.5 mL) and allow the child to swallow before more medication is placed in the mouth (Fig. 35.3). A nipple without the bottle attached is sometimes used to administer medication to infants. Place the medication directly in the nipple and keep the nipple filled with medication as the infant sucks so no air is taken in while the infant takes the medication. Always place the infant or young child upright (at least a 45-degree angle) to avoid aspiration. The toddler or young preschooler may enjoy using the oral syringe to squirt the medicine into his or her mouth. Older children can take oral medication from a medicine cup or measured medicine spoon. As children adapt to swallowing tablets or capsules, administration is similar to that of adults. When helping the younger child learn how to swallow medication, the tablet or capsule can be placed at the back of the tongue or in a small amount of food such as ice cream or apple sauce. Always tell children if there is medicine in the food; otherwise, they may not trust you.

Nasal Administration

Nasally administered medications are typically drops and sprays. Administering nose drops to infants and young children may be difficult, and additional help may be needed to help maintain the child's position. Ensure medication is at room temperature. Have the child blow his nose or use a bulb syringe to clear nasal passage of secretions. For nose drops, position the child supine with the head hyperextended to ensure that the drops will flow back into the nares. A pillow or folded towel can be used to facilitate this hyperextension. Place the tip of the dropper just at or inside the nasal opening, taking care not to touch the nares with the dropper (Fig. 35.6). Doing so might stimulate the child to sneeze. Although the nasal membranes are not sterile, the drop solution is, and sneezing would contaminate the dropper, leading to contamination of the drop solution when the dropper is returned to the bottle. Once the drops are instilled, maintain the child's head in hyperextension for at least 1 minute to ensure that the drops have come in contact with the nasal membranes. For nasal sprays, position the child upright with head tilted slightly back and place the tip of the spray bottle just inside the nasal opening and tilted toward the back. Hold one nostril closed (or have the child do this if appropriate) and instruct the child to take a deep breath through the nostril while the medication is being administered. Squeeze the container, providing just enough force for the spray to be expelled from the container. Using too great a force can push the spray solution and secretions into the sinuses or eustachian tube.

Types of Enteral Feeding Tubes

Nasoduodenal (inserted via the nose to the duodenum) or nasojejunal (inserted via the nose to the jejunum) Short-term enteral feeding. Indicated if child has trouble digesting food, cannot use his or her gastrointestinal tract secondary to congenital anomalies or surgery, or is at risk for or has a history of severe reflux or aspiration. • Silicone and polyurethane tubes with weighted tip allow tube to pass from pylorus into small intestines. • Agency may require special training in order to place at bedside; may also be performed in radiology. • Length of use same as nasogastric or orogastric tubes.

Types of Enteral Feeding Tubes

Nasogastric (inserted via the nose into the stomach) Orogastric (inserted via the mouth into the stomach) Short-term enteral feeding Orogastric usually limited to young infants only. • Long-term use or repeated insertion causes irritation and discomfort. • Silicone and polyurethane tubes are very flexible and more comfortable; they require a stylet or guidewire for insertion. • Length of long-term use varies according to the type of tube used and the institution protocol. Periodically, a nasogastric tube is removed and reinserted via the opposite nostril to prevent pressure on the nasal mucosa. • Maintaining orogastric placement between feedings can be difficult due to oral secretions.

TAKE NOTE!

Never force an oral medication into a child's mouth or pinch the child's nose. Doing so increases the risk for aspiration and interferes with the development of a trusting relationship.

CHECKING TUBE PLACEMENT

Once the gavage feeding tube is inserted, checking for placement is essential. Tube placement must be confirmed each time the tube is inserted and before each use. Radiologic confirmation of tube placement is considered the most accurate method, but the risks associated with repeated radiation exposure, high costs, and the impractical nature of obtaining a radiograph before feeding tube use make it unrealistic (Irving et al., 2018). Several methods have been proposed as reliable for checking tube placement, but no single method has been shown to be consistently accurate for continually assessing tube placement. Research has suggested alternative methods such as using measurements of bilirubin, trypsin, and pepsin levels, CO2 monitoring, transillumination, and magnetic detection to enhance assessment of tube placement, but insufficient evidence is available to support these methods. Also, these methods have other limitations such as the cost, the availability of equipment, and the limited availability for bedside testing of these levels. Refer to Box 35.4 for methods to verify feeding tube placement. However, keep in mind that even with these methods, tube malpositioning can occur. Therefore, nurses need to be vigilant in checking for tube placement using the recommended methods and be cautious and proactive if there is any suspicion that the tube may be misplaced. If the gavage feeding tube is to remain in place, secure it to the child's cheek. Do not tape the tube to the child's forehead, because this could lead to irritation and pressure on, and possible breakdown of, the nasal mucosa. Also, measure the length of the tube extending from the nose or mouth to the end and record this information. Double-check this measurement before administering each intermittent tube feeding to verify that the feeding tube is in the proper position. Once the position of the gavage feeding tube is confirmed, the feeding solution or medication can be administered.

