Bathing not only promotes cleanliness and stimulates circulation to the skin, but also provides exercise and may help the child relax and feel more comfortable (Skill 3-1). Explain the procedure in appropriate terms. Always remain with the child when bathing occurs. Be sure to check any allergies the child may have. Always assess conditions that influence the type of bath given, such as a recent surgical incision, EEG monitor, a cast, an intravenous (IV) line or Foley catheter in place, and so on. Examine the infant or child for skin abnormalities such as rashes, birthmarks, bruises, breaks in the skin, and so on. Never use baby powder after the bath because the powder can be inhaled and cause breathing problems. Skill 3-1 can be taught to parents for home use.

Skill 3-1 Bathing an Infant or Small Child

Shampoo (as appropriate)

Lotion (as appropriate)

Safety Issues (Rationale)

• Never leave a child unattended around water (children can drown in as little as 1 inch of water).

• Place a towel or rubber mat on the bottom of the tub or basin (prevents the child from slipping).

• Verify that the room temperature is warm enough and draft-free (prevents chilling).

• Only sponge bathe the baby until the cord has fallen off (the cord should be kept dry to promote healing).

• Only sponge bathe the baby until the circumcision has healed (the circumcision should not get wet in order to promote healing).

• Always run cold water first (prevents burns).

• Hold on to infant securely, supporting the head while bathing (babies are slippery when wet).

Method (Rationale)

1. Explain procedure (allays anxiety).

2. Assemble equipment.

3. Wash hands. Use gloves if body fluid precautions are warranted (ensures that standard precautions are followed).

4. Run water. Temperature should be 100° F (38° C). Check the temperature by submerging your wrist in the water or placing drops on the inside surface of your forearm. It should feel comfortably warm. (May use bath thermometer if available.) (Helps prevent burns as skin is actually thinner than an adult’s).

5. Begin by removing secretions from the child’s eyes with cotton ball immersed in plain water. Use a separate cotton ball for each eye (ensures cleanliness and prevents any cross-contamination).

6. Shampoo hair (if necessary); wash the scalp of an infant younger than 1 year of age as necessary. Pour water over head. Apply shampoo, and rinse. Avoid eyes. Dry head with towel when finished (helps prevent chilling).

7. Bathe remainder of body. End with the perineal area. Remember to wash from front to back (always wash from clean to dirty) Wrap in towel when finished (prevents chilling).

8. Apply lotion as needed (provides moisturizing and hydration).

9. Dress in clean clothing. Keep top edge of diaper below umbilicus site if cord has not fallen off (promotes healing and reduces irritation).

10. Teach hygiene practices to the parents as needed: frequency of bathing, shampooing hair, cleaning genitals, avoiding bubble bath (can cause vaginal irritation), and so on.

Skills Checklist

Prepare the child and family.

Assemble equipment.

Wash hands.

Prepare basin, check temperature.

Clean infant’s eyes, wash hair and scalp.

Bathe the rest of the child; prevent chilling.

Dry. Apply lotion as needed.

Wash hands.

Teach as appropriate.

Document procedure. Be sure to note any abnormal skin conditions. (e.g., bath performed per hospital policy. Cried briefly but consoled easily by parents. No abnormal skin conditions noted~signature).

Nursing Brief

Always wash hands before and after any procedure performed.

Bulb Suctioning

A bulb syringe is used when it is necessary to provide an open airway by removing secretions from an infant’s mouth and nose (Skill 3-2). Secretions may be the result of mucus or regurgitation of a feeding. Always assess the condition of the child after suctioning. There should be no sign of respiratory distress. Be sure parents know how to suction their baby’s mouth and nose prior to discharge from the hospital.

Skill 3-2 Suctioning with a Bulb Syringe

Safety Issues (Rationale)

• Be sure infant shows no signs of respiratory distress after the procedure.

• Do not insert bulb straight to the back of the throat (could result in a vagal response or gagging).

• Suction nares carefully (avoids traumatizing tissue).

Method (Rationale)

1. Explain the procedure to the parent (allays anxiety).

2. Gather equipment.

3. Wash hands; wear gloves (ensures that standard precautions are followed).

4. Hold infant’s head (stabilizes head).

5. Compress bulb and insert into mouth (along side of mouth), and release bulb slowly (releasing the bulb will pull secretions into the bulb tip).

6. Remove bulb syringe, and empty by compressing several times as needed onto tissues or washcloth (removes secretions).

7. Suction nares carefully if necessary in same manner (suctioning the mouth first ensures that nasal secretions are not placed in the mouth).

8. Discard tissues, or place washcloth with soiled linen.

9. Rinse bulb syringe with water, or take it apart and clean if applicable.

10. Remove gloves, and wash hands (ensures that standard precautions are followed).

Skills Checklist

Assess need for suctioning.

Insert into mouth, release bulb.

Suction nose if needed

Remove gloves, and wash hands.

Document procedure (e.g., mouth and nares suctioned; minimal white secretions removed. No distress noted during procedure~signature).

Fever, Hyperthermia, and Sponge Bathing

Fever is defined as body temperature above 38° C (100.4° F) rectally. The child’s metabolic rate will increase 10% for every 1° C increase. The physician may only recommend monitoring the fever, since it is the body’s way of defending itself against illness and is part of the immune process. Fever with temperatures less than 39° C (102.2° F) does not require treatment if the child is generally healthy (Kliegman et al., 2007). Antipyretic agents such as acetaminophen (10 to 15 mg/kg orally every 4 to 6 hours) and ibuprofen (5 to 10 mg/kg orally every 6 to 8 hours) may be ordered because they are considered safe and effective in proper doses for treatment of fever for children. (Always refer to a drug reference manual for specific information.) Ibuprofen should only be used for children older than 6 months of age. Aspirin is not recommended because of the risk for Reye syndrome. Cooling the child by reducing the room temperature and removing blankets and clothing may be beneficial if an antipyretic has been given approximately 1 hour beforehand. The antipyretic works to lower the “set point” associated with the fever, much like regulating a thermostat (body temperature is regulated by the hypothalamus).

Hyperthermia is defined as the body temperature exceeding the set point, such as from heat stroke or seizures. Tepid sponge bathing in warm water may be ordered to reduce hyperthermia (Hockenberry and Wilson, 2009). Tepid sponge bathing, however, is not effective in treating fever. When performed, the sponge bath may be given in a tub or in the child’s bed (Skill 3-3). The child should not be permitted to shiver because shivering causes vasoconstriction and increased metabolism and can lead to a rise in temperature. The bath is given for approximately 20 minutes. Alcohol should never be added to the water because it reduces the heat too rapidly and can be absorbed (leading to brain damage or even death in infants). A table of Celsius (centigrade) and Fahrenheit temperature equivalents is provided in Appendix E.

Skill 3-3 Sponge Bath to Reduce Hyperthermia

Equipment

Basin of tepid water (see Method)

Three washcloths, towel(s)

Two bath blankets

Waterproof sheet

Safety Issues

• Never leave a child unattended around water.

• Sponge bath should take approximately 20 minutes.

• If the child shivers, stop the procedure.

• Assess color and pulse frequently.

• Record temperature before and 30 minutes after the procedure.

• Never add alcohol to water.

Method (Rationale)

1. Explain the procedure to the patient and family (allays anxiety).

2. Assemble the equipment at the bedside.

3. Water temperature should be 37° C (98.6° F); needs only be 1° C or 2° F less than the child’s temperature to be effective (Hockenberry and Wilson, 2009).

4. Wash hands. Apply gloves if applicable (ensures that standard precautions are followed).

5. Record temperature, pulse, and respirations (establishes a baseline).

6. The child is placed in the tub, and water is put over the back and chest or (if done in the bed)

7. Cover the patient with a bath blanket or sheet. Fanfold linens to the foot of the bed. Place a waterproof sheet and bath blanket beneath the patient. Remove patient’s gown.

8. Wash the patient’s face and neck with tepid water.

9. Lift the corner of the bath blanket, and bathe the child’s body, one area at a time.

10. Place moist, folded cloths over blood vessels that lie close to the skin (underarms and groin).

11. Turn the patient and repeat the procedure, beginning with the neck, and then going to the shoulders, the back, and so forth.

12. Check color and pulse to be sure that the child is tolerating the procedure without adverse effects (report changes to charge nurse as patient’s condition may be changing).

13. If the child begins to shiver, the procedure should be immediately stopped (shivering causes vasoconstriction, increases temperature).

14. When the bath is completed, remove the waterproof sheet and blanket. Rub the skin dry (stimulates circulation), and replace the hospital gown and cover with sheet.

15. Arrange pillows and bedding for the patient’s comfort.

16. Take the patient’s temperature within 30 minutes of the time the procedure ended, and record it. If the temperature has not started to go down, check to see whether the procedure should be repeated. Note: The temperature is not expected to drop to normal but merely to a more reasonable level. Also record pulse and respirations (report changes to charge nurse as patient’s condition may be changing).

17. Document: Time procedure began, length of time administered, untoward reactions, patient’s vital signs before and after procedure.

Skills Checklist

Prepare the child and family.

Assemble equipment.

Wash hands.

Record temperature, pulse, respirations.

Drape patient (if done in the bed)

Remove gown.

Wash face, neck, other body parts, one at a time.

Place cloths; proceed to back of patient.

Check color, pulse.

Pat dry; regown.

Assess comfort.

Record temperature, pulse, respirations.

Wash hands.

Document procedure.

Collection of Specimens

Collection of Urine Specimens

Urine specimens are often collected in doctors’ offices and clinics, as well as in the hospital (Skill 3-4). All urine specimens need to be labeled and sent to the lab immediately because bacteria accumulate at room temperature. If there is a delay, the urine specimen is to be kept refrigerated or on ice. An example would be if the patient were taking a urine specimen that was obtained at home, to a laboratory. Documentation of the procedure, including child’s reactions, is also done. The physician may request that the specimen be collected with the clean-catch method, catheterization, or 24-hour collection.

Skill 3-4 Obtaining a Specimen for Urinalysis

Equipment

Sterile container

Urine collection bag (infant)

Safety Issues (Rationale)

• Wear gloves because of contact with body fluids.

• Check urine collection bag frequently.

• Label specimen clearly.

• Deliver specimen immediately to the laboratory (bacteria may grow at room temperature).

Method (Rationale)

1. Explain the procedure (allays anxiety).

2. Wash hands; wear gloves (ensures that standard precautions are followed).

3. Use a sterile container, or apply a urine collection device.

4. If a bag is used, secure the diaper over the bag or cut a slit so that the bag is outside the diaper (prevents leakage).

5. Check bag every 20 to 30 minutes (prevents leakage).

6. Label all specimens clearly, and attach the proper laboratory slip. Collected specimens should be transported in a plastic bag (check institution policy).

7. Record in nurse’s notes. Document time; also color, amount, and any odor (e.g., 30 ml clear yellow odorless urine collected in urine bag and sent to lab~signature).

Skills Checklist

Explain procedure.

Obtain container/urine collection device (infant).

Wash hands; glove.

Apply urine collection device (infant) or have child void.

Recover specimen.

Remove gloves and wash hands.

Label, send to laboratory.

Document procedure.

When applying newborn and pediatric urine collectors, the skin must be clean and perfectly dry. (Avoid oils, baby powders, and lotion soaps that may leave a residue on the skin and interfere with the ability of the adhesive to stick.) Apply the collection bag first to the area between the anus and genitals for boys and start at the narrow bridge of skin separating the vagina from the anus for girls. Press adhesive firmly against the skin and avoid wrinkles. Remove paper from the adhesive patch, working upward to finish applying the collection bag. Monitor closely for urine output.

The physician may also order a specimen so that the nurse can check certain lab results immediately, either in the clinic or the hospital. Examples of this may include specimens such as protein, albumin, glucose, ketones, or blood. These are checked with a urine dipstick without being sent to the lab. Results are recorded on the patient’s chart.

Obtaining a Clean-Catch Specimen

Children who can voluntarily void can assist in obtaining a clean-catch specimen. Be sure to use familiar terms that the young child understands, such as “pee-pee” or “tinkle” when describing what the child is to do. Many children will be reluctant to void into a specimen container; have the parents assist as much as possible. Always wear protective equipment for standard precautions such as gloves when handling any specimen.

