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

Equipment

 Bulb syringe

 Tissues

 Washcloth

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.

 Explain procedure.

 Wash hands; glove.

 Position infant.

 Compress bulb.

 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.

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.

Obtaining a Specimen with Catheterization

Obtaining a specimen with a catheter is the same as for adults, except that the size of the catheter is usually an 8 or 10 Foley catheter (check institution policy). When necessary for surgical patients, the catheter may be inserted once the child has undergone anesthesia. This is less traumatic for children, who are usually frightened by this procedure. It is also difficult to keep the awake child still for catheter insertion, which increases the risk of contamination.

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.

Obtaining a 24-Hour Urine Specimen

At times, a 24-hour urine specimen may be requested to determine the rate of urine production and to measure the excretion of specific chemicals from the body. This requires close supervision by the nurses on each shift to maintain accuracy of the test because lost specimens necessitate restarting the test. Older children can help with collection of their own specimens; collection bags are required for infants and small children. A sign may be posted to alert personnel of a 24-hour urine collection.

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).

Collection 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.