ch 39: pediatric variations

therapeutic management for hyperthermia

-if a cooling blanket is used, cover the patient with a sheet or lightweight blanket; frequently monitor the temp -if a tepid bath is used: keep the water temperature 1°C less than the child's body temp; sponge or spray for about 20 minutes Dry the child by gently rubbing the skin surface with a towel to stimulate circulation Retake the temp after 30 minutes Reduce activity level Give frequent, small drinks of clear liquids Dress the child in lightweight clothing; use a light blanket if the child is cold or shivering

establish trust and provide support

-if the relationship is based on trust, the child will associate the nurse with caregiving activities that give comfort and pleasure -the first visit with the child should not include anything painful

contact precautions

-C. diff, RSV, herpes simplex, scabies, impetigo -direct contact -contact with items in the environment -nurses should wear gloves and possibly gowns for changing diapers when there are loose or explosive stools -during feedings, wear gowns if the child is likely to vomit or spit up (burping a child) -the most common piece of medical equipment that transmits hospital acquired infections is the stethoscope

medical surgical restraints

-a necessary part of the procedure

therapeutic management for fevers

-acetaminophen is the preferred drug (okay for infants), ibuprofen also preferred and is okay to administer to children as young as 6mo of age, DONT give aspirin -take the temperature again after 30 minutes of antipyretic administration -traditional cooling measures: Minimum clothing Exposing the skin to air Reducing room temp Increasing air circulation Applying cool moist compresses to the skin (sponging or tepid bath is ineffective for fever) -febrile seizures lasting less than 10 minutes do not cause brain damage or other debilitating effects

provide an explanation

-age appropriate explanations are one of the most widely used interventions for reducing anxiety in children: --->explain what is to be done and what is expected of the child ----> long explanations could cause anxiety --->keep it short, simple, and appropriate to the child's level of comprehension --->for young children that cannot think conceptually, use objects to supplemental verbal info --->look at guidelines on pages 1070-1

environmental factors

-all windows should be secured -window blind and curtain cords should be out of reach -pacifiers should not be tied onto or around the infant's neck -electrical outlets should have covers -infants are helpless in water and some children may turn on the hot water faucet and be severely burned -a special hazard for children is the danger of entrapment under an electronically controlled bed when it is activated to descend -baby walkers should not be used -even preemies are capable of surprising mobility; therefore, portholes in incubators must be securely fastened when not in use -crib sides should always be raised and fastened securely -never tie nets to the movable crib sides or use knots that do not permit quick release -place infants "back to sleep" (on their backs) on a firm surface -no pillows in the crib -avoid overheating the infant -avoid exposure to tobacco smoke, alcohol, and illicit drugs

factors to consider with IV meds

-amount of drug to be administered -minimum dilution of drug and whether child is fluid restricted -type of solution in which drug can be diluted -length of time over which drug can be safely administered -rate limitations of child, vascular system, and infusion equipment -time that this or another drug is to be administered -compatibility of all drugs that child is receiving IV -compatibility with infusion fluids -syringe pumps are typically used

maintaining healthy skin

-assessment of the skin is easiest to accomplish during bathing -risk factors for skin breakdown include Impaired mobility Protein malnutrition Edema Incontinence Sensory loss Anemia Infection Failure to turn the patient Intubation -se the Braden Q scale or the Glamorgan scale -reactive hyperemia (flushing): earliest sign of tissue compromise and pressure-related ischemia -accurate documentation of redness or obvious skin breakdown is essential and recorded at least daily (should be each shift) Include: Color, Size (diameter and depth), Location, Presence of sinus tracts, Odor, Exudate, Response to treatment Interventions to prevent pressure ulcers in critically ill children: Turning children every 2 hours Using pillows, blanket rolls, and positioning devices Draw sheets to minimize shear Utilization of pressure reduction surfaces Moisture reduction through the use of dry-weave diapers and disposable under-pads Skin moisturizer Nutrition consults Avoid friction (may leave the appearance of an abrasion) Avoid *shear* (may cause tissue death) Elevate the HOB no more than 30 degrees for short amounts of time Use the knee latch Avoid *epidermal stripping* caused by tape removal Tape is placed so that there is no tension, traction, or wrinkles Remove tape carefully by using counter tension on the skin Feces, urine, wound drainage, gastric drainage can all cause skin breakdown

info on restraining methods

-before initiating restraints, the nurse completes a comprehensive assessment of the patient to determine whether the need for a restraint outweighs the risk of not using one -the nurse needs to assess the child's development, mental status, potential to hurt others or self, and safety -an order must be obtained as soon as possible that specifies the time frame the restraint can be used, the reason why they are being used, and reasons for discontinuation -should assess the child at least every 2 hours -tie knots that allow for quick release and have 1 finger width between child and restraint -restraints for violent, self-destructive behavior are limited to situations with a significant risk for patients physically harming themselves or others because of behavioral reasons and when nonphysical interventions are not effective -before initiating a behavioral restraint, the nurse should assess the patient's mental, behavioral, and physical status to determine the cause for the child's potentially harmful behavior -behavioral restraints must be ordered every hour for children younger than 9 and every 2 hours for children 9-17 years of age; 18 and older is every 4 hours

