Pediatric Variations of Nursing Interventions

Pediatric Variations of Nursing Interventions

Marilyn J. Hockenberry

General Concepts Related to Pediatric Procedures

Informed Consent

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:

The patient has the right to accept or refuse any health care. If a patient is treated without consent, the hospital or health care provider may be charged with assault and held liable for damages.

Requirements for Obtaining Informed Consent

Written informed consent of the parent or legal guardian is usually required for medical or surgical treatment of a minor, including many diagnostic procedures. One universal consent is not sufficient. Separate informed permissions must be obtained for each surgical or diagnostic procedure, including the following:

Other situations that require patient or parental consent include the following:

Decision making involving the care of older children and adolescents should include the patient’s assent (if feasible) and the parent’s consent. Assent means that the child or adolescent has been informed about the proposed treatment, procedure, or research and is willing to allow a health care provider to perform it. Assent should include the following:

Health care providers should use multiple methods to provide information, including age-appropriate methods (e.g., videos, peer discussion, diagrams, and written materials). The nurse should provide an assent form for the child to sign, and the child should keep a copy. By including the child in the decision-making process and gaining his or her acceptance, staff members demonstrate respect for the child. Assent is not a legal requirement but an ethical one to protect the rights of children.

Eligibility for Giving Informed Consent

Treatment Without Parental Consent.

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 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, people 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.

Refusal to give consent can occur when the treatment such as blood transfusions conflicts with the parents’ religious beliefs. All states recognize such exceptions and have statutory procedures to permit treatment if the life or health of such a minor is in jeopardy or if delayed treatment would create a risk to the minor’s health. Evaluation for child abuse or neglect can occur without parental consent and without notification to the state before evaluation in most states.

Adolescents, Consent, and Confidentiality.

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. However, adolescents 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 them to consent to treatment for one or more “medically emancipated” conditions such as sexually transmitted infections, mental health services, alcohol and drug dependency, pregnancy, and contraceptive advice without the parents’ knowledge (AAP, 2003; Anderson, Schaechter, and Brosco, 2005; Tillett, 2005). Consent to abortion is controversial, and statues vary widely by state. State law preempts HIPAA, regardless of whether that law prohibits, mandates, or allows discretion about a disclosure.

Preparation for Diagnostic and Therapeutic Procedures

Technologic advances and changes in health care have resulted in more pediatric procedures being performed in a variety of settings. Many procedures are both stressful and painful experiences. For most procedures the focus of care is psychologic preparation of the child and family. However, some procedures require the administration of sedatives and analgesics.

Psychologic Preparation

Preparing children for procedures decreases their anxiety, promotes their cooperation, supports their coping skills and may teach them new ones, and facilitates a feeling of mastery in experiencing a potentially stressful event. Many institutions have developed preadmission teaching programs designed to educate the pediatric patient and family by offering hands-on experience with hospital equipment, the procedure performed, and departments they will visit. Preparatory methods may be formal such as group preparation for hospitalization. Most preparation strategies are informal, focus on providing information about the experience, and are directed at stressful or painful procedures. The most effective preparation includes providing sensory-procedural information and helping the child develop coping skills such as imagery, distraction, or relaxation.

The Guidelines boxes describe general guidelines for preparing children for procedures along with age-specific guidelines that consider their developmental needs and cognitive abilities. In addition to these suggestions, nurses should consider the child’s temperament, existing coping strategies, and previous experiences in individualizing the preparatory process. Children who are distractible and highly active or those who are “slow to warm up” may need individualized sessions (i.e., shorter for active children and more slowly paced for shy children). Youngsters who tend to cope well may need more emphasis on using their present skills, whereas those who appear to cope less adequately can benefit from more time devoted to simple coping strategies such as relaxing, breathing, counting, squeezing a hand, or singing. Children with previous health-related experiences still need preparation for repeat or new procedures; however, the nurse must assess what they know, correct their misconceptions, supply new information, and introduce new coping skills as indicated by their previous reactions. Especially for painful procedures, the most effective preparation includes providing sensory-procedural information and helping the child develop coping skills such as imagery or relaxation (see Guidelines boxes).

image Guidelines

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 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 and the typical responses to be expected from 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 39-1, p. 1135) 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 he or she can do during procedure (e.g., lie still, count out loud, squeeze a hand, hug a doll).

