On completion of this chapter the reader will be able to: • Identify instances in which informed consent is required and in which minors may be considered emancipated. • Formulate general guidelines for preparing children for procedures, including surgery. • Implement play in therapeutic procedures. • List general strategies for enhancing compliance in children and families. • Outline general hygiene and care procedures for hospitalized children. • Implement feeding techniques that encourage food and fluid intake. • Describe methods of reducing the temperature in a child with fever or hyperthermia. • Describe systems that can be used for infection control. • Describe safe methods of administering oral, parenteral, rectal, optic, otic, and nasal medications to children. • Identify nursing responsibilities in maintaining fluid balance. • Demonstrate correct procedures for postural drainage and tracheostomy care. • Describe the procedures involved in providing nutrition via gavage, gastrostomy, and parenteral routes. • Describe the procedures involved in administering an enema and ostomy care to children. http://evolve.elsevier.com/wong/essentials Animations—Central Venous Access via Femoral Vein; Central Venous Access via Jugular Vein; Foley Catheter Insertion; IV Line Placement; Lumbar Puncture, Infant; PICC Line Placement; Tracheostomy Case Study—Pediatric Procedures 1. The person must be capable of giving consent; he or she must be over the age of majority (usually age 18 years) and must be considered competent (i.e., possessing the mental capacity to make choices and understand their consequences). 2. The person must receive the information needed to make an intelligent decision. 3. The person must act voluntarily when exercising freedom of choice without force, fraud, deceit, duress, or other forms of constraint or coercion. • Minor surgery (e.g., cutdown, biopsy, dental extraction, suturing a laceration [especially one that may have a cosmetic effect], removal of a cyst, closed reduction of a fracture) • Diagnostic tests with an element of risk (e.g., bronchoscopy, angiography, lumbar puncture, cardiac catheterization, bone marrow aspiration) • Medical treatments with an element of risk (e.g., blood transfusion, thoracentesis or paracentesis, radiotherapy) Other situations that require patient or parental consent include: • Photographs for medical, educational, or public use • Removal of the child from the health care institution against medical advice • Postmortem examination, except in unexplained deaths, such as sudden infant death, violent death, or suspected suicide • Helping the patient achieve a developmentally appropriate awareness of the nature of his or her condition • Telling the patient what he or she can expect • Making a clinical assessment of the patient’s understanding • Soliciting an expression of the patient’s willingness to accept the proposed procedure Parents have full responsibility for the care and rearing of their minor children, including legal control over them. As long as children are minors, their parents or legal guardians are required to give informed consent before medical treatment is rendered or any procedure is performed. If the parents are married to each other, consent from only one parent is required for non-urgent pediatric care. If the parents are divorced, consent usually rests with the parent who has legal custody (Berger and American Academy of Pediatrics [AAP], Committee on Medical Liability, 2003). Parents also have a right to withdraw consent later. Exceptions to requiring parental consent before treating minor children occur in situations in which children need urgent medical or surgical treatment and a parent is not readily available to give consent or refuses to give consent. For example, a child may be brought to an emergency department accompanied by a grandparent, child care provider, teacher, or others. In the absence of parents or legal guardians, persons in charge of the child may be given permission by the parents to give informed consent by proxy. 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 (AAP, 2003; Berger and AAP, Committee on Medical Liability, 2003). The nurse should document any efforts made to obtain consent. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) was passed to help protect and safeguard the security and confidentiality of health information. Because adolescents are not yet adults, parents have the right to make most decisions on their behalf and receive information. Adolescents, however, are more likely to seek care in a setting in which they believe their privacy will be maintained. All 50 states have enacted legislation that entitles adolescents to consent to treatment without the parents’ knowledge to one or more “medically emancipated” conditions such as sexually transmitted infections, mental health services, alcohol and drug dependency, pregnancy, and contraceptive advice (AAP, 2003; Anderson, Schaechter, and Brosco, 2005; Tillett, 2005). Consent to abortion is controversial, and statutes vary widely by state. State law preempts HIPAA regardless of whether that law prohibits, mandates, or allows discretion about a disclosure. Preparing Children for Procedures • Determine details of exact procedure to be performed. • Review parents’ and child’s present understanding. • Base teaching on developmental age and existing knowledge. • Incorporate parents in the teaching if they desire, especially if they plan to participate in care. • Inform parents of their supportive role during procedure, such as standing near child’s head or in child’s line of vision and talking softly to child, as well as typical responses of children undergoing the procedure. • Allow for ample discussion to prevent information overload and ensure adequate feedback. • Use concrete, not abstract, terms and visual aids to describe procedure. For example, use a simple line drawing of a boy or girl and mark the body part that will be involved in the procedure. Use nonthreatening but realistic models.