lumbar puncture

-children are usually easiest to control in the side-lying position, with the head flexed and the knees drawn up toward the chest -children can be reassured that, although they are trusted, holding will serve as a reminder to maintain the desired position -a flexed-sitting may be used depending on the child's ability to cooperate and whether sedation will be used -*the sitting position may interfere with chest expansion and diaphragm excursion, and in infants the soft, pliable trachea may collapse so observe the difficulty with breathing* -monitor vital signs, and observe for any changes in LOC, motor activity, and other neuro signs -post-lumbar puncture headache may occur and is related to postural change, this is less severe when the child lies flat; more common in adolescent

positive reinforcement

-children need to hear that they did the best they could no matter how they behaved -reward systems are appealing to children -the nurse should return shortly after the procedure to strengthen the supportive relationship

postoperative care (PPW)

-continuous monitoring -vital signs assessment -managing pain -respiratory tract infection -patient education -discharge instructions

postoperative care

-continuous monitoring of the child's cardiopulmonary status is essential during the immediate postoperative period -post-anesthesia complication such as airway obstruction, post-extubation croup, laryngospasm, and bronchospasm make maintaining a patent airway and maximum ventilation critical -monitoring O2 sats, supplemental oxygen, maintaining body temp, and promoting fluid and electrolyte balance are important in immediate post op care -vital signs are evaluated in terms of side effects from anesthesia, shock, or resp. compromise -malignant hyperthermia is a potential fatal pharmacogenetic disorder Symptoms: hypercarbia, elevated temperature, tachycardia, tachypnea, acidosis, muscle rigidity, and rhabdomyolysis inhaled anesthetics and the muscle relaxant succinylcholine trigger the disorder, producing hypermetabolism family Hx of high fever associated with surgical procedures increases risk treatment includes discontinuation of triggering agent, oxygen, IV fluids, and cooling measures -pain management is a nursing responsibility after surgery Routinely scheduled analgesics is better than as needed administration Incentive spirometer *Deep breathing (give analgesics prior to this and use a pillow or a favorite stuffed animal)* Position changing at least every 2 hours -bc respiratory tract infections are potential complications, make every effort to aerate the lungs and remove secretions (present measures as games)

provide distraction

-distraction is a powerful coping strategy (singing, listening to music with headphones, counting aloud, blowing bubbles, etc.)

alternative methods of restraint (use first)

-diversional activities -parental participation -therapeutic holding

informed consent should include?

-expected care or treatment -potential risks -benefits -alternatives -what might happen if patient chooses not to consent

determination of drug dosage

-factors related to growth and maturation significantly alter an individual's capacity to metabolize and excrete drugs -beyond the newborn period, many drugs are metabolized more rapidly by the liver, necessitating larger doses or more frequent administration -various formulas involving age, weight and body surface area (BSA) as the basis for calculations have been devised to determine children's drug dosages -children's dosages are most often expressed in units of measure per body weight (mg/kg) -BSA is based on the West nomogram

positioning for procedures

-femoral venipuncture -extremity venipuncture or injection -lumbar puncture -bone marrow aspiration or biopsy

bathing

-for children confined to bed use bath cloths; if able let the child clean themselves and assist with hard to reach areas -for infants and toddlers: bath cloths or towel method -chlorhexidine is best but not in infants younger than 2 months of age -never leave little ones unattended in the bath tub; hold on to them -school age and adolescents can shower or bathe -closely supervise kids with cognitive impairments, physical limitations, suicidal or psychiatric problems -areas that require special attention are the ears, between skinfolds, the neck, the back, and the genital area -in the Vietnamese and Cambodian cultures, the foreskin is not retracted until adulthood

stool specimens

-frequently collected from children to identify parasites and other organisms that cause diarrhea, assess GI function, and check of occult blood -try not to contaminate with urine; may need to put a urine collection bag over the urethra -to obtain a stool specimen, place plastic wrap over the toilet bowl before defecation -collect from two different areas; take to lab immediately, or refrigerate

performance of the procedure

-ideally, the same nurse who explains the procedure should perform or assist with the procedure -minimizing the number of people present during procedure can decrease anxiety -to avoid a delay during a procedure, have extra supplies available -use treatment rooms for procedures -never perform "traumatic" procedures in safe areas -as the procedure is nearing completion, the nurse should inform the child that it is almost over in language the child understands

infection control (PPW)

-nosocomial infections: 2 million/year -role of centers for disease control and prevention standard precautions -transmission‐based precautions -airborne, droplet, and contact precautions

feeding the sick child

-in most cases, children can determine their own need for food -refusing to eat may also be one-way children can exert power and control in an otherwise helpless situation -forcing a child to eat meets with rebellion and reinforces the behavior as a control mechanism -fluids should not be forced, and the child should not be awakened to take fluids -gentle persuasion with preferred beverages will usually meet with success -look at guidelines on page 1079 -well tolerated foods include gelatin, diluted clear soups, carbonated drinks, flavored ice pops, dry toast, and crackers These are not nutritious but can provide needed calories and fluids -if young children are not supervised while eating, they may just play with their food -it is best to take advantage of hungry periods by serving high quality foods and snacks -charting the amount consumed is a nursing responsibility -document specifics, not percentages (one pancake; 4 ounces juice, etc.)

infiltration

-inadvertent administration of a nonvesicant solution/med into surrounding tissue -more difficult to detect in infants and small children. The increased amount of subcutaneous fat and the amount of tape used to secure the catheter often obscure the early sign of infiltration; don't forget to examine dependent areas -a good blood return, or lack thereof is not always an indicator of infiltration in small infants -*flushing the catheter and observing for edema, redness, or streaking along the vein are appropriate for assessment of the IV* -*immediately stop the infusion, elevate the extremity, and notify the health care provider if intravasation/extravasation is seen*

extravasation

-inadvertent administration of a vesicant solution/med into surrounding tissue -vesicant/sclerosing agent: causes varying degrees of cellular damage when each small amounts escape to tissue

transporting infants and children

-infants and small children can be carried short distances -use a suitable conveyance for more extended trips -bassinettes or cribs -strollers or wagons -wheelchair or stretcher -small infants can be carried one of three ways; look at images on page 1085 -the method of transportation depends on their age, condition, and destination -older children are safe in wheelchairs or on stretchers -younger children can be transported via crib, stretcher, wagon, wheelchair -critically ill children should always be transported on a stretcher or bed -carry BP cuff, pulse oximeter, cardiac monitor/defibrillator, airway equipment and emergency meds during the transport

eyedrops and ointments

-instilling eyedrops is the same as adults, but dropping it onto the conjunctival sac rather than the eyeball itself feels better -wipe from inner canthus out to prevent contamination to other eye -in infants, place drops in inner nasal area where nose and eyes meet so when the infant opens its eyes it will go in -playing a game could be helpful such as asking the child to open their eye on the count of three -ointment should be placed on the lower conjunctival sac -if both are ordered, give drops first and wait 3 mins -ointments should be given near bedtime since vision can be blurred

oral hygiene

-integral part of daily hygiene -some children need a reminder to do this -it's the first introduction for some

expect success

-it is best to approach a child as though cooperation is expected -children sense anxiety and uncertainty in an adult and respond by striking out or actively resisting -a firm approach with a positive attitude tends to convey a feeling of security to most children

parental fluid therapy

-let an older child help pick the site to help them maintain some type of control -in small infants, a superficial vein of the hand, wrist, forearm, foot, or ankle is usually most convenient and most easily stabilized -in older children choose the upper arm and leave hands free -foot veins should be avoided in children learning to walk and those that already walk -superficial veins of the scalp have not valves, insertion is easy, and they can be used in infants up to about 9 months of age, but they should be used only when other site attempts have failed -the smallest gauge and shortest length catheter that will accommodate the prescribed therapy should be chosen -*if selecting a scalp vein, a rubber band should be used as the tourniquet with a piece of tape to grasp it when removing it, should be cut off!*

bladder catheterization

-look at Table 39-5 on page 1090 -*do not advance the catheter too far into the bladder. Knotting of catheters and tubes within the bladder has been reported in several case studies* -*don't use feeding tubes since they are more prone to knotting* -some parents may fear that the procedure affects the daughter's virginity; give detailed info about the GU anatomy; use a model if need be -use distraction to help the child relax (i.e. blowing bubbles, deep breathing, singing a song) -use lidocaine jelly to anesthetize the area before insertion of the catheter. -children often become agitated at being restrained for either procedure. Use comfort measures through touch and voice, both during and after the procedure, to help reduce the child's distress

preparing the family

-look at both guidelines boxes on page 1073 -preferably two members should demonstrate the procedure before they are expected to care for the child at home -provide the family with the telephone numbers of resource individuals who are available to assist them in the event of a problem a family-centered preop preparation program may consist of a tour of: -a tour of the perioperative area -video to take home -additional explanations and demonstrations as needed -pamphlets to guide parents on supporting (4th grade reading level) -phone calls to coach parents 1-2 days prior to the surgery -toys and supplies

skin care and general hygiene

-maintaining healthy skin -bathing -oral hygiene -hair care -feeding the sick child -controlling elevated temperatures or hyperthermia

airborne precautions

-measles, varicella, TB -< 5microns -respirator type mask (N95 mask) -negative pressure room

administration (IM)