• Allow child to practice procedures that 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., 120 West Main Street, PO Box 267, Cambridge City, IN 47327, 800-238-7951, e-mail:,

image Guidelines

Age-Specific Preparation of Children for Procedures Based on Developmental Characteristics

Infant—Developing Trust and Sensorimotor Thought

Toddler—Developing Autonomy and Sensorimotor to Preoperational Thought

Preschooler—Developing Initiative and Preoperational Thought

School-Age Child—Developing Industry and Concrete Thought

Adolescent—Developing Identity and Abstract Thought

*Applies to any age.

Children differ in their “information-seeking dimension.” Some actively ask for information about the intended procedure, but others characteristically avoid it. Parents can often guide nurses in deciding how much information is enough for the child because they know whether he or she is typically inquisitive or satisfied with short answers. Asking older children their preferences about the amount of explanation is also important.

The exact timing of the preparation for a procedure varies with the child’s age and the type of procedure. No exact guidelines govern timing; but in general the younger the child, the closer the explanation should be to the actual procedure to prevent undue fantasizing and worrying. With complex procedures more time may be needed for assimilation of information, especially with older children. For example, the explanation for an injection can immediately precede the procedure for all ages; but preparation for surgery may begin the day before for young children and a few days before for older children, although the nurse should elicit older children’s preferences.

Parental Presence and Support.

Children need support during procedures, and for young children the greatest source of support is the parents. They represent security, protection, safety, and comfort. Several studies have reported a positive impact on parental distress and satisfaction and no difference in technical complications when parents remain with children (Piira, Sugiura, Champion, et al., 2005). Controversy exists regarding the role parents should assume during the procedure, especially if discomfort is involved. Several professional associations support the option of family presence during invasive procedures (American Association of Critical Care Nurses, 2006; Emergency Nurses Association, 2005). The nurse should assess the parents’ preferences for assisting, observing, or waiting outside the room and the child’s preference for parental presence. Respect the child’s and parents’ choices. Give parents who wish to stay appropriate explanation about the procedure and coach them about where to sit or stand and what to say or do to help the child through it. Support parents who do not want to be present in their decision and encourage them to remain close by so they can be available to support the child immediately after the procedure. Parents should also know that someone will be with their child to provide support. Ideally this person should inform the parents after the procedure about how the child did.

Provide an Explanation.

Age-appropriate explanations are one of the most widely used interventions for reducing anxiety in children undergoing procedures. Before performing a procedure, explain what is to be done and what is expected of the child. The explanation should be short, simple, and appropriate to the child’s level of comprehension. Long explanations may increase anxiety in a young child. When explaining the procedure to parents with the child present, the nurse uses language appropriate to the child because unfamiliar words can be misunderstood (Table 39-1). If the parents need additional preparation, it is done in an area away from the child. Teaching sessions are planned at times most conducive to the child’s learning (e.g., after a rest period) and for the usual span of attention.

Special equipment is not necessary for preparing a child; but for young children who cannot yet think conceptually, using objects to supplement verbal explanation is important. Allowing children to handle actual items that will be used in their care such as a stethoscope, sphygmomanometer, or oxygen mask helps them develop familiarity with these items and reduces the fear often associated with their use. Miniature versions of hospital items such as gurneys and x-ray and intravenous (IV) equipment can be used to explain what the children can expect and permit them to safely experience situations that are unfamiliar and potentially frightening. Use photographs of children in different areas of the hospital (e.g., radiology department, operating room) to give children a more realistic idea of equipment they may encounter. Written and illustrated materials are also valuable aids to preparation.*

Performance of the Procedure

Supportive care continues during the procedure and can be a major factor in a child’s ability to cooperate. Ideally the same nurse who explains the procedure should perform or assist with the procedure. Before beginning, all equipment is assembled, and the room is readied to prevent unnecessary delays and interruptions that increase the child’s anxiety. To avoid a delay during a procedure, have extra supplies handy. For example, have tape, bandages, alcohol swabs, and an extra needle when performing an injection or venipuncture. Minimizing the number of people present during the procedure also can decrease the child’s anxiety.