Ophthalmic Administration

Ophthalmic medications are typically supplied in the form of drops or ointment. Many children have a fear of having anything placed in their eyes. Therefore, provide an age-appropriate explanation to gain their cooperation. Also, have the child keep his or her eyes closed until you are ready to administer the medication. Ensure that the medication is at room temperature, as chilled medication may be uncomfortable to the child. Proper positioning of the child is necessary to control the child's head, keep the child's hands from interfering, and prevent injury to the eye. Attempt to administer the medication when the child is not crying to ensure that the medication reaches its intended target area. Place the child in the supine position, slightly hyperextending the neck with the head lower than the body so the medication will be dispersed over the cornea. Rest the heel of your hand on the child's forehead to stabilize it. Retract the lower eyelid and place the medication in the conjunctival sac; maintain sterile technique by being careful not to touch the tip of the tube or dropper to the sac. For eye drops, place the prescribed number of drops into the lower conjunctival sac (Fig. 35.4). For ointment, apply the medication in a thin ribbon from the inner canthus outward without touching the eye or eyelashes. If the child is old enough to cooperate, instruct the child to gently close the eyes to allow the medication to be dispersed. Administering eye medication: gently press the lower lid down and have the child look up as the medication is instilled into the lower conjunctival sac. If a child is uncooperative, he or she may need to be immobilized in order to administer the eye drops. Alternatively, one or two drops on the inner canthus of the closed eye can be administered while the child is lying supine. Then instruct the child to open his or her eyes and the drops will enter the eye. Wipe any excess medication from the skin. Punctal occlusion after application is also important to slow systemic absorption and ensure that the medicine stays in the eye. Children often require ophthalmic medications at home. Parents or caregivers need instruction about how to administer this type of medication.

Peripherally inserted central catheter (PICC)

Peripherally inserted central catheter (PICC) Short- to moderate-term therapy Insertion via a peripheral vein such as basilic, cephalic, or brachial vein Catheter typically threaded into superior vena cava; distal tip terminates in the superior vena cava, inferior vena cava, or proximal right atrium Insertion via saphenous vein with tip terminating in inferior vena cava above the diaphragm for infants Single or multiple lumens Can be inserted at the bedside; requires additional training and advanced skill

NURSING PROCEDURE 35.2 Inserting a Gavage Feeding Tube

Purpose: To provide a means for delivering nutrition to the child's functioning gastrointestinal tract 1. Verify the order for gavage feeding. 2. Explain the procedure to the child and parents using appropriate language geared to the child's development level. 3. Gather the necessary equipment; remove formula for feeding from refrigerator if appropriate and allow it to come to room temperature. 4. Wash hands and put on gloves. 5. Inspect the child's nose and mouth for deformities that may interfere with passage of the tube. 6. Position the infant supine with the head slightly elevated and with the neck slightly hyperextended so that the nose is pointed upward. If necessary, place a rolled towel or blanket under the neck to help in maintaining this position. Assist the older child to a sitting position, if appropriate. Alternatively, have the parent or another person hold the child to promote comfort and reassurance. Enlist the aid of additional persons, such as a parent or other health care team member, to assist in maintaining the child's position. 7. Determine the tubing length for insertion: Use morphologic measurement from the tip of the nose to the earlobe to the middle of the area between the xiphoid process and umbilicus or age-related height-based method, ensuring accurate height and calculations (see Table 35.6). Mark this measurement on the tube with an indelible pen or with a piece of tape. 8. Lubricate the tube with a generous amount of sterile water (many small-bore feeding tubes have a water-activated lubricant) or water-soluble lubricant to promote passage of the tube and minimize trauma to the child's mucosa. 9. Insert the tube into one of the nares or the mouth. Direct a nasally inserted tube straight back toward the occiput; direct an orally inserted tube toward the back of the throat. 10. Advance the tube slowly to the designated length; encourage the child (if capable) to swallow frequently to assist with advancing the tube. 11. Watch for signs of distress, such as gasping, coughing, or cyanosis, indicating that the tube is in the airway. If these signs develop, withdraw the tube and allow the child to rest before attempting reinsertion. 12. Temporarily secure tube, remove stylet if applicable, and check for proper placement of the tube. Refer to Box 35.4. 13. Document the type of tube inserted; length of tubing inserted; measurement of external tubing length, from nares to end of tube, after insertion; and confirmation of placement.

