Download Chapter 22 Health Care Adaptations for the Child and Family

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Chapter 22
Health Care Adaptations for the Child and Family
Objectives
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.
Objectives (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.
Objectives (cont.)
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.
Objectives (cont.)
Summarize the care of a child receiving supplemental oxygen.
Recall the principles of tracheostomy care.
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List the adaptations necessary when preparing a pediatric patient for surgery.
Admission to the Pediatric Unit—Nursing Responsibilities
Informed 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
Identification
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 Hospital 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 Hospital Setting—the Do’s (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
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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 Hospital 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 for
Performing Procedures
Nursing actions prior to a procedure include
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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 Restraining the Infant
Method depends on age, level of consciousness, and how far the child must travel
Older children are transported as adults are
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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 Restraining the Infant (cont.)
Verifying 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 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
Basic Data Collection
Observation
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How does the child look?
Growth and development
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Are child’s size and actions age-appropriate?
Level of interaction between child and environment
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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 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
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Child’s health and eating habits
Sleeping
Toileting
Activity patterns
Use of special words or gestures in order to communicate with others
The Physical Survey
Head-to-toe review upon admission and then at least once per shift or clinic visit
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Vital signs
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Temperature
Weight
Blood pressure
Pulse
Respiration rate
Hydration status
Heart sounds
Lung sounds
Bowel sounds
Skin—rashes/lesions
Pulse 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)
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
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A BP reading taken when an infant is crying may not be accurate
Pathogenesis of Fever and the Use of Antipyretics
Infection stimulates immune substances to work along with prostaglandins to stimulate the
hypothalamus to raise body temperature
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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 lungs
Hyperthermia
An increase in core body temperature occurs with central nervous system impairment
Prostaglandins are not involved
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Homeostasis mechanism is bypassed
Treatment involves vigorous cooling measures
Techniques to Measure
Body Temperature
Techniques to Measure
Body Temperature (cont.)
Usually done in one of five places
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Oral
Axillary
Temporal artery
Tympanic
Core (not widely recommended due to increase risk of rectal mucosal tearing)
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Pain
The fifth vital sign
Must be addressed in the plan of care
Weight
Provides a means of determining progress
Necessary to determine safe medication dosages
Height
Infants
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Birth to 2 years
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Measured lying on a flat surface
Children
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2 to 18 years
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Measured in a standing position
Head Circumference
Measured on all infants and toddlers
Place tape measure slightly above eyebrows, above ear, and around occipital prominence
Collecting Specimens
Verify physician order
Obtain lab requisitions, correct containers, and supplies
Collect specimen
Label clearly and attach proper forms
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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 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 Medications 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 Infants and Children
Gastric influences
Intestinal influences
Topical medications (ointments)
Parenteral medications
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Metabolism of Medications in 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
Infants 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
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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
Administering Medications to Infants and Children
Nursing 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 Teaching
Is essential to ensure compliance when the child is sent home with medications
Teaching should include
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Techniques of measuring and administering each dose
Techniques for encouraging child compliance
Importance of writing and following a schedule for medication administration
Methods of Drug Administration
Oral
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Preferred route
Parenteral
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The importance of administering and completing the medications as prescribed
Nosedrops, eardrops, eyedrops
Rectal
Subcutaneous and intramuscular injections
Intravenous
Long-term venous access devices
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Saline lock
Peripheral
PICC
Central
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Hickman, Groshong, and Broviac catheters
Implanted ports
Calculating Drug Doses
Body surface area
Milligrams per kilogram (mg/kg)
Dimensional analysis
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Formula for Dimensional Analysis
Unit
× Dosage wanted
Dosage on hand
Unit to give
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Safety Alert
Maximum volume for IM administration
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Infants—0.5 mL
Toddlers—1 mL
School-age/adolescent
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Deltoid—1 mL
Vastus lateralis—2 mL
Total 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
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Hypoglycemia
Hyperglycemia
Electrolyte imbalances
Nursing Care of a Child Receiving Parenteral Fluids
Observe the child hourly for
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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
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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 Parenteral Fluids (cont.)
Key components to remember when providing intravenous therapies
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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 Errors
6 Rights of Medication Administration
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Patient
Drug
Dose
Time
Route
Documentation
Factors to Consider for Pediatric IVs
Developmental characteristics
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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 Interactions
Selected drug-environment interactions
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Phototoxicity
Selected drug-drug interactions
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Phenytoin (Dilantin) and antacid
Selected drug-food interactions
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Iron supplement and egg yolks
Nutrition, Digestion, and Elimination
Gavage feeding
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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 Elimination (cont.)
Gastrostomy
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Tube surgically placed through the abdominal wall into the stomach
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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 Elimination (cont.)
Enema
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Used in infants or children who cannot have food by mouth because of anomalies or
strictures of the esophagus, severe debilitation, or coma
Administration is essentially the same as with adults
Modifications include
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Type
Amount
Distance of insertion
Isotonic solutions
Tap water is contraindicated
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Plain water is hypotonic to the blood and could cause a rapid fluid shift and
overload if absorbed through the intestinal wall
Respiration
Tracheostomy
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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 (cont.)
Indications for suctioning
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Noisy breathing
Bubbling of mucus
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Moist cough or respirations
Complications
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Tracheoesophageal fistula
Stenosis
Tracheal ischemia
Infection
Atelectasis
Cannula occlusion
Accidental extubation
Signs and symptoms to observe
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Restlessness
Rising pulse rate
Fatigue
Apathy
Dyspnea
Sternal retractions
Pallor
Cyanosis
Inflammation or drainage around insertion site
General Considerations for the Child Receiving Oxygen Therapy
Signs of respiratory distress include increased pulse rate and respirations
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Restlessness
Flaring nares
Intercostal an substernal retractions
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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 Receiving Oxygen Therapy (cont.)
Safety considerations
Infection prevention and control
Prolonged exposure to high concentrations
Therapy is terminated gradually
Management of an Airway Obstruction
Abdominal Thrusts
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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 Obstruction
Preoperative and Postoperative Care
Preoperative
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Cyanosis
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
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Nursing interventions are aimed at assisting the child to master a threatening
situation and minimize physical and psychological complications
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Body Art, Body Jewelry, Tattoos
Most body jewelry designed to stay in place
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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
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Tattoos or permanent cosmetics at risk for developing edema or burning during MRI
Document presence of any tattoos
Question for Review
What is the nursing responsibility in the monitoring of IV therapy for the pediatric patient?
Review
Objectives
Key Terms
Key Points
Online Resources
Review Questions