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.