Administering Medication via a Syringe Pump

Purpose: To provide accurate and safe administration of IV medication 1. Verify the medication order. 2. Gather the medication and necessary equipment and supplies. 3. Wash hands and put on gloves. 4. Attach the syringe pump tubing to the medication syringe and purge air from the tubing by gently filling the tubing with medication from the syringe. 5. Insert the syringe into the pump according to the manufacturer's directions. 6. Clean the appropriate port on the child's IV access device or tubing, flush the device or tubing if appropriate (e.g., an intermittent infusion device [saline lock or heparin lock]), and attach the syringe tubing to the IV tubing or device. 7. Set the infusion rate on the pump as ordered. 8. When the medication infusion is completed, flush the syringe pump tubing to deliver any medication remaining in the tubing, according to institution protocol. 9. Document the procedure and the child's response to it

Rectal Administration

Rectal medications are typically supplied in the form of suppositories. The rectal route is not a preferred route for medication administration in children because the drug's absorption may be erratic and unpredictable and the method is invasive. The rectal route can be extremely upsetting to the toddler and preschooler because of age-related fears, and may be embarrassing to the school-age child or adolescent. However, the rectal route may be used when the child is vomiting or receiving nothing by mouth (NPO). Use age-appropriate explanations and reassurance. Helping the child to maintain the correct position may be necessary to ensure proper insertion and safety of rectal suppositories. Lubricate the suppository well with a water-soluble lubricant. With the child in the side-lying position, insert the suppository into the rectum quickly but gently. Use a gloved finger or use a finger cot to insert the suppository. Insert the suppository above the anal sphincter. For an infant or child younger than the age of 3, use the fifth finger for insertion. For an older child, use the index finger. To prevent expulsion of the suppository, hold the buttocks together for several minutes or until the child loses the urge to defecate. If the child has a bowel movement within 10 to 30 minutes after administration of the medication, examine the stool for the presence of the suppository. If it is observed, notify the physician or nurse practitioner to determine if the drug needs to be administered again.

Rights of Pediatric Medication Administration

Right Approach • Consider child's developmental level. • Provide age-appropriate explanations.

Rights of Pediatric Medication Administration

Right Dose • Calculate the recommended dose according to child's weight and double-check your calculations. • Always question the pharmacist and/or prescriber if the ordered dose falls outside the recommended dose range. • Unusually large or small volumes or dosages should always be verified.

Rights of Pediatric Medication Administration

Right Medication • Check order and expiration dates. • Know action of medication and potential side effects (use pharmacy, drug formulary). • Ensure that the medication provided is the medication that is ordered.

Rights of Pediatric Medication Administration

Right Patient • Confirm child identity by two ways. Children may deny their identity in an attempt to avoid an unpleasant situation, play in another child's bed, or remove ID bracelet. • Confirm identity each time medication is given. • Verify child's name with caregiver to provide additional verification. • Use technology when available (i.e., bar code systems).

Rights of Pediatric Medication Administration

Right Route of Administration • Check ordered route and ensure this is the most effective and safest route for this child; clarify any order that is confusing or unclear. • Give the medication by the route ordered. If there is a need to change route, always check with prescriber (e.g., if a child is vomiting and has an order for an oral medication, the medication may need to be given via the IV or rectal route).

Rights of Pediatric Medication Administration

Right Time • Give within 20 to 30 minutes of the ordered time. • For a medication given on an as-needed (PRN) basis, know when it was last given and how much was given during the past 24 hours.

TAKE NOTE!

Rotate sites where the tube is secured to the abdomen to prevent tension on the stoma or skin breakdown.