* • Emphasize that no other body part will be involved. • If the body part is associated with a specific function, stress the change or noninvolvement of that ability (e.g., after tonsillectomy, child can still speak). • Use words and sentence length appropriate to child’s level of understanding (a rule of thumb for the number of words in a child’s sentence is equal to his or her age in years plus 1). • Avoid words and phrases with dual meanings (see Table 22-1, p. 641) unless child understands such words. • Clarify all unfamiliar words (e.g., “Anesthesia is a special sleep”). • Emphasize sensory aspects of procedure—what child will feel, see, hear, smell, and touch and what child can do during procedure (e.g., lie still, count out loud, squeeze a hand, hug a doll). • Allow child to practice procedures that will require cooperation (e.g., turning, deep breathing, using an incentive spirometry). • Introduce anxiety-inducing information last (e.g., starting an intravenous line). • Be honest with child about unpleasant aspects of a procedure but avoid creating undue concern. When discussing that a procedure may be uncomfortable, state that it feels differently to different people. • Emphasize end of procedure and any pleasurable events afterward (e.g., going home, seeing parents). • Stress positive benefits of procedure (e.g., “After your tonsils are fixed, you won’t have as many sore throats”). • Provide a positive ending, praising efforts at cooperation and coping. *Soft-sculptured dolls and customized adapters and overlays for preparing children and families about procedures and as teaching models for technical care are available from Legacy Products, Inc., 508 S. Green St., PO Box 267, Cambridge City, IN 47327; 800-238-7951; e-mail: info@legacyproductsinc.com; http://www.legacyproductsinc.com. Age-Specific Preparation of Children for Procedures Based on Developmental Characteristics Infant—Developing Trust and Sensorimotor Thought Realize that older infants may associate objects, places, or persons with prior painful experiences and will cry and resist at the sight of them. Keep frightening objects out of view.* Perform painful procedures in a separate room, not in crib (or bed).* Use nonintrusive procedures whenever possible (e.g., axillary or tympanic temperatures, oral medications).* Toddler—Developing Autonomy and Sensorimotor to Preoperational Thought Explain procedure in relation to what child will see, hear, taste, smell, and feel. Emphasize those aspects of procedure that require cooperation (e.g., lying still). Tell child it is okay to cry, yell, or use other means to express discomfort verbally. Designate one health care provider to speak during procedure. Hearing more than one can be confusing to a child* Communicate using gestures or demonstrations. Use a few simple terms familiar to child. Give child one direction at a time (e.g., “Lie down” and then “Hold my hand”). Use small replicas of equipment; allow child to handle equipment. Use play; demonstrate on doll but avoid child’s favorite doll because child may think doll is really “feeling” procedure. Prepare parents separately to avoid child’s misinterpreting words. Preschooler—Developing Initiative and Preoperational Thought Explain procedure in simple terms and in relation to how it affects child (as with toddler, stress sensory aspects). Allow child to play with miniature or actual equipment. Encourage “playing out” experience on a doll both before and after procedure to clarify misconceptions. Use neutral words to describe the procedure (see Table 22-1, p. 641). Fears of Bodily Harm, Intrusion, and Castration Point out on drawing, doll, or child where procedure is 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. Realize that procedures involving genitalia provoke anxiety. Allow child to wear underpants with gown. School-Age Child—Developing Industry and Concrete Thought Increased Language Skills; Interest in Acquiring Knowledge Explain procedure using correct scientific and medical terminology. Explain procedure using simple diagrams and photographs. Discuss why procedure is necessary; concepts of illness and bodily functions are often vague 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. Adolescent—Developing Identity and Abstract Thought Involve adolescent in decision making and planning (e.g., time, place, individuals present during procedure, clothing, whether they will watch procedure). Impose as few restrictions as possible. Explore what coping strategies have worked in the past; they may need suggestions of various techniques. Accept regression to more childish methods of coping. Realize that adolescent may have difficulty accepting new authority figures and may resist complying with procedures.
Pediatric Variations of Nursing Interventions
General Concepts Related to Pediatric Procedures
Informed Consent
Case Study—Pediatric Procedures
Requirements for Obtaining Informed Consent
Eligibility for Giving Informed Consent
Informed Consent of Parents or Legal Guardians
Treatment Without Parental Consent
Adolescents, Consent, and Confidentiality
Preparation for Diagnostic and Therapeutic Procedures
Psychologic Preparation
Nursing Care Guidelines
Nursing Care Guidelines
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Before undergoing any invasive procedure, the patient or the patient’s legal surrogate must receive sufficient information on which to make an informed health care decision. Informed consent should include the expected care or treatment; potential risks, benefits, and alternatives; and what might happen if the patient chooses not to consent. To obtain valid informed consent, health care providers must meet the following three conditions: