Chapter 22 Power Point

Chapter 22Chapter 22

Health Care Adaptations for the Health Care Adaptations for the Child and FamilyChild and Family

ObjectivesObjectives

• List five safety measures applicable to the care of the hospitalized child.

• Illustrate techniques of transporting infants and children.

• Plan the basic daily data collection for hospitalized infants and children.

• Identify normal vital signs of infants and children at various ages.

2Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Objectives Objectives (cont.)(cont.)

• Devise a nursing care plan for a child with a fever.

• Discuss the techniques of obtaining urine and stool specimens from infants.

• Position an infant for a lumbar puncture.• Calculate the dosage of a medicine that is in

liquid form.• Demonstrate techniques of administering oral,

eye, and ear medications to infants and children.



• Compare the preferred sites for intramuscular injection for infants and adults.

• Discuss two nursing responsibilities necessary when a child is receiving parenteral fluids and the rationale for each.

• Demonstrate the appropriate technique for gastrostomy tube feeding.



• Summarize the care of a child receiving supplemental oxygen.

• Recall the principles of tracheostomy care.

• List the adaptations necessary when preparing a pediatric patient for surgery.


Informed ConsentInformed Consent

• Ensure the parent/guardian signing consent for any procedure understands the purpose and risks involved

• Nurse acts as a patient advocate by ensuring the consent has been signed before the procedure

• When possible, provide the patient with age-appropriate information


IdentificationIdentification

• ID bracelet must be applied upon admission to the nursing unit

• Parent/guardian is also given one to wear and the identification numbers must match what is on the child’s bracelet

• ID bracelet must be verified before any medication, treatment, or procedure is provided


Essential Safety Measures in the Essential Safety Measures in the Hospital Setting—the Do’sHospital Setting—the Do’s

• Keep crib sides up at all times when the child is unattended in bed

• Identify a child by ID bracelet and NOT by room or bed number

• Use a bubble-top or plastic-top crib for infants and children capable of climbing over the crib rails


Essential Safety Measures in the Essential Safety Measures in the Hospital Setting—the Do’s Hospital Setting—the Do’s (cont.)(cont.)

• Place cribs so that children cannot reach sockets or appliances

• Inspect toys for sharp edges and removable parts

• Keep medications and solutions out of reach of the child

• Prevent cross-infection; do not borrow items such as toys from one child and give to another without cleaning the toy per hospital policy first

• Take proper precautions whenever oxygen is being administered


Essential Safety Measures in the Essential Safety Measures in the Hospital Setting—the Don’tsHospital Setting—the Don’ts

• Do not allow ambulatory patients to use wheelchairs or stretchers as toys

• Do not leave an active child in a baby swing, feeding table, or high chair unattended

• Do not leave a small child unattended when out of the crib

• Do not leave medications at the bedside

• Do not prop nursing bottles or force-feed small children—risk of choking


Preparation Steps forPreparation Steps forPerforming ProceduresPerforming Procedures

• Nursing actions prior to a procedure include– Verifying written order of health care provider– Gathering equipment– Identifying the patient– Explaining the procedure to the parent/child– Providing privacy– Performing hand hygiene– Utilizing standard/transmission-based

precautions


Transporting, Positioning, and Transporting, Positioning, and Restraining the InfantRestraining the Infant

• Method depends on age, level of consciousness, and how far the child must travel

• Older children are transported as adults are

• Young children—cribs, wagons, pediatric-sized wheelchair, or gurney

• Side rails are up• ID bracelet has been

checked to ensure the correct child is being transported

• The nurse documents time, method of transport, where child is transported, and who is accompanying child


Transporting, Positioning, and Transporting, Positioning, and Restraining the Infant Restraining the Infant (cont.)(cont.)


Verifying the Child AssessmentVerifying the Child Assessment

• Children are different from adults.

• Data collection is done to determine the level of wellness, the response to medication or treatment, or the need for referral.