Total Parenteral Nutrition

Route Central venous access to allow rapid dilution of hypertonic solution

Peripheral Parenteral Nutrition

Route Peripheral vein

Subcutaneous and Intradermal Administration

SQ administration distributes medication into the fatty layers of the body. It is used primarily for insulin administration, heparin, and certain immunizations, such as the MMR. The amount of SQ tissue differs among individuals. Therefore, when selecting a site and needle size, choose the most appropriate based on adequacy and condition of the SQ tissue and the frequency and duration of the therapy. The preferred sites for SQ administration include the anterior thigh, lateral upper arms, and abdomen (Bowden & Greenberg, 2016; Immunization Action Coalition, 2018). Use a 3/8- or 5/8-in, 23- to 25-gauge needle. Pinch up the skin to isolate the tissue from the muscle or pull it taut depending on the amount of adipose tissue present and length of needle, with the nondominant hand. Insert the needle at a 45- to 90-degree angle, release the skin if pinched, and inject the medication. Remove the needle at the same angle it was inserted. Intradermal (ID) administration deposits medication just under the epidermis. The forearm is the usual site for administration. ID administration is used primarily for tuberculosis screening and allergy testing. A 1-mL syringe with a 5/8-in, 25- or 27-gauge needle is commonly used to administer the medication. Insert the needle, with the bevel up, beneath the skin at a 5- to 15-degree angle. Keep the fingers and thumb resting on the sides of the syringe to ensure the proper angle.

DETERMINING TUBING LENGTH FOR INSERTION

Several methods exist for determining proper tube length and significant variation in clinical practice is common. Therefore, it is imperative to know your institutions policy and procedures and be up to date on current evidence-based practice guidelines. Traditionally, morphologic methods, measuring from the nose to ear to mid-xiphoid to umbilicus (NEMU) or just nose to ear to mid-xiphoid (NEX), have been used to determine tube length for insertion. Recent research supports the use of the NEMU method over the NEX method, as it demonstrates consistent placement into the body of the stomach (Irving et al., 2018). Improving the accuracy of predicting tube length will lead to an increase in successful nasogastric tube placements, and therefore, improved outcomes and decreased health care costs. Determining tubing length for insertion of a nasogastric tube has also been done by using age-related height-based (ARHB) methods. This method can be time consuming and error-prone due to the mathematical calculations and has not been well studied in neonates (Clifford et al., 2015). Refer to Table 35.6 for ARHB equations.

Promoting Growth and Development

Some children receive all of their nutritional needs through tube feedings, whereas other children use tube feedings as a supplement to eating by mouth. Feeding time is a special time for infants and children. Occasionally, babies who are fed solely through an enteral feeding tube may forget or lose the desire to eat by mouth. Use a pacifier to help avoid this, allowing the infant to associate the pacifier in his or her mouth with a feeding. The sucking motion will also exercise the jaw and promote the flow of the feedings. The saliva produced during sucking aids in digestion. Combined with holding the infant and cuddling, rocking, and talking to him or her, this promotes a more normal feeding time. Talking with children, playing music, or reading a story promotes an active feeding time. At home, encourage parents to include the feeding as a part of regular family mealtime together to provide socialization for the child. Allow the child to participate in the feedings by gathering supplies and administering the actual feeding so that the child may experience independence and adaptation. If the child also eats food by mouth, feed him or her by mouth first and then administer the tube feeding. Children with feeding tubes should be allowed as normal a routine as possible. For example, they can crawl, walk, and jump just like children of the same age and developmental level. However, in some cases, contact sports such as football, hockey, and wrestling should be avoided because of the higher risk of injury. Securing the tubing under the child's clothing will prevent it from becoming accidentally dislodged and prevent the child from pulling and playing with it. Using one-piece outfits, an Ace wrap, or stretchy gauze to cover the tube can help protect it.

Focus on Safety GOAL: Accurately Identify Patients

Steps: When administering medications to a child be sure to use at minimum two patient identifiers that are directly associated with the patient and the medication to be given, such as full name, patient ID number, birth date, telephone number, or other person-specific identifier.

Educating the Child and Parents

Teaching the child and parents or caregivers about medication administration is key. Many medications are given in the home, making the parents or caregivers the persons responsible for administration. They need to know what medications they are giving and why, how to give them, and what to expect from the drug, including adverse effects. Caregivers and parents often incorrectly dose over-the-counter medications and prescription medications or fail to follow or understand medication instructions given, such as not completing the full course of the medication or missing doses (Yin et al., 2016). Therefore, ensure thorough instruction, including frequency of administration, when the next dose is due, and length of time the medication is to be given. Emphasize the importance of completing the prescribed dose. Demonstrate use with an actual syringe if possible, encourage return demonstration of medication administration, advise against the use of home-measuring devices (such as a spoon), and emphasize the importance of always using the calibrated dispensing device that was given with the medication. If the medication is to be given via injection, parents and caregivers need to learn how to administer the injection properly. Encourage questions or concerns from parents or caregivers. Parents and caregivers commonly need suggestions about the best ways to administer the medication to their child. Provide them with tips for administration, such as mixing unpleasant-tasting medications with apple sauce or yogurt or offering a favorite liquid as a chaser. Also teach the parents how to properly measure the amount of drug to be given. Teaching Guidelines 35.2 gives pointers about oral medication administration. Refer to Chapter 30 for further information on teaching children and families about medication administration.

Equipment

The choice of equipment is determined by the solution or medication to be administered, the duration of the therapy, the age and developmental level of the child, the child's status, and the condition of his or her veins. Various types of IV devices are commercially available. In addition, different types of tubing and infusion control devices may be necessary.

Preventing Medication Errors

The incidence of potentially harmful medication errors may be three times as high in pediatrics compared to adults (Mueller et al., 2019). This can be related to weight-based dosing calculations, fractional dosing, and the need for the use of decimal points. Children are also more susceptible because many drugs used in pediatrics are formulated and packaged for adults and lack U.S. Food and Drug Administration (FDA) approval and dosing guidelines for children. Recent legislative changes have led to a dramatic increase in pediatric drug trials and improvement in accurate pediatric dosing. Over the past 5 years, more pediatric drug trials have occurred than in the previous 30 years (U.S. Food and Drug Administration, 2016). The need for safety takes on even greater importance due to the physiologic, psychological, and cognitive differences inherent in children. Children are more vulnerable to medication errors as they vary in weight, BSA, and organ maturity which effect their ability to metabolize and excrete medications; they depend on others for medication administration, they are often unable to communicate if an adverse reaction is occurring and they need special compound medication formulations (Mueller et al., 2019). Confirming the child's identity and double-checking the dosage before administration of any medication are two critical safeguards that play a major role in preventing medication errors. Other ways to prevent medication errors include the following: Confirm that the children's weight is accurate. Always weigh children in kilograms. Double-check medication calculations; utilize another health care provider when possible, especially for high-risk medications. If a dose seems unusually small or large, verify the order. Utilize medication ordering and dispensing systems, if available. Always report medication errors or near-miss errors to help prevent future mistakes. Utilize the Joint Commission's official "Do Not Use" list (link to this list is provided on http://www.jointcommission.org/assets/1/18/Do_Not_Use_List.pdf).

Dose Determination by Body Weight

The most common method for calculating pediatric medication doses is based on body weight. The recommended dosage is usually expressed as the amount of drug to be given over a 24-hour period (mg/kg/day) or as a single dose (mg/kg/dose). It is important to differentiate between the 24-hour dosage and the single dose. Use these guidelines to determine the correct dose by body weight: Weigh the child. If the child's weight is in pounds, convert it to kilograms (divide the child's weight in pounds by 2.2). Check a drug reference for the safe dose range (e.g., 10 to 20 mg/kg of body weight). Calculate the low safe dose (Box 35.2). Calculate the high safe dose (Box 35.2). Determine if the dose ordered is within this range. The pediatric dosage should not exceed the minimum recommended adult dosage. Generally, once a child or adolescent weighs 40 to 50 kg or greater, the adult dose is frequently prescribed (Bowden & Greenberg, 2016). However, it remains important to always verify that the dose does not exceed the recommended adult dose.

