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Pediatric Variations of Nursing Interventions ...

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Chapter 39: Pediatric Variations of Nursing Interventions I.

Informed consent o Should include  Expected care or treatment  Potential risks  Benefits  Alternatives  What might happen if the patient chooses not to consent  o Must meet the following three conditions  Must be capable of giving consent  Must receive the info needed to make an informed consent  Must act voluntarily  Requirements for Obtaining Informed Consent o Separate informed permissions must be obtained for each o Major/minor surgery o Diagnostic tests (with an element of risk) o Medical treatments (with an element of risk) o Photographs o Removal of the child against medical advice (AMA) o Postmortem exam (except in the case of unexplained deaths) o Release of medical info  Eligibility of giving informed consent o The nurse witnesses the patient’s, parent’s or legal guardian’s signature o The nurse may reinforce what the patient has been told o If parents are unavailable, telephone consent may be obtained in the presence of two witnesses o In most states 18 is considered legal age o An emancipated minor (pregnancy, marriage, high school graduation, independent living, or military service)  Treatment without parental consent o Occurs when the child needs urgent medical or surgical treatment and a parent is not readily available or refuses to give consent o 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 o 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 o All 50 states have enacted legislation that entitles adolescents to consent to treatment without the parents’ knowledge

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STIs, pregnancy, mental health services, contraceptive advice, alcohol and drug dependency  Consent to abortion is controversial and statues vary widely by state  Preparation for diagnostic and therapeutic procedures o Psychological preparation  The 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 1069  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  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 o Parents should know that someone will be with their child to provide support o 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  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 o Ideally, the same nurse who explains the procedure should perform or assist with the procedure o Minimizing the number of people present during procedure can decrease anxiety o To avoid a delay during a procedure, have extra supplies available o Use treatment rooms for procedures o Never perform “traumatic” procedures in safe areas o As the procedure is nearing completion, the nurse should inform the child that it is almost over in language the child understands o It is best to approach a child as though cooperation is expected o Children sense anxiety and uncertainty in an adult and respond by striking out or actively resisting o A firm approach with a positive attitude tends to convey a feeling of security to most children o 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?” o Many children respond to tactics that appeal to their maturity or courage o Distraction is a powerful coping strategy

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Singing, listening to music with headphones, counting aloud, blowing bubbles, etc. o The child should be allowed to express feelings of anger, anxiety, fear, frustration, or any other emotion o Postprocedural support o Play is an excellent activity for all children o Infants and young children should have the opportunity for gross motor movement o Older children are able to vent their anger and frustration in acceptable pounding or throwing activities (Play doh is great) o Puppets allow the child to communicate feelings in a nonthreatening way o Play can be used to teach, express feelings, or achieve a therapeutic goal o Children need to hear from adults that they did the best they could in the situation-no matter how they behaved o Preparing the family o Look at both guidelines boxes on page 1073 o Preferably two members should demonstrate the procedure before they are expected co care for the child at home o Provide the family with the telephone numbers of resource individuals who are available to assist them in the event of a problem  Surgical procedures- preop care o 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 o 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 o 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 o 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 o 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  The goals for using preoperative medications include  reducing anxiety, amnesia, sedation, antiemetic effect, reduction of secretions o Post-anesthesia complication such as airway obstruction, post-extubation croup, laryngospasm, and bronchospasm make maintaining a patent airway and maximum ventilation critical o Malignant hyperthermia is a potential fatal pharmacogenetic disorder  Symptoms: hypercarbia, elevated temperature, tachycardia, tachypnea, acidosis, muscle rigidity, and rhabdomyolysis o 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  Compliance o The nurse needs to assess the level of compliance o Family characteristics associated with good compliance include  Family support  Family reminders  Good communication  Expectations for successful completion of the therapeutic regimen o Numerous strategies should be used; be creative o The nurse instructs the family about the treatment plan o Education alone does not ensure compliant behavior o Written materials are essential (4th grade level) o Assess reason for any compliance refusal (do not be judgmental) o Assess the treatment and/or medication schedule to see if it is feasible w/their home schedule o Use positive reinforcement (stars, stickers and reward) o Sometimes discipline may be required (time out or withholding privileges) II. Skin Care and General Hygiene  Maintaining Healthy Skin o Assessment of the skin is easiest to accomplish during bathing

o Risk factors for skin breakdown include  Impaired mobility  Protein malnutrition  Edema  Incontinence  Sensory loss  Anemia  Infection  Failure to turn the patient  Intubation o Use the Braden Q scale or the Glamorgan scale o Reactive hyperemia: earliest sign of tissue compromise and pressure-related ischemia o 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 o 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  Bathing o For children confined to bed use bath cloths; if able let the child clean themselves and assist with hard to reach areas o For infants and toddlers: bath cloths or towel method o Chlorhexidine is best but not in infants younger than 2 months of age o Never leave little ones unattended in the bath tub; hold on to them o School age and adolescents can shower or bathe

