Words and Phrases to Avoid	Suggested Substitutions
Shot, bee sting, stick	Medicine under the skin
Organ	Special place in body
Test	See how [specify body part] is working
Incision, cut	Special opening
Edema	Puffiness, swelling
Stretcher, gurney	Rolling bed
Stool	Child’s usual term
Dye	Special medicine
Pain	Hurt, discomfort, “owie,” “boo-boo,” sore, achy
Deaden	Numb, make sleepy
Fix	Make better
Take (as in “take your temperature or blood pressure”)	See how warm you are; check your pressure; hug your arm
Put to sleep, anesthesia	Special sleep so you won’t feel anything
Catheter	Tube
Monitor	TV screen
Electrodes	Stickers, ticklers
Burn	Warm
Dressings, dressing change	Bandages

Increased Language Skills

Use verbal explanation, but avoid overestimating child’s comprehension of words.

Encourage child to verbalize ideas and feelings.

Rephrase questions to make sure of what child is asking.

Concept of Time and Frustration Tolerance Still Limited

Implement same approaches as for toddler, but may plan longer teaching session (10 to 15 minutes); may divide information into more than one session.

Illness and Hospitalization May Be Viewed as Punishment

Clarify why each procedure is performed; a child will find it difficult to understand how medicine can taste bad and make him or her feel better at the same time.

Ask for child’s thoughts regarding why a procedure is performed.

State directly that procedures are never a form of punishment.

Animism

Keep equipment out of sight, except when shown to or used on child.

Fears of Bodily Harm, Intrusion, and Castration

Point out on drawing, doll, or child where procedure will be performed.

Emphasize that no other body part will be involved.

Use nonintrusive procedures whenever possible (e.g., axillary temperatures, oral medication).

Apply an adhesive bandage over puncture site.

Encourage parental presence.

Realize that procedures involving genitalia produce anxiety.

Allow child to wear underpants with gown.

Explain unfamiliar situations, especially noises or lights.

Striving for Initiative

Involve child in care whenever possible (e.g., to hold equipment, remove dressing).

Give choices when they exist, but avoid excessive delays.

Praise child for helping and for attempting to cooperate; never shame child for lack of cooperation.

School-Age Child: Developing a Sense of Industry and Concrete Thought

Increased Language Skills; Interest in Acquiring Knowledge

Explain procedures using correct scientific or medical terminology.

Explain reason for procedure using simple diagrams of anatomy and physiology.

Explain function and operation of equipment in concrete terms.

Allow child to manipulate equipment; use doll or another person as model to practice using equipment whenever possible (doll play may be considered childish by older school-age child).

Allow time before and after procedure for questions and discussion.

Improved Concept of Time

Plan for longer teaching sessions (about 20 minutes).

Prepare before procedure.

Increased Self-Control

Gain child’s cooperation.

Tell child what is expected.

Suggest ways of maintaining control (e.g., deep breathing, relaxation, counting).

Striving for Industry

Allow responsibility for simple tasks (e.g., collecting specimens).

Include in decision making (e.g., what time of day to perform procedure, the preferred site).

Encourage active participation (e.g., removing dressings, handling equipment, opening packages).

Developing Relationships with Peers

May prepare two or more children for same procedure or encourage one peer to help prepare another.

Provide privacy from peers during procedure to maintain self-esteem.

Adolescent: Developing a Sense of Identity and Abstract Thought

Increasingly Capable of Abstract Thought and Reasoning

Supplement explanations with reasons why procedure is necessary or beneficial.

Explain long-term consequences of procedures.

Realize that adolescent may fear death, disability, or other potential risks.

Encourage questioning regarding fears, options, and alternatives.

Conscious of Appearance

Provide privacy.

Discuss how procedure may affect appearance (e.g., scar) and what can be done to minimize it.

Emphasize any physical benefits of procedure.

Concerned More with Present Than with Future

Realize that immediate effects of procedure are more significant than future benefits.

Striving for Independence

Involve in decision making and planning (e.g., time and place; individuals present during procedure; clothing; whether they will watch procedure).

Impose as few restrictions as possible.

Suggest methods of maintaining control.

Accept regression to more childish methods of coping.

Realize that adolescent may have difficulty accepting new authority figures and may resist complying with procedures.

Developing Peer Relationships and Group Identity

Same as for school-age child but assumes even greater significance.

Allow adolescents to talk with other adolescents who have had the same procedure.

Preparing the Family

The process of patient education involves giving the family information about the child’s condition, the regimen that must be followed and why, and other health teaching as indicated. The goal of this education is to enable the family to modify behaviors and adhere to the regimen that has been mutually established.

General principles of family education are as follows:

1. Establish a rapport with the family.

2. Avoid using any specialized terms or jargon. Clarify all terms with the family.

3. When possible, allow family members to decide how they want to be taught (e.g., all at once or over a day or two). This gives the family a chance to incorporate the information at a rate that is comfortable.