Tunneled central venous catheter (e.g., Groshong, Hickman/Broviac)

Tunneled central venous catheter (e.g., Groshong, Hickman/Broviac) Usually for long-term use Catheter inserted by a physician via small incision in jugular, femoral, or subclavian vein and tunneled in the subcutaneous tissue under the skin Initially sutured in place to stabilize position; sutures removed after approximately 1-2 weeks when cuff on catheter attaches to subcutaneous tissue Single or multiple lumens Some have valves that prevent backflow of blood and air entrance

Maintaining IV Fluid Therapy

Throughout the course of therapy, monitor the fluid infusion rate and volume closely, as often as every hour. If a volume control set is used to administer the IV infusion, fill the device with the allotted amount of fluid that the child is to receive in 1 hour. Doing so prevents inadvertent administration of too much fluid. Never assume that just because an infusion pump is in use, the infusion is being administered without problems. Pumps can malfunction. The tubing can become blocked, or the IV device can move out of the vein lumen. Not enough fluid, fluid overload, or infiltration of the solution into the tissues can occur. In addition to monitoring the fluid infusion, closely monitor the child's output. Expected urine output for children and adolescents is 1 to 2 mL/kg/hour. TAKE NOTE! When measuring the output of an infant or child who is not toilet trained or who is incontinent, weigh the diaper to determine the output. Remember that 1 g of weight is equal to 1 mL of fluid. Flushing the IV line when the device is used intermittently may be necessary to maintain patency, such as before and/or after medication is administered and after obtaining blood specimens. However, there is much debate as to how often flushing should be done and the best flush solution to use, heparin or saline. Saline has been found to be more compatible with the numerous solutions and medications administered intravenously, and is less expensive and less irritating to the vein. In addition, using saline lessens the incidence of pain and phlebitis. Heparin is expensive and incompatible with numerous medications and solutions, and it can affect clotting time, depending on the concentration of the flush solution used but has also been found to increase catheter patency and decrease infusion failures. Evidence appears to support that both heparin and normal saline are effective for maintaining patency of peripheral IV catheters and which fluid used will depend on provider and agency preference. Additional research is needed to determine the best solution, volume and concentration of the flush solution, and interval for flushing. A recent systematic review of randomized control studies did show that continuous infusion of low-dose heparin did result in increased catheter patency and decreased infusion failures while intermittent heparin flushing showed minimal benefits (You et al., 2017). See Evidence-Based Practice 35.1. Flushing solutions and procedure will vary; therefore, it is important to always follow your agency's policy or provider order for flushing IV lines. If the child is receiving IV therapy via a central venous access device, provide site care using sterile technique and flush the device according to agency policy. Note the exit site for the device and inspect it frequently for signs of infection. If the device has multiple lumens, label each lumen with its use (i.e., blood specimen, medication, or fluid). Always check the compatibilities of solutions and medications being given simultaneously. TAKE NOTE! When flushing or administering medications through a PICC line, follow the manufacturer's recommended syringe size, because PICC lines are fragile. Using a larger-volume syringe (i.e., 5 mL or larger) exerts less pressure on the PICC, thereby reducing the risk of rupture

Inserting a Nasogastric or Orogastric Feeding Tube

Tubes for gavage feeding can be inserted via the nose or mouth. For infants, who are obligate nose breathers, insertion via the mouth may be appropriate. Oral insertion also promotes sucking in the infant. For the older child, nasal insertion is usually the preferred method. If the tube is to remain in place, the nose also is considered to be more comfortable. Nursing Procedure 35.2 gives the steps for inserting a gavage feeding tube.

Administering TPN

Typically, the physician or nurse practitioner determines the concentration and components of the TPN solution based on a thorough assessment of the child's status, including the results of laboratory testing. This information is used as a baseline for evaluating the effectiveness of therapy. The solution is prepared under sterile conditions in the pharmacy. For TPN, a central venous access device is inserted and secured, if one is not already in place. Use specialized tubing with an in-line filter (to prevent small microparticles from entering the circulation). TPN solutions may be refrigerated until they are to be used. Once started, a single solution of TPN should hang for no longer than 24 hours (Weinstein & Hagle, 2014). The infusion of the solution is initiated at a slow rate that is gradually increased as ordered based on how the child tolerates the therapy. TPN solutions are highly concentrated glucose solutions that can cause hyperglycemia if given too rapidly. Use of an infusion pump is essential to control the rate of infusion. Fat emulsions are administered periodically to meet the child's need for essential fatty acids. These solutions are given as a piggyback solution into the TPN line, but below the in-line filter. Throughout TPN therapy, be vigilant in monitoring the infusion rate, and report any changes in the infusion rate to the physician or nurse practitioner immediately. Gradual adjustments may be made to the rate, but only as ordered by the physician or nurse practitioner. Initially, check blood glucose levels frequently, such as every 4 to 6 hours, to evaluate for hyperglycemia. These levels can be obtained with a bedside glucose meter. Minimize the trauma and discomfort associated with frequent invasive procedures by using the principles of atraumatic care. If blood glucose levels are elevated, SQ administration of insulin may be needed. Once the child's glucose levels stabilize, the frequency of blood glucose level testing decreases, such as every 8 to 12 hours, based on the facility's policy.

