Pediatric Procedures



Pediatric Procedures





Preparation for Procedures


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Preparation of the child for a procedure is one of the most important tasks of the nurse. Children fear pain and bodily injury, so it is important for nurses to prepare the child with honest, age-appropriate explanations and carry out the procedure in the least stressful manner to the child. Hockenberry and Wilson (2009) refer to this as atraumatic care or care without trauma. Once nurses understand the stressors that affect hospitalized children, the effect of these stressors can be minimized with providing atraumatic care.


With infants, the parents are given the explanation and will want to comfort the infant after the procedure. Toddlers can be given brief, simple explanations just before the procedure and may need to be restrained while the procedure is performed. Be sure the toddler does not view this as punishment. Parents may want to be there during the procedure to provide comfort but should not be viewed as the restrainer. An exception would be therapeutic holding done by the parent. The nurse always provides comfort after the procedure. Preschoolers need simple explanations and should be allowed to touch and handle equipment if possible. Preschoolers engage in “magical thinking” and believe they have all-powerful thoughts. They may feel responsible for bad thoughts that coincide with events and need to be reassured that their thoughts did not cause the event and that a procedure is not a punishment. They may need to be restrained as well. Always provide comfort (adhesive bandages, stickers) after a procedure. The school-age child needs explanations through the use of drawings, pictures, and contact with equipment. Restrain only if needed. Praise cooperation, and explain steps as you proceed. School-age children may be able to perform stress-reducing techniques such as visualization during the procedure. The adolescent generally needs no restraint, only clear explanations and praise for cooperation. Remember that child life specialists not only provide education before procedures, but often help children through procedures as well by providing distraction and other assistance. These specialists are helpful in the hospital and clinic setting.




Basic Hygiene and Care


Bathing


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


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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.





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


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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).




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


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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.




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


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Skills Checklist




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.




Home Care Guidelines for Intermittent Catheterization Using a “Clean” Technique


Some children require frequent catheterization such as those with spina bifida. Parents can be taught how to catheterize their child at home. When children are old enough, they too can learn this procedure. A mirror is helpful for girls. Remember, repeated exposure to latex can cause latex allergies; therefore non-latex catheters are recommended. A clean technique is generally used. Always be sure the bladder is completely emptied to reduce the risk for urinary tract infections (UTIs). Steps include the following:



It is preferred practice to use a sterile catheter each time to avoid potential UTIs. However, if sterile catheters are not always available, additional guidelines may be recommended by the physician.




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 …”




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.






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.




Collection of Nasopharyngeal Cultures


A nasopharyngeal culture may be ordered to rule out certain respiratory infections such as pertussis in children. Have the child look up, dip the swab tip into saline, and with the wire bent, insert the swab to the back of the nares and into the nasopharyngeal area. Remove after several seconds, place the swab into the culture media, label, and transport to the lab with the specimen requisition form. Comfort the child after the procedure. Record the specimen collection and the child’s response.


Other respiratory secretion specimens may be ordered to rule out such conditions as respiratory syncytial virus (RSV) or tuberculosis. An adequate specimen may be obtained using a suction device such as a mucus trap with a catheter inserted into the trachea. A nasal washing may also be attempted to obtain an RSV culture. This involves instillation of sterile saline, followed by aspiration of the contents (Hockenberry and Wilson, 2009).



imageCollection of Spinal Fluid for Culture


The nurse assists the physician with a lumbar puncture, which is done to obtain cerebrospinal fluid (CSF) for diagnosis and treatment. Disposable lumbar puncture sets are available. EMLA cream should be applied to the site at least 1 hour previous to the lumbar puncture. Children may require additional analgesia or anesthesia, depending on the physician’s orders.


Normal spinal fluid is clear. The pressure ranges from 60 to 180 mm Hg. It is somewhat lower in infants. The procedure for children is essentially the same as for adults. The main difference lies in the child’s ability to cooperate with positioning. The nurse explains that the child must lie quietly and that there will be help in doing this. Sensations during a lumbar puncture include a cool feeling when the skin is cleansed and a feeling of pressure when the needle is inserted.


The child lies on the side with the back parallel to the side of the treatment table. The knees are flexed, and the head is brought down close to the flexed knees. The nurse can keep the child in this position by placing the child’s head in the crook of one arm and the knees in the crook of the other arm. The nurse then clasps hands together at the front of the child and leans forward, gently placing his or her chest against him or her (Figure 3-3). Infants may be supported in the sitting position with their backs curved and head flexed forward. The way in which the child is held can directly affect the success of the procedure and prevent serious complications. Always monitor the child’s respiratory status during a lumbar puncture. There is a potential for airway obstruction related to neck flexion.


Dec 22, 2016 | Posted by in NURSING | Comments Off on Pediatric Procedures
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