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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.
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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.
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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.
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Objectives (cont.)
• 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.
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Admission to the Pediatric Unit—
Nursing Responsibilities
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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 ageappropriate information
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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
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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 plastictop crib for infants and
children capable of climbing
over the crib rails
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Essential Safety Measures in the
Hospital Setting—the Do’s (cont.)
• Place cribs so that
• Prevent cross-infection;
children cannot reach
do not borrow items
sockets or appliances
such as toys from one
child and give to another
• Inspect toys for sharp
without cleaning the toy
edges and removable
per hospital policy first
parts
• Keep medications and • Take proper precautions
whenever oxygen is
solutions out of reach
being administered
of the child
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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
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Preparation Steps for
Performing 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
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Transporting, Positioning, and
Restraining the Infant
• Method depends on age, • Side rails are up
level of consciousness, • ID bracelet has been
and how far the child
checked to ensure the
must travel
correct child is being
• Older children are
transported
transported as adults are • The nurse documents
• Young children—cribs,
time, method of
wagons, pediatric-sized
transport, where child
wheelchair, or gurney
is transported, and
who is accompanying
child
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Transporting, Positioning, and
Restraining the Infant (cont.)
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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.
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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
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Basic Data Collection
• Observation
• Is the child tipping his
head or rubbing his
– How does the child look?
• Growth and development ears?
– Are child’s size and actions • Is child maintaining a
age-appropriate?
rigid body posture in
order to breathe?
• Level of interaction
between child and
• Are there any obvious
environment
bruises (especially in
various stages of
– Is child’s behavior
withdrawn, normal for age
healing) or cuts?
and development, or
• How clean is the child?
inappropriate?
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The History Survey
• Allows the nurse to teach • Should also include
parents about child’s
– Child’s health and
needs as well as injury
eating habits
and illness prevention
– Sleeping
• Should include questions
– Toileting
about complementary
– Activity patterns
and alternative medicine,
– Use of special words or
over-the-counter
gestures in order to
medications, and
communicate with
immunization history
others
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The Physical Survey
• Head-to-toe review
upon admission and
then at least once per
shift or clinic visit
• Vital signs
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–
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Temperature
Weight
Blood pressure
Pulse
Respiration rate
•
•
•
•
•
Hydration status
Heart sounds
Lung sounds
Bowel sounds
Skin—rashes/lesions
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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
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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
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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
– 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
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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
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Techniques to Measure
Body Temperature
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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
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Weight
• Provides a means of determining progress
• Necessary to determine safe medication
dosages
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Height
• Infants
– Birth to 2 years
• Measured lying on a
flat surface
• Children
– 2 to 18 years
• Measured in a
standing position
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Head Circumference
• Measured on all
infants and
toddlers
• Place tape
measure slightly
above eyebrows,
above ear, and
around occipital
prominence
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Collecting 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
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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
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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
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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
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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
– 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
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Administering Medications to
Infants and Children
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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
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Parent 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 administration
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Methods of Drug Administration
• Oral
– Preferred route
• Parenteral
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–
–
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
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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
– Infants—0.5 mL
– Toddlers—1 mL
– School-age/adolescent
• Deltoid—1 mL
• Vastus lateralis—2 mL
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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
– Hypoglycemia
– Hyperglycemia
– Electrolyte imbalances
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Nursing Care of a Child Receiving
Parenteral 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
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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
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Preventing Medication Errors
• 6 Rights of Medication Administration
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–
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Patient
Drug
Dose
Time
Route
Documentation
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Factors to Consider for Pediatric IVs
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•
•
•
•
•
•
•
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
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Avoiding Drug Interactions
• Selected drug-environment interactions
– Phototoxicity
• Selected drug-drug interactions
– Phenytoin (Dilantin) and antacid
• Selected drug-food interactions
– Iron supplement and egg yolks
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Nutrition, Digestion, and
Elimination
• 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
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Nutrition, Digestion, and
Elimination (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.
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Nutrition, Digestion, and
Elimination (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
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Respiration
• 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
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Respiration (cont.)
• Indications for suctioning
– Noisy breathing
– Bubbling of mucus
– 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
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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
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
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General Considerations for the Child
Receiving Oxygen Therapy (cont.)
• Safety
considerations
• Infection prevention
and control
• Prolonged exposure
to high
concentrations
• Therapy is
terminated gradually
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Management of an Airway
Obstruction
• 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
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Procedure for Clearing an Airway
Obstruction
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Preoperative and Postoperative
Care
• 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
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Body 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
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Question for Review
• What is the nursing responsibility in the
monitoring of IV therapy for the pediatric
patient?
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Review
•
•
•
•
•
Objectives
Key Terms
Key Points
Online Resources
Review Questions
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