ATRAUMATIC CARE

Use positions that are comforting to the child, such as therapeutic hugging, during injections. Have the child sit on the caregiver's lap with the caregiver holding the child's arms and legs to his or her body. Refer to Chapter 30, Figure 30.1. After administration, encourage the parents or caregivers to hold and cuddle the child and offer praise.

TAKE NOTE!

Use the medicine cup or syringe with proper calibration instead of household cups or measuring spoons, since they are not calibrated and may deliver an incorrect dose of medication.

ATRAUMATIC CARE

Use therapeutic play to assist the child in preparation and coping for the procedure (see Chapter 33 for more information). Insertion of an IV therapy device is traumatic. Follow the principles of atraumatic care, including the following: Gather all equipment needed before approaching the child. If possible, select a site using hand veins rather than wrist or upper arm veins to reduce the risk of phlebitis. Avoid sites where excessive movement may occur, such as the lower extremity veins and areas of joint flexion if possible because these are associated with an increased risk of thrombophlebitis and other complications (Bowden & Greenberg, 2016). Ensure adequate pain relief using pharmacologic and nonpharmacologic methods prior to insertion of the device (see Chapter 36 for more information about management of pain related to procedures). Allow the antiseptic used to prepare the site to dry completely before attempting insertion. Use a barrier such as gauze or a washcloth or the sleeve of the child's gown under the tourniquet to avoid pinching or damaging the skin. If the child's veins are difficult to locate, use a device to transilluminate the vein (utilizes a bright light, which illuminates the vein's size and direction of travel). Make only two attempts to gain access; if you are unsuccessful after two attempts, allow another individual two attempts to access a site. If still unsuccessful, evaluate the need for insertion of another device. TAKE NOTE! Some facilities have policies in place allowing only one stick per nurse with a maximum of two sticks; then the doctor needs to be notified unless the situation is an emergency. Encourage parental participation as appropriate in helping to position the child or to provide comfort positioning, such as therapeutic hugging. Coordinate care with other departments such as the laboratory for blood specimen collection to minimize the number of venipunctures for the child. Secure the IV line using a minimal amount of tape or transparent dressing. Protect the site from bumping by using a security device such as the IV house dressing

Applying Eye Medications

Wash your hands with soap and water. Dry them thoroughly using a clean cloth. • Cleanse the eye. Move from the nose side of the eye outward. Use a clean area of the cloth each time you wipe and a separate cloth for each eye. Use warm water to help clear crusty eye drainage. • Allow the eye drops or ointment to come to room temperature (if the medication was stored in the refrigerator). If necessary, warm the eye drops or ointment tube in the palm of your hand. Keep the cap on to avoid any spillage. Make sure medication is well mixed if needed. • Remove the cap, placing it on a dry, clean surface. • For young children (3 years or younger), obtain assistance from an additional adult to keep their arms and fingers away during the procedure. If doing this procedure alone, wrap the child in a towel or blanket, keeping the arms inside. • Have the child look up and to the other side. The eye drops should flow away from the child's nose. • Place the wrist of the hand you will be using to give the drops against the child's forehead. With the other hand, gently pull down the lower eyelid. Have the medication about 2.54 cm (1 in) away from the eye. • Gently squeeze the eye drop bottle, dispensing the proper number of drops away from the tear ducts which are in the inner corner of the eye, or gently squeeze the ointment tube, dispensing a small trail (about 2 cm) of ointment into the gap between the lower portion of the eye and the bottom eyelid. Twist or rotate the tube when you reach the outer eye to help disconnect the ointment from the tube. • Make sure the tip of the bottle or tube does not make contact with the eye or any other surface. • For eye drops, gently press your finger against the inside corner where the eye meets the nose for about 1 minute, blocking the tears and medication from exiting through the tear duct. This will help the eye retain more of the medication. If the child is old enough, he or she may be able to do this unassisted. • For ointment, have the child close his or her eye and not rub the area. • Ask the child not to blink or squeeze the eye shut more than normal, as this may wash away the medication prematurely. • Gently dab away any tears or excess medication on the face with a clean tissue. • Wash your hands again and dry them thoroughly.

Providing Atraumatic Care

When administering any medication, including oral medications, use the principles of atraumatic care (see Chapter 30 for more information). Children can experience stress and fear or upset when they must take medications. The child may become upset or stressed when he or she must be secured snugly or positioned to minimize movement. The child may experience further discomfort if the medication has an unpleasant taste or results in pain, such as with an injection. ATRAUMATIC CARE Encourage the child to participate in care and provide the child with developmentally appropriate options, such as which fluid to drink with the medication or which flavor of ice pop to suck on before or after the administration To decrease discomfort and pain for the child who is to receive an injection, apply a topical anesthetic such as eutectic mixture of local anesthetic (EMLA) cream or vapocoolant spray to the site before injection when possible (Kroger et al., 2018) and inject the most painful medication last (see Chapter 36 for additional information). Also, utilize developmentally appropriate distraction techniques, such as music, books, blowing bubbles or a pinwheel, and deep breathing exercises (see Chapter 30 for additional information). Ensuring that the child doesn't move is essential to prevent injury when administering an injection. When administering an injection to a young child, at least two adults should hold him or her; this may also be necessary to help an older child to remain still.

TAKE NOTE!

When selecting an IV site in an extremity, always choose the most distal site. Doing so prevents injury to the veins superior to the site and allows additional access sites should complications develop in the most distal site.

TAKE NOTE!

When using the nipple method, make sure to cut several holes in the base of the nipple to allow air circulation and site assessment.

Methods for Verification of Feeding Tube Placement

• Obtain radiographic confirmation of proper tube placement in children who are considered high risk for aspiration, such as children with neurologic impairment, children obtunded, sedated, unconscious, critically ill, reduced gag reflex or static encephalopathy, or when nonradiologic methods are not feasible or bedside results are conflicting. • Nonradiologic verification is used in children who are not considered high risk for aspiration, document pH of aspirate; document insertion distance and external length of tube in the chart. Mark and document the tube's exit site from the nose or mouth. • Use bedside techniques at regular intervals to determine proper tube positioning. • Measuring pH • Gastric secretions have a pH less than 5. Small intestine secretions will usually have a pH greater than 6, but this does not reliably predict proper tube placement. A pH greater than 6 can occur with respiratory or esophageal placement, with proper tube placement (gastric or intestinal) when feedings are given continuously, or if the child is receiving acid-inhibiting medications. Therefore, if the pH is greater than 5, additional assessment is warranted. • Observing appearance of fluid aspirated from tube (can be used in conjunction with pH testing but is not a reliable single verification method) • Gastric secretions are usually grassy green or clear and colorless and can have off-white or tan mucous shreds. It may also be brown tinged if blood is present. • Intestinal secretions are often bile stained, light golden yellow to brownish green. They tend to be thicker and more translucent than gastric secretions. • Respiratory secretions can be white, yellow, straw colored, or clear. • Instill air into the tube and then auscultate for the sound (gastric auscultation) (can be used in conjunction with other assessment methods). • Check external markings on tube and external tube length (tube remaining from nares to end of tube) to determine if the tube seems to have migrated or been misplaced. • Continually assess for signs indicative of feeding tube misplacement, such as unexplained gagging, vomiting, or coughing; signs and symptoms of respiratory distress; and decreased oxygen saturations. • If bedside techniques reveal conflicting results or the child is at high risk, radiologic confirmation is recommended. • Review routine chest and abdominal radiographs (if obtained) to double-check correct tube position. Always follow agencies' policy and procedures.

Topics to be Covered for Home Enteral Nutrition

• Type and size of tube • Type of nutritional support • Rationale for therapy • Expected results from therapy • Duration of therapy • Frequency of feedings • Feeding solution and equipment • Tube insertion technique (if appropriate) • Methods to check for correct placement • Steps for administering the feeding (and medication, if ordered) • Procedure for flushing tube • Procedure for venting the tube, if appropriate • Frequency of weighing the child • Signs and symptoms of complications and when to notify physician or nurse practitioner • Troubleshooting problems, such as clogging of the tube or dislodgement (see Teaching Guidelines 35.4) • Daily tube care (e.g., cleaning the site, rotating tube) • Site assessment • Technique for reinsertion/replacement of tube as appropriate • Equipment suppliers • Resources for support • Follow-up visits and referrals


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