-most children are unpredictable, and few are totally cooperative when receiving an injection -it is advisable to have someone available to help hold the child if needed -use phrases such as "putting the medicine under the skin" -if medication is given around the clock, wake the child instead of surprising them in their sleep -look at guidelines on page 1099

psychological preparation

-most effective is the provision of sensory-procedural information and helping the child develop coping skills, such as imagery, distraction, or relaxation -look at guidelines box on page 1060

toys

-nurses are responsible for assessing the safety of toys that the child plays with -if the child is on oxygen avoid toys that are electrical or cause friction -toys should be nonallergic, washable, and unbreakable, and should be able to pass the choke tube test (toilet paper tube) -latex balloons pose a choking hazard in all age groups and should not be allowed in hospital settings

treatment w/out parental consent

-occurs when the child needs urgent medical/surgical treatment and a parent is not readily available or refuses to give consent -in emergencies, including danger to life or the possibility of permanent injury, appropriate care should not be withheld or delayed because of problems obtaining consent -parental refusal to give consent for life-saving treatment or to prevent serious harm can occur and requires notification to child protective services to render emergency treatment -all 50 states have enacted legislation that entitles adolescents to consent to treatment w/out the parents' knowledge -STIs, pregnancy, mental health services, contraceptive advice, alcohol/drug dependency -consent to abortion is controversial and statues vary widely by state

assent

-older child or adolescent has been informed about the proposed treatment, procedure, or research and is willing to let a HCP perform it -nurse should provide an assent form for the child to sign and give them a copy too -only an ethical requirement (not legal one) but demonstrates respect for children includes: 1) helping pt achieve developmentally appropriate awareness of the nature of their condition 2) telling the pt what they can expect 3) making a clinical assessment of the pt's understanding 4) soliciting an expression of the pt's willingness to accept the procedure

eligibility for giving informed consent

-parent or legal guardian status -nurse witnesses their signature -it is the physician's legal responsibility to explain the procedure, risk, benefits, and alternatives -the nurse may reinforce what pt has been told -if parents are unavailable, telephone consent may be obtained in the presence of two witnesses -18 is considered legal age in most states, but a few have legal action to designate a 'mature minor' as young as 14 -an emancipated minor can give consent (pregnancy, marriage, high school grad, independent living, or military service)

preoperative care

-parental presence -anxiety reduction -amnesia -sedation -antiemetic effect -reduction of secretions -infants require special attention to fluid needs. They should not be without oral fluids for an extended period preoperatively to avoid glycogen depletion and dehydration -wearing a hospital gown without underwear or pajama bottoms can te traumatic, so let the child wear into the OR and remove them after the induction of anesthesia -children are at a higher risk for ineffective response to anesthesia because of higher anxiety associated with Infants- stranger anxiety Toddlers and preschoolers- separation anxiety Fear of injury or death- adolescents

involving the child

-permitting choices gives them some measure of control (use "it's time for your medicine. Do you want to drink it plain or with a little water?" Instead of, "Do you want to take your medicine now?") -many children respond to tactics that appeal to their maturity or courage

the use of play in procedures and encouraging expression of feelings

-play is an excellent activity for all children -infants and young children should have the opportunity for gross motor movement -older children are able to vent their anger and frustration in acceptable pounding or throwing activities (Play doh is great) -puppets allow the child to communicate feelings in a nonthreatening way -play can be used to teach, express feelings, or achieve a therapeutic goal -children need to hear from adults that they did the best they could in the situation-no matter how they behaved

droplet precautions

-pneumonia, HIB, meningitis, epiglottitis, strep, influenza -> 5 microns -droplets drop at about 3 feet

bone marrow aspiration or biopsy

-position depends on chosen site -children: posterior/anterior iliac crest used -infants: tibia is used because it's easier to get to -anesthesia needed

informed consent

-pt or pts legal surrogate must receive sufficient info on which to make an informed health care decision -pt has right to accept or refuse any health care -if pt treated w/out consent, HCP may be charged with assault and held liable for damages

keep I/O record on children with

-receiving IV therapy -major surgery -receiving a diuretic or on corticosteroid therapy -severe thermal burns or injuries -renal disease or renal damage -congestive heart failure -dehydration -diabetes mellitus -oliguria -respiratory distress -chronic lung disease

urine specimens

-school-age children are cooperative but curious. they are concerned about the reasons behind this and are likely to ask questions regarding the disposition of their specimen and what one expects to discover from it -self-conscious adolescents may be reluctant to carry a specimen through a hallway or waiting room and appreciate a paper bag for disguising the container -the presence of menses may be an embarrassment or a concern to teenage girls -preschoolers and toddlers are usually unable to void on request. It is often best to offer them water or other liquids that they enjoy and wait about 30 minutes until they are ready to void voluntarily -in infants wipe the abdomen with an alcohol pad and fan it dry; the cooling effect often causes voiding within 2 minutes. apply pressure over the suprapubic area or stroke the paraspinal muscles (along the spine) to elicit the Perez reflex; in infants 4-6 months, this reflex causes crying, extension of the back, flexion of the extremities, and urination -use familiar terms such as "pee" or "tinkle" (ask parents) -some samples can be taken from the diaper by aspiration with a syringe

requirements for obtaining informed consent

-separate informed permissions must be obtained for each -major/minor surgery -diagnostic tests (w/ risk) -medical treatments (w/ risk) -photographs -removal of the child against medical advice (AMA) -postmortem exam (except in the case of unexplained deaths) (ex: SIDS, violent death, suicide) -release of medical info

hair care

-should be done at least once per day -once/twice a week shampooing is sufficient unless contraindicated (profuse sweating, oily hair, etc) -african american hair needs special combs with wide teeth; petroleum jelly should NOT be used, ask child or parent what they typically use; if braiding the hair, weave it loosely while the hair is damp. The hair tightens as it dries, which could result in tension folliculitis

parental presence

-some research shows that parental presence during the induction of anesthesia include reduced anxiety for the child and the parents Lower doses of postop analgesia Lower incidence of severe emergence of delirium symptoms Shorter discharge time for short procedures Some parents are unable to deal with being present when anesthesia is administered Appropriate education is essential to help parents understand the stage of anesthesia, what to expect, and how to support their child