Organizing the Infant AssessmentOrganizing the Infant Assessment

• Select a warm, non-stimulating room• Expose only areas of body to be examined• Observe without touching first, with minimal

touching next, and with invasive touch last to assess reflexes and blood pressure

• Talk softly• Utilize pacifier to comfort infant• Swaddle/hold after assessment complete• Utilize parent teaching opportunities• Document findings

Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 15

Basic Data CollectionBasic Data Collection

• Observation– How does the child look?

• Growth and development– Are child’s size and actions

age-appropriate?

• Level of interaction between child and environment– Is child’s behavior

withdrawn, normal for age and development, or inappropriate?

• Is the child tipping his head or rubbing his ears?

• Is child maintaining a rigid body posture in order to breathe?

• Are there any obvious bruises (especially in various stages of healing) or cuts?

• How clean is the child?


The History SurveyThe History Survey

• Allows the nurse to teach parents about child’s needs as well as injury and illness prevention

• Should include questions about complementary and alternative medicine, over-the-counter medications, and immunization history

• Should also include – Child’s health and

eating habits– Sleeping– Toileting– Activity patterns– Use of special words or

gestures in order to communicate with others


The Physical SurveyThe Physical Survey

• Head-to-toe review upon admission and then at least once per shift or clinic visit

• Vital signs– Temperature– Weight– Blood pressure– Pulse– Respiration rate

• Hydration status• Heart sounds• Lung sounds• Bowel sounds• Skin—rashes/lesions


Pulse RatePulse Rate

• Apical pulse advised for children younger than 5 years of age

• Radial pulse used for children older than 5 years of age

• Pulse rate increases as temperature increases


Blood Pressure (BP)Blood Pressure (BP)

• The width of the cuff should be ⅔ of the upper arm

• Electronic BP machines do not require auscultation with stethoscope

• Normal BP is lower in children than in adults

• Can secure BP cuff over brachial, popliteal, or femoral artery

• A BP reading taken when an infant is crying may not be accurate


Pathogenesis of Fever and the Pathogenesis of Fever and the Use of AntipyreticsUse of Antipyretics

• Infection stimulates immune substances to work along with prostaglandins to stimulate the hypothalamus to raise body temperature– Triggers vasoconstriction, shivering, and decreased

peripheral perfusion– Decreases body heat loss while maintaining

homeostasis• Antipyretic medications inhibit prostaglandin

production• Fever increases metabolic demand on the

heart and lungsElsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 21

Hyperthermia Hyperthermia

• An increase in core body temperature occurs with central nervous system impairment

• Prostaglandins are not involved– Homeostasis mechanism is bypassed

• Treatment involves vigorous cooling measures


Techniques to Measure Techniques to Measure Body TemperatureBody Temperature


Techniques to Measure Techniques to Measure Body Temperature Body Temperature (cont.)(cont.)

• Usually done in one of five places– Oral– Axillary– Temporal artery– Tympanic– Core (not widely recommended due to

increase risk of rectal mucosal tearing)


PainPain

• The fifth vital sign

• Must be addressed in the plan of care


WeightWeight

• Provides a means of determining progress

• Necessary to determine safe medication dosages


HeightHeight

• Infants– Birth to 2 years

• Measured lying on a flat surface

• Children – 2 to 18 years

• Measured in a standing position


Head Circumference Head Circumference

• Measured on all infants and toddlers

• Place tape measure slightly above eyebrows, above ear, and around occipital prominence


Collecting SpecimensCollecting Specimens

• Verify physician order

• Obtain lab requisitions, correct containers, and supplies

• Collect specimen

• Label clearly and attach proper forms

• Send to laboratory according to hospital policy

• Record in nurses’ notes and on intake and output record what specimens were obtained and, where appropriate, the amount of output


Examples of SpecimensExamples of Specimens

• Urine• Stool• Blood• Cerebral spinal fluid• Wounds• Body fluids, such as

peritoneal fluid or fluid from surgical drain

• It is important to follow hospital protocols in the collection and handling of any laboratory specimen

• Urine should not be collected from a disposable diaper as chemicals in the diaper will alter the results


Physiological Responses to Physiological Responses to Medications in Infants and ChildrenMedications in Infants and Children