4. Provide accurate information to the family about the illness.

5. Assist family members in identifying obstacles to their ability to comply with the regimen and in identifying the means to overcome those obstacles. Then help family members find ways to incorporate the plan into their daily lives.

If equipment will be needed at home (e.g., suction machines, syringes), begin making the necessary arrangements in advance so that discharge can proceed smoothly. Whenever possible, make arrangements for the family to use the same equipment in the home that they are using in the hospital. This allows them to become familiar with the items. In addition, the staff can help troubleshoot the equipment in a controlled environment. Plan the teaching sessions well in advance of the time the family will be responsible for performing the care. The more complex the procedure, the more time is needed for training.

Review the instructions with family members. Encourage note taking if they desire. Allow ample practice time under supervision. At least one family member, but 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.

Guidelines

Family Preparation for Procedures

Family education for specific procedures are included throughout this unit. General concepts applicable to most family education sessions include the following:

1. Name of the procedure

2. Purpose of the procedure

3. Length of time anticipated to complete the procedure

4. Anticipated effects

5. Signs of adverse effects

6. Assess the family’s level of understanding

7. Demonstrate and have family return demonstration (if appropriate)

Skin Care and General Hygiene

Skin Care

General Guidelines

Keep skin free of excess moisture (e.g., urine or fecal incontinence, wound drainage, excessive perspiration).

Cleanse skin with gentle soap (e.g., Dove) or cleanser (e.g., Cetaphil). Rinse well with plain, warm water.

Provide daily cleansing of eyes, oral area, diaper or perineal area, and any areas of skin breakdown.

Apply non–alcohol-based moisturizing agents after cleansing to retain moisture and rehydrate skin.

Use minimum tape and adhesives. On very sensitive skin, use a protective, pectin-based or hydrocolloid skin barrier between skin and tape and adhesives.

Place pectin-based or hydrocolloid skin barriers directly over excoriated skin. Leave barrier undisturbed until it begins to peel off. With wet, oozing excoriations, place a small amount of stoma powder (as used in ostomy care) on site, remove excess powder, and apply skin barrier. Hold barrier in place for several minutes to allow barrier to soften and mold to skin surface. See Table 4-2 for common wound care products.

TABLE 4-2

Wound Dressing Category Definitions and Examples of Products

Category	Description	Examples
Gauze or sponge for external use	Nonresorbable	Pads
	Sterile or nonsterile	Island dressings
	Strip, piece, or pad
	Woven or nonwoven mesh cotton cellulose
	Simple chemical derivatives of cellulose
	Intended for medical purposes
Hydrophilic wound dressing	Sterile or nonsterile	Alginate dressings
	Nonresorbable	Foam dressings
	Material with hydrophilic properties	Hydropolymer dressings
	No added drugs or biologics	Sheet gel dressings
	Intended to cover wound and absorb exudate	Hydrocolloid dressings
		Composite dressings
		Hydrogel dressings
Occlusive wound dressing	Sterile or nonsterile	Transparent adhesive dressings
	Nonresorbable	Thin film dressings
	Synthetic polymeric material with or without adhesive backing	Foam dressings
		Hydrocolloid dressings
	Intended to cover wound, provide or support moist wound environment, and allow exchange of gases	Composite dressings
		Hydropolymer dressings
Hydrogel wound dressing	Sterile or nonsterile	Alginate dressings
	Nonresorbable	Hydropolymer dressings
	Matrix of hydrophilic polymers or other material combined with at least 50% water	Hydrogel dressings
		Gauze dressings impregnated with hydrogel (without active ingredients)
	Intended to cover wound, absorb wound exudates, control bleeding or fluid loss, and protect against abrasion, friction, desiccation, contamination
Porcine wound dressing	Made from pigskin
	Temporary burn dressing

From van Rijswijk L: Recommendations to change the FDA classification of various wound dressings, Ostomy Wound Manag 45(3):31, 1999. Used with permission.

Alternate electrode and probe placement sites and thoroughly assess underlying skin, typically every 8 to 24 hours.

Eliminate pressure secondary to medical devices such as tracheostomy tubes, wheelchairs, braces, and gastrostomy tubes.

Be certain fingers or toes are visible whenever extremity is used for IV or arterial line.

Reduce friction by keeping skin dry (may apply absorbent powder such as cornstarch) and using soft, smooth bed linens and clothes.

Use a draw sheet to move a child in bed or onto a stretcher to reduce friction and shearing injuries; do not drag the child from under the arms.

Position in neutral alignment; pillows, cushions, or wedges may be needed to prevent hip abduction and pressure to bony prominences, such as heels, elbows, and sacral and occipital areas. When the child is positioned laterally, pillows/cushions between the knees, under the head, and under the upper arm will help promote neutral body alignment. Avoid donut cushions because they can cause tissue ischemia. Elevate the head of bed 30 degrees or less to reduce pressure, unless contraindicated

Do not massage reddened, bony prominences because this can cause deep tissue damage; provide pressure relief to these areas instead.

Routinely assess the child’s nutritional status. A child who is on nothing by mouth (NPO) status for several days and who is receiving only IV fluids is nutritionally at risk. This can also affect the skin’s ability to maintain its integrity. Hyperalimentation (TPN,TNA) should be considered for these children at risk.

Identify children who are at risk for skin breakdown before it occurs. Employ measures such as pressure-reducing devices (reduce pressure more than would usually occur on a regular hospital bed or chair) or pressure-relieving devices (maintain pressure below that which would cause capillary closing) to prevent breakdown (Table 4-3).

TABLE 4-3

Pressure Reduction and Relief Devices

Description	Advantages	Disadvantages	Examples*
Overlay†
Foam: Varying density; 3- to 4-inch convoluted and nonconvoluted	Primarily pressure reduction, although in children may have pressure relief advantages; can be cut to fit cribs	Can be soiled by incontinent patient; inability to reduce skin moisture because of lack of airflow	Bio Clinic Brand BioGard (Sunrise Medical), Geo-Matt (Span America), Ultra Form Pediatric (American Health Systems, Inc.)
Gel or water filled: Pressure reduction; water or gel conforms to patient’s contours	One-time charge; low cost for water; gels are expensive Relieves pressure and shear; nonpowered, easy cleaning	Mattress is a dense collection of viscous fluid cells; there have been reports that the mattress is cold to the touch; patients may have to spare vital calories to warm the mattress Heavy	Comfort Zone Gel Overlay (Tele-Made Disposables, Inc.), RIK Fluid Overlay (KCI)
Alternating-pressure mattress: An overlay with rows of air cells and pump; pump cycles air to provide inflation and deflation over pressure points	Intent is to relieve pressure points to create pressure gradients that enhance blood flow	Studies show inconsistent results; some have reported very low deflation interface pressures, but only the deflation pressures were used for analysis; tissue interface pressures during inflation are consistently higher and must be incorporated into the statistical analysis; clinical trials indicate higher pressure ulcer incidence rates when compared with other products	Aero Pulse (Medline), AlphaBed (Huntleigh Healthcare), Beta (Volkner Turning Systems), PressureGuard CFT (Span America)
Static air: Designed with interlocking air cells that provide dry flotation; inflated with a blower	Mattress overlays that are designed with multiple chambers, allowing air exchange between the compartments	Pressure reduction depends on adequate air volume and periodic reinflation	ROHO (The ROHO Group) Sof-Care (Gaymar)
Low–air-loss specialty overlay: Multiple airflow cushions that cover the entire bed; pressures can be set and controlled by a blower	Surface materials are constructed to reduce friction and shear and to eliminate moisture; pressure relief; can be used for prevention and/or treatment of ulcers	Surface mattress and pump are a rental item; not available for cribs	Acucair (Hill-Rom), BioTherapy (BioClinic), First Step Select (KCI), Plexus Aire Select (Gaymar), PressureGuard APM2 (Span America)
Specialty Beds‡
Low–air-loss beds: Bed surface consists of inflated air cushions; each section is adjusted for optimum pressure relief for patient’s body size; some models have built-in scales	Provides pressure relief in any position; treatment for stages III and IV pressure ulcers; available in pediatric crib sizes	Bed is more bulky than a hospital bed, and some homes may not be able to accommodate its size; reimbursement is questionable	Clinitron (Hill-Rom), KinAir IV (KCI), TheraPulse ATP (KCI), TotalCare SpO2RT (Hill-Rom)
Low–air-loss mattress replacements	Provides pressure relief in any position; fits on hospital frame	Requires mattress storage	First Step Select (KCI), Flexicair Eclipse (Hill-Rom)
Air-fluidized beds: Air is blown through beads to “float” patient	Provides pressure relief for oncology patients and for treatment of full-thickness pressure ulcers, postoperative flaps, burns; lighter-weight home care units available	Can be difficult to transfer patient	Clinitron (Hill-Rom), FluidAir Elite (KCI), Skytron (KEISEI Medical)
Kinetic therapy: Therapy surfaces that provide continuous gentle side-to-side rotation of 40 degrees or more on each side; table-based or cushion-based	Has been demonstrated to improve mucous transport, redistribute pulmonary blood flow, and mobilize pulmonary interstitial fluid; has been used for trauma victims and unstable spinal cord injuries (should use table-based; once stabilized, may use cushion-based)	Used only in acute care settings	RotoProne (KCI), RotoRest Delta Kinetic (KCI), Synergy Air Elite (Hill-Rom), Triadyne (KCI)
Continuous lateral rotation beds (CLRT): Less than 40 degrees side-to-side rotation	Helps reposition unstable spinal cord injury patient; promotes comfort and shifts pressure points		BariAir (KCI), TotalCare SpO2RT (Hill-Rom), V-Cue Dynamic Air Therapy System (Hill-Rom)