24-hr urine collection

-special collection bags are required for infants and small children -older children require special instruction about notifying someone when they need to void or have a bowel movement so that urine can be collected separately and is not discarded -have the child urinate and discard, this starts the 24hr. time period then collect every urine after this, have the child void at the 24hr. mark

urine collection bags

-special urine collection bags with self-adhering material around the opening at the point of attachment may be used -to prepare the infant, the genitalia, perineum, and surrounding skin are washed and dried thoroughly because the adhesive will not stick to a moist, powdered, or oily skin surface -attach to the perineum first and then attach towards the symphysis pubis -with boys, the penis and sometimes the scrotum are placed inside the bag -check the bag frequently and remove as soon as a specimen is available -*when using a urine collection bag, cut a small slit in the diaper and pull the bag through to allow room for urine to collect and to facilitate checking on the contents* -for diagnosis and management of urinary tract infections in infants 2-24 mo. of age a positive screen obtained from a bag specimen need to be confirmed by culture via bladder catherization or suprapubic aspiration due to an unacceptably high rate of false-positives -clean catch means the sample is obtained after the uretheral meatus is cleaned and the first few ml of urine are voided (midstream specimen)

determining the site (IM)

-the amount and character of the medication to be injected -the amount and general condition of the muscle mass -the frequency or # of injections to be given during the course of treatment -the type of medication being given -factors then may impede access to or cause contamination of the site -the child's ability to assume the required position safely -small infants- not more than 0.5 mL -young children and larger infants- no more than 1 mL -look at Table 39.6 on pages 1097-8 -the ventrogluteal site is best and is easily accessible in several positions. Distraction and prevention of unexpected movement may be more easily achieved by placing the child supine on a parent's lap for this site

allow expression of feelings

-the child should be allowed to express feelings of anger, anxiety, fear, frustration, or any other emotion -allow them to cry unless -coping behaviors should be allowed unless it inflicts harm

compliance (adherence)

-the extent to which the pt's behavior coincides with the prescribed regimen -the nurse needs to assess the level of compliance -family characteristics associated with good compliance include: Family support Family reminders Good communication Expectations for successful completion of the therapeutic regimen -numerous strategies should be used; be creative (clinical judgement, direct observation, monitoring appts, monitoring therapeutic response, pill counts, chemical assay) -education alone does not ensure compliant behavior -written materials are essential (4th grade level) -assess reason for any compliance refusal (do not be judgmental) -assess the treatment and/or medication schedule to see if it is feasible w/their home schedule -use positive reinforcement (stars, stickers and reward) -sometimes discipline may be required (time out or withholding privileges)

extremity venipuncture or injection

-the most common sites of venipuncture are the veins of the extremities especially the arm and hand -place the child in the parent's lap with the child facing the parent and in the straddle position -place the child's arm on a firm surface -have the parent hug the child -this type of restraint also comforts the child

blood specimens

-the nurse is responsible for making certain that specimens, such as serial examinations and fasting specimens, are collected on time and that the proper equipment is available -venous blood samples can be obtained by venipuncture or by aspiration from a peripheral or central access device -attempting to aspirate blood from the peripheral lock may shorten the life of the device. When using an IV infusion site for specimen collection, consider the typeof fluid being infused -although central lines can also be used to withdraw blood specimens, risks include catheter-associated bloodstream infection and occlusion -in young children, adhesive bandages pose an aspiration hazard, so avoid using them or remove the adhesive bandage as soon as the bleeding stops -arterial blood gases- crying, fear, and agitation affect values, therefore make every effort to comfort the child -capillary blood samples should be taken from a finger stick (older than 6 mo.) or a heel stick (younger than 6 mo.) --->warm the heel for 3 minutes, clean site with alcohol, use an automatic lancet device --->omplication: necrotizing osteochondritis from the lancet penetration; look at landmarks on the next slide -children fear the loss of their blood -explain to them that their body continuously produces blood provides them a measure of reassurance --->say, "look how red it is; you're really making a lot of nice red blood" -toddlers are most distressed by venipuncture followed by school-age children and then adolescents -look at atraumatic care on page 1093

respiratory specimens

-the nurse must make it clear to child that a coughed specimen, not mucus cleared from the throat, is needed -demonstrate a deep cough for the child -infants and small children may need to be suctioned (tracheal to elicit a cough); nasal wash, nasopharyngeal swab, or throat culture