To promote long-term coping and adjustment, give special consideration to the patient’s age, coping skills, and procedure to be performed in determining where a procedure will occur. Treatment rooms should be used for procedures requiring sedation such as bone marrow aspirates and LPs in younger children. Traumatic procedures should never be performed in “safe” areas such as the playroom. If the procedure is lengthy, avoid conversation that could be misinterpreted by the child. As the procedure is nearing completion, the nurse should inform the child that it is almost over in language the child understands.

Involve the Child.

Involving children helps to gain their cooperation. Permitting choices gives them some measure of control. However, a choice is given only in situations in which one is available. Asking children, “Do you want to take your medicine now?” leads them to believe that they have an option and provides them the opportunity to legitimately refuse or delay the medication. This places the nurse in an awkward, if not impossible, position. It is much better to state firmly, “It’s time to drink your medicine now.” Children usually like to make choices, but the choice must be one that they do indeed have (e.g., “It’s time for your medicine. Do you want to drink it plain or with a little water?”).

Many children respond to tactics that appeal to their maturity or courage. This also gives them a sense of participation and achievement. For example, preschool children are proud that they can hold the dressing during the procedure or remove the tape. The same is true for school-age children, who often cooperate with minimal resistance.

Provide Distraction.

Distraction is a powerful coping strategy during painful procedures (Uman, Chambers, McGrath, et al., 2006). It is accomplished by focusing the child’s attention on something other than the procedure. Singing favorite songs, listening to music with a headset, counting aloud, or blowing bubbles to “blow the hurt away” are effective techniques. (For other nonpharmacologic interventions, see Chapter 30.)

Postprocedural Support

After the procedure the child continues to need reassurance that he or she performed well and is accepted and loved. If the parents did not participate, the child is united with them as soon as possible so they can provide comfort.

Encourage Expression of Feelings.

Planned activity after the procedure is helpful in encouraging constructive expression of feelings. For verbal children reviewing the details of the procedure can clarify misconceptions and garner feedback for improving the nurse’s preparatory strategies. Play is an excellent activity for all children. Infants and young children should have the opportunity for gross motor movement. Older children are able to vent their anger and frustration in acceptable pounding or throwing activities. Play-Doh is a remarkably versatile medium for pounding and shaping. Dramatic play provides an outlet for anger and places the child in a position of control in contrast to the position of helplessness in the real situation. Puppets also allow the child to communicate feelings in a nonthreatening way. One of the most effective interventions is therapeutic play, which includes well-supervised activities such as permitting the child to give an injection to a doll or stuffed toy to reduce the stress of injections (Fig. 39-1).

FIG 39-1 Playing with medical objects provides children with the opportunity to play out fears and concerns with supervision by a nurse or child life specialist.

Use of Play in Procedures

The use of play is an integral part of relationships with children. As such its value in specific situations is discussed throughout this book such as in Chapter 26 in relation to hospitalization. Many institutions have elaborate and well-organized play areas and programs under the direction of child life specialists. Other institutions have limited facilities. No matter what the institution provides for children, nurses can include play activities as part of nursing care. Play can be used to teach, express feelings, or achieve a therapeutic goal. Consequently it should be included in preparing children for and encouraging their cooperation during procedures. Play sessions after procedures can be structured such as directed toward needle play or general, with a wide variety of equipment available with which children can play.

Routine procedures such as measuring blood pressure and oral administration of medication may be of concern to children. Box 39-1 describes suggestions for incorporating play into nursing procedures and activities for the hospitalized child that facilitate learning and adjustment to a new situation.

Box 39-1   Play Activities for Specific Procedures

Deep Breathing

• Blow bubbles with a bubble blower.

• Blow bubbles with a straw (no soap).

• Blow on a pinwheel, feather, whistle, harmonica, balloon, or party blower.

• Practice band instruments.

• Have a blowing contest using balloons,* boats, cotton balls, feathers, marbles, Ping-Pong balls, pieces of paper; blow such objects on a table top over a goal line, over water, through an obstacle course, up in the air, against an opponent, or up and down a string.

• Suck paper or cloth from one container to another using a straw.

• Dramatize stories such as, “I’ll huff and puff and blow your house down” from the “Three Little Pigs.”

• Do straw-blowing painting.

• Take a deep breath and “blow out the candles” on a birthday cake.

• Use a little paint brush to “paint” nails with water and blow nails dry.

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Sep 16, 2016 | Posted by in NURSING | Comments Off on Pediatric Variations of Nursing Interventions

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