Special sterile containers are available for clean-catch specimens; follow the directions of the manufacturer. All require cleansing of the perineum or tip of the penis. When cleaning girls, cleanse the perineum with a soap or antiseptic agent, wiping from front to back. Repeat twice and follow with sterile water to prevent contamination of the specimen. After the urine stream has started, and the first few milliliters of urine are voided, the midstream specimen should be caught in the sterile container, with care taken not to contaminate the container.

Infants and young children may have a sterile urine bag applied (see Skill 3-4). Check frequently under the diaper as leakage from the bag may occur. A slit may also be cut in the diaper to allow the bag to remain on the outside of the diaper where it is more visible.

Nursing Brief

The rule of thumb for urine output is 0.5 to 2 mL/kg/hr.

Collection of Stool Specimens

Stool specimens from older children are obtained as for an adult (Skill 3-5). This is embarrassing for most children, who are turned off by the suggestion. The ambulatory child can use a collection device (potty hat) placed beneath a toilet seat. It is difficult for a child to tell the nurse that the sample has been collected. The nurse can acknowledge these feelings by giving the child permission to express them without being critical. The nurse might say, “I know this must be embarrassing for you. It is for grown-ups, too, but we need this because …”

Skill 3-5 Obtaining a Stool Specimen

• Wash hands. Wear gloves to obtain specimen.

• Label specimen appropriately.

Method (Rationale)

1. Explain procedure to child or parent (allays anxiety).

2. Wash hands; wear gloves (ensures that standard precautions are followed).

3. Obtain stool specimen directly from the diaper (if it has not been contaminated by urine) with the tongue blade, or use the tongue blade to retrieve the specimen from the collection device.

4. The specimen is labeled properly, and the laboratory slip is attached.

5. Some specimens must be sent to the laboratory while they are warm.

6. The nurse documents the time; also the color, amount, consistency of the stool and the purpose for which it was collected (e.g., blood, ova, parasites, bacteria); and any related information (e.g., 20 ml. loose, brown stool specimen obtained for culture and sent to lab~signature).

Remove gloves, wash hands.

Label, send to laboratory.

Document procedure.

Collection of Blood Specimens

Blood specimens are generally collected by the laboratory technician or a specially trained nurse. Children generally fear this procedure. EMLA (eutectic mixture of lidocaine and prilocaine) cream can be used to lessen the pain. Remember, however, that the cream needs to be in place approximately 60 minutes before the blood sample is taken (if LMX or lidocaine cream is used, allow 30 minutes). If time permits, have the blood specimen obtained in the treatment room, keeping the child’s bed a safe place. The antecubital fossa is a common site for venipuncture in children older than 2 years of age. The dorsum of the hand or foot can also be used (Figure 3-1). The heel is often used in infants (Figure 3-2). If blood is to be collected from the heel, it needs to be warmed with a warmed washcloth or commercial warmer to increase the blood flow. The external jugular vein can be used in infants when other sites have not worked. The femoral vein may be used when other sites have been exhausted. Jugular and femoral venipuncture are only performed by the physician. Both the jugular and the femoral veins are large; therefore, after venipuncture, the child is checked frequently to ensure that there is no bleeding. The child is soothed accordingly if either of these sites is used, because crying and thrashing may precipitate oozing or hemorrhage. If a child has a central venous catheter or port, specially trained nurses can obtain the blood specimen by following hospital procedure. Always use standard precautions when obtaining or assisting with blood specimens. Regardless of the location used to obtain the blood specimen, the nurse charts the site used, the name of the blood test, and any untoward developments.

Figure 3-1 Using a parent to hold and comfort the child during a blood specimen procedure.

Communication

Many children fear losing blood, and reminding children who are old enough to understand that they are continuously producing blood helps to reassure them. Application of an adhesive bandage reassures them that their body fluids will not leak out. This is particularly helpful for preschoolers.

Collection of Throat Cultures

A throat culture is frequently ordered by the physician when a child has a “sore throat” or a strep infection is suspected (Skill 3-6). The child may need to be temporarily restrained when a throat specimen is obtained. The child needs to stick out the tongue and say “ah” while the nurse swabs the pharyngeal area and tonsils. If the child is unable to cooperate, a tongue depressor should be used to hold down the tongue while obtaining the swabbed specimen. If the child has a diagnosis suspicious of epiglottitis, the throat culture should not be done because the airway may become edematous (swollen) and occlude (block air movement) from the trauma of specimen collection.