femoral venipuncture

-the nurse places the child supine with the legs in a frog position -infant's legs easily controlled by nurse -only the one side is exposed so nurse is protected from urination

parental presence and support

-the nurse should assess the parents' preferences for assisting, observing, or waiting outside the room as well as the child's preference for parental presence -parents should know that someone will be with their child to provide support

oral meds

-the oral route is preferred -most meds are dissolved or suspended in liquid preparations -solid preparations are not recommended for young children because of the danger of aspiration -complaints of dislike from the child is accepted so try to camouflage if needed; avoid essential food items because the child may later refuse to eat them -look at atraumatic care on page 1095 dispensing oral meds: -the most accurate means for measuring small amounts of medication is the plastic disposable calibrated oral syringe -this is also a great way to transport and administer meds -measures less than 1 tsp are impossible to determine accurately with a medicine cup -the teaspoon is also an inaccurate measuring device (5 mL = 1 tsp); a household measuring spoon can be used -if a dropper is used, it should only be the dropper that is supplied with that particular medication (viscosity of meds changes sizes of drops); do not squirt med from dropper into a plastic med cup because some of the med will adhere to the side of the cup -place the infant in a semi reclining position -place the syringe or dropper along the side of the infant's tongue and administer the liquid slowly in small amounts, waiting for the child to swallow between deposits -*in infants up to 11 months of age and children with neurologic impairments, blowing a small puff of air in the face frequently elicits a swallow reflex* -another method is to allow the infant to suck the med that has been placed in an empty nipple or inserting the syringe or dropper into the side of the mouth, parallel to the nipple while the infant nurses -meds are NOT added to formula because the child may then refuse the formula -may sometimes need to use physical coercion with continual verbal explanation; watch for aspiration

IV administration is used when

-there is poor absorption as a result of diarrhea, vomiting, or dehydration -need a high serum concentration of a drug -have resistant infections that require parenteral medication over an extended time -need continuous pain relief -require emergency treatment

PICC lines

-this catheter is the least costly and has less chance of complications that other central venous access devices (CVADs), so this is a good choice for pediatric patients -*most PICC lines are not sutured into place, so care is needed when changing the dressing* -*do not use scissors near catheters/lines, if cut quickly clamp closest to the insertion site to prevent blood loss* -maintenance includes: dressing changes, flushing to maintain patency, and prevention of occlusion or dislodgment -LOOK at table 39-8 pg. 1103

special needs when the child is not permitted to take fluids by mouth or fluids are limited

-to ensure that your patient does not receive fluids, a sign needs to be place somewhere obvious -oral hygiene is extremely important when fluids are restricted or withheld -*give ice chips to keep out moist when NPO*, if allowed; spray the mouth with an atomizer, kept the mouth moist by swabbing with saline-moistened gauze -serve fluids in small containers go give the illusion of larger servings -remember the pacifier so infants still satisfy the sucking need

selecting the syringe and needle (IM)

-typically use a TB syringe -flushing with an air bubble is not recommended in doses less than 1 mL because syringes are calibrated to deliver a prescribed drug dose, and the amount of medication left in the hub and needle is not part of the syringe barrel calibrations -remember to read info to see if Z-track method is recommended for kids: (iron dextran, diphtheria, tetanus toxoid) -use long enough needle to reach the muscle; larger diameter indicated if the fluid is viscous

behavioral restraints

-used if risk that patient will harm self or others is high

intraosseous infusion

-used when venous access can't be readily achieved in peds pts -provides a rapid, safe, lifesaving route -used on children who are unconscious or an analgesia since it's painful -complications include fractures, skin necrosis, osteomyelitis, and cellulitis

checking dosage

-when a dose is ordered that is outside the usual range or when there is some question regarding the preparation or the route of administration, the nurse should check with the prescribing practitioner before proceeding with the administration, because the nurse is legally liable for any drug administered -double check drugs with another nurse before administering to a child; ALWAYS check with another nurse: antiarrhythmics, anticoagulants, chemo, insulin, narcotics, epinephrine, sedatives (PINCH+) -MEDICATION RIGHTS

informed consent must meet what three conditions?

1) the person must be capable of giving consent: age at majority (usually age 18) 2)the person must receive the information needed to make an intelligent decision 3)the person must act voluntarily when exercising freedom of choice (w/out fraud, deceit, coercion, etc.)

steps for specimen collection

1. Assemble the necessary equipment. 2. Identify the child using two patient identifiers (e.g., patient name and medical record or birth date; neither can be a room number). Compare the same two identifiers with the specimen container and order. 3. Perform hand hygiene, maintain aseptic technique, and follow Standard Precautions. 4. Explain the procedure to parents and child according to the developmental level of the child; reassure the child that the procedure is not a punishment. 5. Provide atraumatic care, and position the child securely. 6. Prepare area with antiseptic agent. 7. Place specimens in appropriate containers, and apply a patient ID label to the specimen container in the presence of the child and family. 8. Discard puncture device in puncture-resistant container near the site of use. 9. Wash the procedural preparation agent off if povidone/iodine is used, if skin is sensitive, and for infants. 10. Remove gloves, and perform hand hygiene after the procedure. Have children wash their hands if they have helped. 11. Praise the child for helping. 12. Document pertinent aspects of the procedure, such as number of attempts, site and amount of blood or urine withdrawn, as well as type of test performed.

weighed-diaper method

1g of wet diaper = 1 mL of urine -weigh the wet diaper and subtract the weight of the dry diaper disadvantages of the weighed-diaper method include: -the inability to differentiate one type of loss from another -loss of urine or liquid stool from leakage or evaporation -additional fluid in the diaper from absorption of atmospheric moisture

The preferred site for intramuscular injections in infants is: A. Deltoid B. Dorsogluteal C. Rectus femoris D. Vastus lateralis

D. Vastus lateralis

performance of the procedure (PPW)

Expect success Involve the child Provide distraction ◦ Use play during procedures Allow expression of feelings Provide postprocedural support ◦ Allow expression of feelings

to reduce unpleasant sensations when administering meds

Eye: Apply finger pressure to the lacrimal punctum at the inner aspect of the eyelid for 1 minute to prevent drainage of medication to the nasopharynx and the unpleasant "tasting" of the drug. Ear: Allow medications stored in the refrigerator to warm to room temperature before instillation. Nose: Position the child with the head hyperextended to prevent strangling sensations caused by medication trickling into the throat rather than up into the nasal passages.

preparation for procedures

Psychologic preparation ◦ Age‐specific guidelines for preparation ◦ Developmental and cognitive ability Establishment of trust Parental presence and support Explanation of procedures Physical preparation

management of peripheral IVs

securing: never use opaque tape, IV houses can be used to cover the site to prevent children from messing with it or pulling it out, this minimizes padded board and restraint use removal: reduce anxiety, child can help remove tape so they have some control, use common sense when deciding if you need extra assistance (child's developmental level, age, etc) complications: -infiltration -extravesation

controlling elevated temperatures

Set point: the body temperature that is regulated by the hypothalamus Fever (hyperpyrexia): an elevation in the set point Hyperthermia: body temperature that exceeds the set point -Treatment of elevated temperature depends on whether it is attributable to a fever or hyperthermia

trach care

Tubes: -Have more acute angle than adult tubes. -Soften with body temperature to shape to contour of child's trachea. -No inner cannula is necessary, because this material resists accumulation of dried secretions -Assess thickness, quantity, odor, and color of mucous secretions. -Assess stoma and skin surrounding for signs of inflammation or infection, redness, swelling, or drainage. -Provide adequate humidification and hydration to thin secretions and decrease the risk of mucus plugging. -Suctioning only as necessary to maintain patency of tube. -Do not suction routinely, can cause mucosal damage, bleeding, and bronchospasm. -Provide tracheostomy care every 8 hr. -Change nondisposable tracheostomy tubes every 6 to 8 weeks. -Reposition every 2 hr to prevent atelectasis and pneumonia. -Keep emergency tracheostomy tube, one size smaller, at bedside decennulation: -Accidental decannulation in first 72 hr after surgery is emergency because tracheostomy tract has not matured and replacement can be difficult. -Always have additional staff member present when moving tube or during any situation in which decannulation can occur. -Have scissors to cut the old strings in an emergency. -Occlusion is a situation in which the tube is clogged with secretions and prevents adequate air exchange. -Maintain a patent airway with suctioning.

optic, otic, and nasal administration

eyedrops and ointments techniques: -may be difficult to obtain cooperation from the child infection control concerns

nasogastric, orogastric, or gastrostomy administration (PPW)

advantages: -ability to administer medications around the clock without disturbing the child disadvantages: -occlusion, clogging -adequate flushing

rectal administration of medications

advantages: -alternative route when oral route is difficult or contraindicated disadvantages: -less reliable -if feces is still there the absorption wont be as effective technique: -lubricate with warm water (jelly can effect rate of absorption) -insert quickly and hold buttocks together for a few minutes until urge to defecate has passed -if only half is needed, cut lengthwise -drugs given by enema are diluted in the smallest amount possible to minimize likelihood of being evacuated

standard precautions prevent contamination from

blood, all body fluids, secretions, and excretions except sweat, nonintact skin, mucous membranes, includes respiratory hygiene/cough etiquette, includes safe injection practices including the use of a new sterile needle or cannula each time medication or fluid is withdrawn from a vial or bag and for each injection

administration of medication

determination of drug dosage: -body surface area checking dosage identification: -two identifiers preparing the parents preparing the child

procedures related to elimination

enemas: -purpose -techniques (age/weight appropriate) ostomies: -purpose -techniques -skin/stoma care

alternative feeding techniques (cont'd)

enhance absorption of feeds: -use pacifier during deeds ‐‐> nonnutritive sucking improves digestion -quiet, calm environment -consistent feeding techniques by caregiver/family members nasoduodenal and nasojejunal tubes: -skin‐level devices used to prevent leakage total parenteral nutrition (TPN) -provides for total nutritional needs -intravenous infusion of highly concentrated nutrient solutions family teaching and home care important -if fam doesn't speak english well, color coding meds for which time of day to take them can be helpful

safety in the home(PPW)

environmental factors: -electrical equipment -furniture -strangulation toys: -choking hazards preventing falls: -falls; risk assessment

the goals for using preoperative medications include

reducing anxiety, amnesia, sedation, antiemetic effect, reduction of secretions

alternative feeding techniques

gavage feedings: -nasogastric tubes -orogastric tubes gastrostomy feedings jejunostomy feedings may be continuous drip or intermittent (bolus) feedings -when a child is concurrently receiving continuous-drip gastric or enteral feedings and parenteral therapy, the potential exists for inadvertent administration of the enteral formula through the circulatory system. The possibility for error increases when the parenteral solution is a fat emulsion, (milky in appearance)o Safeguards to prevent this potentially serious error include: -use a separate, specifically designed enteral feeding pump mounted on a separate pole for continuous-feeding solutions -label all tubing of continuous enteral feeding with brightly colored tape of labels -use specifically designed continuous-feeding bags to contain the solutions instead of parenteral equipment, such as a burette -whenever access or connections are made, trace the tubing all the way from the patient to the bag to ensure that the correct tubing source is selected

procedures for maintaining respiratory function

inhalation therapy: -oxygen therapy delivery devices: -->plastic hood/oxyhood: min flow rate 4-5 L/min -->nasal cannula prongs or O2 masks: concentrations of 24%-40 % at flow rate of 1-6 L/min, provide humidification for rates great than 4L/min -oxygen toxicity: use lowest level needed to maintain SaO2, use of mask with CPAP, BIPAP, PEEP while child is on mechanical ventilator can decrease amount needed -monitoring O2 therapy: results less than 91% require nursing intervention, less than 86% is life threatening -end‐tidal CO2 monitoring -bronchial (postural) drainage -chest physical therapy

procedures for maintaining respiratory function (cont.)

intubation indications: -Respiratory failure or arrest, agonal or gasping respirations, apnea -Upper airway obstruction -Significant increase in work of breathing, use of accessory muscles -Potential for developing partial or complete airway obstruction—respiratory effort with no breath sounds, facial trauma, and inhalation injuries -Potential for or actual loss of airway protection, increased risk for aspiration -Anticipated need for mechanical ventilation related to chest trauma, shock, increased intracranial pressure -Hypoxemia despite supplemental oxygen -Inadequate ventilation mechanical ventilation: if sudden deterioration of patient occurs: Displacement: The tube is not in the trachea or has moved into a bronchus (right mainstream most common). Obstruction: Secretions or kinking of the tube. Pneumothorax: Chest trauma, barotraumas, or noncompliant lung disease. Equipment failure: Check the oxygen source, Ambu bag, and ventilator. tracheostomy: -suctioning : no more than 5 seconds for infants and 10 seconds for children, nasal (mushroom tip), oral (hard tip), allow children to rest after each aspiration for O2 to return to normal, only do suctioning when needed to maintain patency -routine care daily chest tubes remove fluid or air from pleural or pericardial space

maintaining fluid balance

measurement of intake and output: -fluids to be measured -practitioners usually order intake and output measurements -nursing responsibility: to identify when fluids should be measured -diaper weighing technique -care of the child who is on NPO status

types of restraints

mummy wrap/swaddle: short term restraint for exam/treatment that involves the head and neck, can also use a papoose board with straps jacket restraint: used to keep the child safe in chairs, in horizontal positions, or in cribs arm/leg restraints: never tie ends to side rails since it could cause injury if lowered, use correct size/padding, monitor for tissue injury elbow restraint: to prevent child from reaching head or face, referred to as "no-no's"

ways of administering meds

oral intramuscular: -electing the syringe and needle -determining the site -administering medication subcutaneous and intradermal intravenous

compliance strategies

organizational: -involves care setting and the therapeutic plan treatment: -relate to the child's refusal or inability to take prescribed medications behavioral: -designed to modify behavior directly

fall prevention

perform a fall risk assessment risk factors for falls: -medication effects -altered mental status -altered or limited mobility -postop children -history of falls -infants or toddlers in cribs with the rails down prevention of falls requires alterations in the environment: -bed in lowest position, locked and side rails up -call light within reach -ensure that all items are within reach -keep lights on at all times (dim light when sleeping) -lock wheelchairs when transferring -appropriate size gown and nonskid socks -keep the floor clean and free of clutter -assist the child with ambulation as needed

intravenous devices

peripheral intermittent infusion device or lock: generally same use as adults central venous access devices: -short term/nontunneled catheter: used in acute care, emergency, and intensive care units, placed in large veins -long‐term tunneled catheter: same as in adults -implanted infusion ports: same as in adults *use safety techniques, a pocket sewn inside a tshirt can hold catheter lines while at play, if accidentally removed hodl pressure to the entry site to the vein not the entry site to the skin* peripherally inserted central catheters (PICCs)

fundamental procedure steps in collection of specimens

urine: -clean catch -24‐hour specimen -bladder catheterization stool blood respiratory secretions