• Understanding the differences in drug absorption, distribution, metabolism, and excretion between children and adults is essential to provide safe pediatric medication administration

• Age is the most important variable in predicting response to any drug therapy


Absorption of Medications in Absorption of Medications in Infants and Children Infants and Children

• Gastric influences

• Intestinal influences

• Topical medications (ointments)

• Parenteral medications


Metabolism of Medications in Metabolism of Medications in Infants and Children Infants and Children

• Most are metabolized in the liver

• Drugs generally metabolize more slowly, especially because the liver and enzymes do not function at a mature level until 2 to 4 years of age


Excretion of Medications in Excretion of Medications in Infants and ChildrenInfants and Children

• Many medications depend on the kidney for excretion

• If younger than 1 year of age, the immature kidney function prevents effective excretion of drugs from the body

• Combination of – Slow stomach emptying– Rapid intestinal transmit

time– Unpredictable liver function– Inability to effectively

excrete medications via the kidney

• Can result in altered responses and places the child at risk for toxicity


Nursing ResponsibilitiesNursing Responsibilities

• Observe for toxic symptoms whenever medications are administered

• Document positive and negative responses

• Every medication administered should have the safety of the dose prescribed calculated before administration


Parent TeachingParent Teaching

• Is essential to ensure compliance when the child is sent home with medications

• Teaching should include– The importance of administering and completing

the medications as prescribed– Techniques of measuring and administering

each dose– Techniques for encouraging child compliance– Importance of writing and following a schedule

for medication administration36Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Methods of Drug AdministrationMethods of Drug Administration

• Oral– Preferred route

• Parenteral– Nosedrops, eardrops, eyedrops– Rectal– Subcutaneous and intramuscular injections– Intravenous– Long-term venous access devices

• Saline lock• Peripheral• PICC

– Central• Hickman, Groshong, and Broviac catheters• Implanted ports


Calculating Drug DosesCalculating Drug Doses

• Body surface area

• Milligrams per kilogram (mg/kg)

• Dimensional analysis


Formula for Dimensional AnalysisFormula for Dimensional Analysis

Unit × Dosage wanted

Dosage on hand Unit to give


Safety AlertSafety Alert

• Maximum volume for IM administration– Infants—0.5 mL– Toddlers—1 mL– School-age/adolescent

• Deltoid—1 mL• Vastus lateralis—2 mL


Total Parenteral NutritionTotal Parenteral Nutrition

• Also known as hyperalimentation

• Provides nutritional needs to those who cannot use the gastrointestinal tract for nourishment for a prolonged period of time

• Allows highly concentrated solutions of protein, glucose, and other nutrients to infuse into a large vessel

• It is important for the nurse to monitor and report the following– Hypoglycemia– Hyperglycemia– Electrolyte imbalances


Nursing Care of a Child Receiving Nursing Care of a Child Receiving Parenteral FluidsParenteral Fluids

• Observe the child hourly for– Low volume in the bag or the need to refill the

burette– The rate of flow of the solution– Pain, redness, or swelling at the needle

insertion site– Moisture at or around the needle insertion site

• Accurate I&O is kept for all children receiving IV fluids


Nursing Care of a Child Receiving Nursing Care of a Child Receiving Parenteral Fluids Parenteral Fluids (cont.)(cont.)

• Key components to remember when providing intravenous therapies– The developmental level of the child– IV placement– Preparation of the child prior to insertion– Related nursing actions– Protection of the IV site– Mobility considerations– Safety needs


Preventing Medication ErrorsPreventing Medication Errors

• 6 Rights of Medication Administration– Patient– Drug– Dose– Time– Route– Documentation


Factors to Consider for Pediatric IVsFactors to Consider for Pediatric IVs

• Developmental characteristics• Site where IV is to be inserted• Preparation of child• Family Involvement• Related nursing actions• Protection of IV site• Mobility Considerations• Safety needs


Avoiding Drug InteractionsAvoiding Drug Interactions

• Selected drug-environment interactions– Phototoxicity

• Selected drug-drug interactions– Phenytoin (Dilantin) and antacid

• Selected drug-food interactions– Iron supplement and egg yolks


Nutrition, Digestion, and Nutrition, Digestion, and EliminationElimination

• Gavage feeding – Given when infant cannot take food or fluids

by mouth but the gastrointestinal tract is functioning

– Places nutrients directly into the stomach so that natural digestion can occur


Nutrition, Digestion, and Nutrition, Digestion, and Elimination Elimination (cont.)(cont.)

• Gastrostomy– Tube surgically placed through the abdominal wall into

the stomach– Used in infants or children who cannot have food by

mouth because of anomalies or strictures of the esophagus, severe debilitation, or coma

• Brown or green drainage may indicate that the tube has slipped from the stomach into the duodenum. This can cause an obstruction and is reported immediately.


Nutrition, Digestion, and Nutrition, Digestion, and Elimination Elimination (cont.)(cont.)

• Enema– Administration is essentially the same as with adults– Modifications include

• Type• Amount• Distance of insertion

– Isotonic solutions– Tap water is contraindicated

• Plain water is hypotonic to the blood and could cause a rapid fluid shift and overload if absorbed through the intestinal wall


RespirationRespiration

• Tracheostomy – An artificial airway (a

plastic tube) placed in the trachea through the neck

– Nursing care is essential to the survival of the child

– The tube can become plugged by mucus or other secretions and cause the child to suffocate

– Tube prohibits vocalization


Respiration Respiration (cont.)(cont.)

• Indications for suctioning – Noisy breathing– Bubbling of mucus– Moist cough or

respirations• Complications

– Tracheoesophageal fistula– Stenosis– Tracheal ischemia– Infection– Atelectasis– Cannula occlusion– Accidental extubation

• Signs and symptoms to observe– Restlessness– Rising pulse rate– Fatigue– Apathy– Dyspnea– Sternal retractions– Pallor– Cyanosis– Inflammation or

drainage around insertion site


General Considerations for the Child General Considerations for the Child Receiving Oxygen TherapyReceiving Oxygen Therapy

• Signs of respiratory distress include increased pulse rate and respirations– Restlessness– Flaring nares– Intercostal an substernal retractions– Cyanosis– Children with dyspnea often vomit, which increases the danger of

aspiration

• Maintain clear airway by suctioning if needed• Organize nursing care to minimize interruptions • Observe children carefully because vision may

be obstructed by mist and young children are unable to verbalize their needs


General Considerations for the Child General Considerations for the Child Receiving Oxygen Therapy Receiving Oxygen Therapy (cont.)(cont.)

• Safety considerations

• Infection prevention and control

• Prolonged exposure to high concentrations

• Therapy is terminated gradually


Management of an Airway Management of an Airway ObstructionObstruction

• Abdominal Thrusts– Works on the principle that forcing the

diaphragm up causes residual air in the lungs to be forcefully expelled, resulting in popping the obstruction out of the airway


Procedure for Clearing an Airway Procedure for Clearing an Airway ObstructionObstruction


Preoperative and Postoperative Preoperative and Postoperative CareCare

• Preoperative– Children require both

physical and psychological preparation at their level of understanding

– Clarify any misunderstandings the child may have

– Infants should not be maintained on NPO status for longer than 4 to 6 hours; provide a pacifier to assist in meeting developmental need for sucking

• Postoperative– Nursing interventions are

aimed at assisting the child to master a threatening situation and minimize physical and psychological complications


Body Art, Body Jewelry, TattoosBody Art, Body Jewelry, Tattoos

• Most body jewelry designed to stay in place– Can cover with occlusive dressing– May need to remove if in area of surgery– Flexible plastic retainer may help keep holes open

• Nipple rings removed for mammogram• MRI—most body jewelry is not ferromagnetic

– Tattoos or permanent cosmetics at risk for developing edema or burning during MRI

– Document presence of any tattoos


Question for ReviewQuestion for Review

• What is the nursing responsibility in the monitoring of IV therapy for the pediatric patient?


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Chapter 22 Power Point