o Closely supervise kids with cognitive impairments, physical limitations, suicidal or psychiatric problems o Areas that require special attention are the ears, between skinfolds, the neck, the back, and the genital area o In the Vietnamese and Cambodian cultures, the foreskin is not retracted until adulthood  Oral hygiene is an integral part of daily hygiene o Some children will need a reminder to do oral care  Hair care should be done at least once per day o African American hair need 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  Feeding the Sick Child o In most cases, children can determine their own need for food o Refusing to eat may also be one-way children can exert power and control in an otherwise helpless situation o Forcing a child to eat meets with rebellion and reinforces the behavior as a control mechanism o Fluids should not be forced, and the child should not be awakened to take fluids o Gentle persuasion with preferred beverages will usually meet with success o Look at guidelines on page 1079 o 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 o If young children are not supervised while eating, they may just play with their food o It is best to take advantage of hungry periods by serving high quality foods and snacks o Charting the amount consumed is a nursing responsibility o Document specifics, not percentages (one pancake; 4 ounces juice, etc.)  Controlling Elevated Temperatures- Fever o Set point: the body temperature that is regulated by the hypothalamus o Fever (hyperpyrexia): an elevation in the set point o Hyperthermia: body temperature that exceeds the set point o Treatment of elevated temperature depends on whether it is attributable to a fever or hyperthermia o 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 o Take the temperature again after 30 minutes of antipyretic administration o Traditional cooling measures:  Minimum clothing

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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) o Febrile seizures lasting less than 10 minutes do not cause brain damage or other debilitating effects  Controlling Elevated Temperatures- Hyperthermia o If a cooling blanket is used, cover the patient with a sheet or lightweight blanket; frequently monitor the temp o 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 III. Safety o Identification o Infants and unconscious patients are unable to tell or respond to their names. o Toddlers may answer to any name or to a nickname only o Older children may exchange places, give an erroneous name, or choose not to respond to their own names as a joke  Safety- environmental factors o All windows should be secured o Window blind and curtain cords should be out of reach o Pacifiers should not be tied onto or around the infant’s neck o Electrical outlets should have covers o Infants are helpless in water and some children may turn on the hot water faucet and be severely burned o A special hazard for children is the danger of entrapment under an electronically controlled bed when it is activated to descend o Baby walkers should not be used o Even preemies are capable of surprising mobility; therefore, portholes in incubators must be securely fastened when not in use o Crib sides should always be raised and fastened securely o Never tie nets to the movable crib sides or use knots that do not permit quick release o Place infants “back to sleep” (on their backs) on a firm surface

o Not pillows in the crib o Avoid overheating the infant o Avoid exposure to tobacco smoke, alcohol, and illicit drugs  Safety- toys o Nurses are responsible for assessing the safety of toys that the child plays with o If the child is on oxygen avoid toys that are electrical or cause friction o Toys should be nonallergic, washable, and unbreakable, and should be able to pass the choke tube test (toilet paper tube) o Latex balloons pose a choking hazard in all age groups and should not be allowed in hospital settings  Safety- fall prevention o Perform a fall risk assessment o 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 o 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  Infection control o Standard precautions are used to 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 o Airborne precautions (measles, varicella, TB)  < 5microns  Respirator type mask (N95 mask)  Negative pressure room o Droplet precautions (pneumonia, HIB, meningitis, epiglottitis, strep, influenza)

 > 5 microns  Droplets drop at about 3 feet o 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  Transporting infants and children o Small infants can be carried one of three ways; look at images on page 1085 o The method of transportation depends on their age, condition, and destination o Older children are safe in wheelchairs or on stretchers o Younger children can be transported via crib, stretcher, wagon, wheelchair o 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  Restraining Methods o What is a restraint  “any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely…or a drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition” o 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 o The nurse needs to assess the child’s development, mental status, potential to hurt others or self, and safety o 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. o Should assess the child at least every 2 hours o Tie knots that allow for quick release and have 1 finger width between child and restraint o 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

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o 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 o 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 o Mummy wrap video  A mummy restraint is for an infant or small child that requires short-term restraint for exams or treatments that involves the head and neck Positioning for Procedures Positioning for procedures- Femoral Venipuncture o The nurse places the child supine with the legs in a frog position o Only the one side is exposed Extremity venipuncture or injection o The most common sites of venipuncture are the veins of the extremities especially the arm and hand o Place the child in the parent’s lap with the child facing the parent and in the straddle position o Place the child’s arm on a firm surface o Have the parent hug the child o This type of restraint also comforts the child Lumbar puncture o Children are usually easiest to control in the side-lying position, with the head flexed and the knees drawn up toward the chest o Children can be reassured that, although they are trusted, holding will serve as a reminder to maintain the desired position o A flexed-sitting may be used depending on the child’s ability to cooperate and whether sedation will be used o 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 o Monitor vital signs, and observe for any changes in LOC, motor activity, and other neuro signs o Post-lumbar punc...