Pediatric Nursing

Interventions
and
Skills
DR. NEGARIN AKBARI
N U R S I N G D E PA RT M E N T
FENERBAHÇE UNIVERSITY
 Describe
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 nature of the illness or

condition, proposed care, or treatment; potential risks, benefits,
and alternatives; and what might happen if the patient chooses not
to consent. Additionally, discussions should include the procedure
team roles, including trainees involved in care.
 Maintaining Healthy Skin
Maintaining an IV line, removing a dressing, positioning a child in bed,
changing a diaper, using electrodes, and using restraints all have the potential
to contribute to skin injury.
 Applying Evidence to Practice
Keep skin free of excess moisture.

Cleanse skin with mild nonalkaline soap or soap-free cleaning agents for routine bathing.

Provide daily cleansing of eyes, oral and diaper or perineal areas, and any areas of skin
breakdown.
Apply non–alcohol-based moisturizing agents after cleansing to retain moisture and rehydrate
skin.
Use minimum amount of tape and adhesives. On very sensitive skin, use a protective, pectin-
based or hydrocolloid skin barrier between skin and tape or adhesives.
 Applying Evidence to Practice
Alternate electrode and probe placement sites and thoroughly assess underlying skin typically
every 8 to 24 hours.

Eliminate pressure secondary to medical devices such as tracheostomy tubes, braces, and
gastrostomy tubes.

Be certain fingers or toes are visible whenever extremity is used for intravenous or arterial line.
 Applying Evidence to Practice
Use a draw sheet to move child in bed or onto a stretcher; do not drag
child from under the arms.
Do not massage reddened bony prominences because this can cause deep
tissue damage; provide pressure relief to bony prominences.
Routinely assess the child’s nutritional status. A child who is NPO
(nothing by mouth) for several days and is receiving only IV fluid is
nutritionally at risk, which can also affect the skin’s ability to maintain its
integrity. Consider parenteral nutrition.
 Maintaining Healthy Skin
Assessment of the skin is easiest to accomplish during the bath. Examine for early signs of
injury. Risk factors include impaired mobility, protein malnutrition, edema, incontinence,
sensory loss, anemia, infection, failure to turn the patient, and intubation.
Identification of risk factors helps determine children who need a more thorough skin
assessment. Several risk assessment scales are available for use in pediatrics, such as the
Braden Q Scale, the Neonatal Skin Risk Assessment Scale.
 Initial assessment should occur on admission to identify pressure ulcers and wounds that
occurred before admission.
Discuss maintaining
healthy skin,
bathing, and oral
hygiene
 Bathing
Most infants and children can be bathed at the bedside or in a standard bathtub
or shower. Assess the child and family’s preferences for bath time frequency and
family involvement.

Daily chlorhexidine gluconate bathing in the pediatric population can reduce

bacteremia and prevent hospital-acquired infections
 Oral Hygiene
Mouth care is an integral part of daily hygiene and should
be continued in the hospital.

Oral hygiene can prevent infection and promote comfort,

adequate nutrition, and verbal communication. For some
young children, this is their first introduction to the use of
a toothbrush.
 Hair Care
Children should have their hair brushed and combed at least once daily.
The hair should not be cut without parental permission, although clipping hair to
provide access to a scalp vein for IV insertion may be necessary.
If children are hospitalized for more than a few days, the hair may need
shampooing. With infants, the hair may be washed during the daily bath or less
frequently.
For most children, washing the hair and scalp once or twice weekly is sufficient.
Adolescents normally have increased oily sebaceous secretions that require
frequent hair care and more frequent shampoos.
Inspect the hair and scalp before shampooing using a fine toothcomb to assess for
the presence of lice or other scalp abnormalities.
 An elevated temperature, most frequently from fever but
occasionally caused by hyperthermia, is one of the most
common symptoms of illness in children. To facilitate an
Discuss controlling
understanding of fever versus hyperthermia, the
elevated following terms are defined:
temperatures Set point

Fever (hyperpyrexia)

Hyperthermia
Set point: The temperature around which body temperature is regulated by a
thermostat-like mechanism in the hypothalamus.

Hyperthermia: Body temperature exceeding the set point, which usually results from
the body or external conditions creating more heat than the body can eliminate, such
as in heat exhaustion, heatstroke, aspirin toxicity, seizures, or hyperthyroidism.
During the fever (febrile) state, shivering and vasoconstriction generate and
conserve heat during the chill phase of fever, raising central temperatures to the
level of the new set point.
Most fevers in children are of brief duration with limited consequences and are
viral in origin.
Fever has physiologic benefits, including increased white blood cell activity,
interferon production and effectiveness, and antibody production and
enhancement of some antibiotic effects such as penicillin

Contrary to popular belief, neither the rise in temperature

nor its response to antipyretics indicates the severity or
etiology of the infection, which casts doubt on the value of
using fever as a diagnostic or prognostic indicator.
 Therapeutic Management
Therapeutic Management Treatment of elevated temperature depends on whether
it is attributable to a fever or hyperthermia. Because the set point is normal in
hyperthermia but increased in fever, different approaches must be used to lower
body temperature successfully.
The principal reason for treating fever is the relief of discomfort.

However, children with cardiopulmonary disease children may not tolerate the
increase in metabolic demand from a fever and should receive antipyretic
therapy.

Relief measures include pharmacologic and environmental intervention. The

most effective intervention is the use of antipyretics to lower the set point.

Antipyretics include acetaminophen, aspirin, and nonsteroidal anti-inflammatory

drugs (NSAIDs)
Acetaminophen is the preferred drug.
× Aspirin should not be given to children because of its association in children with
influenza virus or chickenpox and Reye syndrome.

One nonprescription NSAID, ibuprofen, is approved for fever reduction in children as

young as 6 months of age. 8 hrs
Another antipyretic, acetaminophen can be given every 4 hours but no more than five
times in 24 hours due to the risk of hepatotoxicity.
Because body temperature normally decreases at night, three or four doses in 24 hours
will control most fevers.

The temperature is usually retaken 30 to 60

minutes after the antipyretic is given to assess its
effect but should not be repeatedly measured.
The child’s level of discomfort is the best
indication for continued treatment
 The nurse can use environmental measures to reduce fever if they are tolerated by the
child and if they do not induce shivering. Shivering is the body’s way of maintaining the
elevated set point by producing heat. Compensatory shivering greatly increases metabolic
requirements above those already caused by the fever.
 Traditional cooling measures, such as wearing minimum clothing; exposing the skin to
air; reducing room temperature; increasing air circulation; and applying cool, moist
compresses to the skin (e.g., the forehead), are effective if used approximately 40 minutes
after an antipyretic is given so the set point is lowered.
 Cooling procedures such as sponging or tepid baths are ineffective in treating febrile
children (these measures are effective for hyperthermia) either when used alone or in
combination with antipyretics, and they cause considerable discomfort .
 Seizures associated with a fever
Seizures associated with a fever occur in 2% to 5% of all children, usually in those between
6 months and 5 years of age. About 30% to 50% of children have subsequent febrile
seizures; a younger age at onset and a family history of febrile seizures are associated with
increased incidence of recurring episodes.

Evidence does not support the use of antipyretic drugs or anticonvulsants to prevent a
second febrile seizure.

Nursing interventions should focus on ways to provide care and comfort during a febrile
illness Simple febrile seizures lasting less than 10 minutes do not cause brain damage.
 NOT IMPORTANT

Hyperthermia
Unlike in fever, antipyretics are of no value in hyperthermia because the set point is already
normal.
Consequently, cooling measures are used. If a child is severely hyperthermic with a core
temperature above 40°C, it may be necessary to perform continuous monitoring of vital signs
including core temperature and urinary output and administer intravenous fluids in a critical
care environment.
Cool applications to the skin help reduce the core temperature.
Frequent temperature monitoring is essential to prevent excessive cooling of the body.
traditionally, cool compresses decrease high temperature.
The metabolic rate increases 10% for every 1°C increase in temperature and three to five times
during shivering, thus increasing oxygen, fluid, and caloric requirements.
 FAMILY TEACHING
and HOME CARE
Fever is one of the most common problems for which parents seek health care.
High levels of parental anxiety (fever phobia) surrounding potential complications of fever
such as seizures and dehydration are prevalent and can result in overusing antipyretics.
Parents need to know that sponging is indicated for elevated temperatures from
hyperthermia rather than fever and that ice water and alcohol are inappropriate, potentially
dangerous solutions.
parents should know how to take the child’s temperature, how to read the thermometer
accurately, and when to seek professional care.
A dedicated thermometer should be used for rectal route.
Oral temperatures should not be taken within 15 minutes of the child eating or drinking hot
or cold food.
 FAMILY-CENTERED CARE
Call the Doctor Immediately If…
Your child is younger than 3 months old and has a temperature of (38 C) or higher.
Your child looks or acts very sick or sleepy, or has a stiff neck, severe headache, severe ear pain,
repeated vomiting or diarrhea, unexplained rash on the skin, confusion, trouble breathing, or inability to
be comforted.
Your child has had a recent seizure.
Your child has a history of immune system problems such as cancer or sickle cell disease.
Your child has been in a very hot place such as a car.
Your child has taken steroid medication.
The fever continues for more than 48 hours in a child younger than 2 years or more than 72 hours in a
child older than 2 years
 Discuss
mummy
restraint, arm
and leg
restraint, and
elbow
restraint
 Mummy Restraint or Swaddle
When an infant or small child requires short-term restraint for
examination or treatment that involves the head and neck (e.g.,
venipuncture, throat examination, gavage feeding), a papoose board
with straps or a mummy wrap effectively controls the child’s
movements.
When used only for the duration of the test or procedure, this is not
considered a restraint.
The mummy restraint or swaddle should not be used for behavior or
long-term restraint.
 Arm and Leg Restraints
Occasionally, the nurse needs to restrain one or more extremities or limit their motion.
Several commercial restraining devices are available, including disposable wrist and ankle
restraints.

Restraints must be appropriate to the child’s size and padded to prevent undue pressure,
constriction, or tissue injury, and the extremity must be observed frequently for signs of
irritation or impaired circulation.
 Elbow Restraint
Sometimes it is important to prevent the child from reaching the head or face

(e.g., after cleft lip or palate surgery, when a scalp vein infusion is in place, or to prevent
scratching in skin disorders).
 Identify
urine
and
stool specimens
There are many diagnostic situations that warrant urine specimens.
The age of the child will affect the collection technique, as well as developmental
considerations.
 It is often best to offer them water or other liquids that they enjoy and wait about 30
minutes until they are ready to void voluntarily.
If there is a delay, the sample should be refrigerated and the lapsed time reported to the
examiner.
Although it is a convenient and noninvasive collection method, direct urine aspiration
from a diaper can alter the specimen results.
Direct aspiration from the diaper may not be suitable for all urine specimen tests.
 Urine Collection Bags

For infants and toddlers who are not toilet trained, special urine collection bags with self-
adhering material around the opening at the point of attachment may be used.
The American Academy of Pediatrics guidelines for diagnosis and management of
urinary tract infections in infants 2 to 24 months old recommend that any positive screen
obtained from a bag specimen be confirmed by culture via bladder catheterization or
suprapubic aspiration due to an unacceptably high rate of false-positive results.
Although the bag specimen collection method is less invasive and traumatic to an infant,
some families and clinicians may prefer to collect only one definitive specimen and avoid
additional delay in obtaining a second specimen.
Clean-Catch Specimens
Clean-catch specimen traditionally refers to a urine sample obtained for culture
after the urethral meatus is cleaned and the first few milliliters of urine are
voided (midstream specimen).
In girls, the perineum is wiped with an antiseptic pad from front to back.
In boys, the tip of the penis is cleansed. If the boy is uncircumcised, the foreskin
is retracted and the glans is cleansed.
It is important that the inside of the
specimen cup or lid is not touched or
contaminated during collection to
ensure accurate results.
 Twenty-Four-Hour Collection
For a 24-hour collection, collection bags are required in infants and small children.

The collection period always starts and ends with an empty bladder. At the time the
collection begins, instruct the child to void and discard the specimen. All urine voided
in the subsequent 24 hours is saved in a container with a preservative or is placed on
ice. Twenty-four hours from the time the precollection specimen was discarded, the
child is again instructed to void, the specimen is added to the container, and the entire
collection is taken to the laboratory.
 Bladder Catheterization
Bladder catheterization or suprapubic aspiration is used when a specimen is
urgently needed or a child is unable to void or otherwise provide an adequate
specimen.
The American Academy of Pediatrics recommends that a urine specimen be
obtained by bladder catheterization or suprapubic aspiration in ill-appearing
febrile infants with no apparent source of infection before antimicrobial
administration and to confirm a positive screen for infection.
Catheterization is a sterile procedure, and Standard Precautions for body
substance protection should be followed. If the catheter is to remain in place, a
Foley catheter is used.
 gives guidelines for choosing the
appropriate-size catheter and length of insertion.
Straight Catheter or Foley Catheter
Size (Length of Insertion Size (Length of Insertion
[cm]) for Boys [cm]) for Girls
5-6 (5) 5-6 (5) Term neonate
5-8 (5) 5-8 (5) Infant to 3 yr
8(6-9) 8(5-6) 4-8 yr
8-10(10-15) 10-12(6-8) 8 yr to prepubertal
12-14(13-18) 12-14(6-8) Pubertal
Children with myelodysplasia and those who have been identified as being sensitive or
allergic to latex are catheterized with catheters manufactured from an alternative material.
When an indwelling catheter is indicated for urinary drainage, a lubricious-coated or
silicone catheter is selected because these materials produce less irritation of the urethral
mucosa compared with Silastic or latex catheters when left in place for more than 72 hours

A 2% lidocaine lubricant with applicator is assembled according to the manufacturer’s

instructions, and several drops of the lubricant are placed at the meatus
 STOOL SPECIMENS
Stool specimens are frequently collected from children to identify parasites and other
organisms that cause diarrhea, assess gastrointestinal function, and check for occult
(hidden) blood.
Stool specimens should be large enough to obtain an ample sampling, not merely a fecal
fragment.
Specimens are placed in an appropriate container, which is covered and labeled.
If several specimens are needed, mark the containers with the date and time and keep
them in a specimen refrigerator.
Exercise care in handling the specimen because of the risk of contamination. If a stool
specimen cannot be obtained, some laboratory tests may allow for internal rectal swab.
 Explain
intramuscular,
subcutaneous,
and
intradermal
.administration
 Type
Of
Injection
Site
 Blood Collection From Peripheral Veins
When venipuncture is performed, the needed specimens are collected as quickly as possible,
and after the needle is withdrawn, pressure is applied to the puncture site with dry gauze until
bleeding stops.
When the venipuncture site is in the antecubital fossa, pressure should be applied with the arm
extended, not flexed, to reduce bruising.
The nurse then covers the site with an adhesive bandage.
In young children, adhesive bandages pose an aspiration hazard, so avoid using them, or
remove the adhesive bandage as soon as the bleeding stops.
If bruising or hematoma develops after venipuncture, applying warm compresses to the
ecchymotic area increases circulation, helps remove extravasated blood, and decreases pain
Selecting the Syringe and Needle
The volume of medication prescribed for intramuscular injections in small children necessitates selection
of a syringe that can measure small amounts of solution. For volumes less than 1 ml, the tuberculin
syringe, calibrated in 0.01-ml increments, is appropriate.
Doses smaller than 0.5 ml may be facilitated by the use of a 0.5-ml, low-dose syringe.

Factors to consider when selecting a site for an intramuscular (IM)

injection on an infant or child include the following:

Determining • The amount and viscosity of the medication to be injected

• The amount and general condition of the muscle mass
the Site • The frequency or number of injections to be given during the course
of treatment
• The type of medication being given
• Factors that may impede access to or cause contamination of the site
• The child’s ability to assume the required position safely
 SUBCUTANEOUS AND INTRADERMAL
ADMINISTRATION
Subcutaneous and intradermal injections are frequently administered to children, but the
technique differs little from the method used with adults. Examples of subcutaneous
injections include insulin, hormone replacement, allergy desensitization, and some
vaccines.
Tuberculin testing, local anesthesia, and allergy testing are examples of frequently
administered intradermal injections.
The angle of the needle for the subcutaneous injection is typically 90 degrees. In
children with little subcutaneous tissue, some practitioners insert the needle at a 45-
degree angle.
 SUBCUTANEOUS AND INTRADERMAL
ADMINISTRATION
subcutaneous injections can be given anywhere there is subcutaneous tissue, common sites
include the center third of the lateral aspect of the upper arm, the abdomen, and the center third
of the anterior thigh. Some providers believe it is not necessary to aspirate before injecting
subcutaneously; for example, this is an accepted practice in the administration of insulin.
Automatic injector devices do not aspirate before injecting.
When giving an intradermal injection into the volar surface of the forearm, the nurse should
avoid the medial side of the arm, where the skin is more sensitive.
 INTRAVENOUS ADMINISTRATION
The IV route for administering medications is frequently used in pediatric therapy. For some
drugs, it is the only effective route. This method is used for giving drugs to children who
• Have poor absorption as a result of diarrhea, vomiting, or dehydration
• Need a high serum concentration of a drug
• Have resistant infections that require parenteral medication over an extended time
• Need continuous pain relief
• Require emergency treatment
 Blood Collection From Arterial Vessels
Arterial blood samples are sometimes needed for blood gas measurement.
Arterial samples may be obtained by arterial puncture using the radial, brachial, or femoral
arteries or from indwelling arterial catheters.
Assess adequate circulation before arterial puncture by observing capillary refill or
performing the Allen test, a procedure that assesses the circulation of the radial, ulnar, or
brachial arteries. When collecting a blood sample from an established arterial line, use the in-
line sampling port, and follow institutional policy. Because unclotted blood is required, use
only heparinized collection tubes or syringes for arterial blood samples.
 Blood Collection by Capillary Methods
Take capillary blood samples from children by fingerstick or heelstick.
Cleanse the area with alcohol or chlorhexidine and allow to dry.
After performing the fingerstick, wipe once with dry gauze before beginning collection.
Gently massage the entire finger to maintain blood flow.
Avoid squeezing just the tip of the finger.
Hold the fingerstick site facing downward to facilitate blood collection.
A common method for taking peripheral blood samples from infants younger than 6
months of age is by heelstick.
Holding the infant’s foot firmly with the free hand, the nurse then
punctures the heel with an automatic lancet device.
An automatic device delivers a more precise puncture depth and is less
painful than using a manual lancet.
the most serious complications of infant heel puncture are necrotizing
osteochondritis from lancet penetration of the underlying calcaneus
bone, resulting in infection, and abscess of the heel.
To avoid osteochondritis, the puncture should be no deeper than 2 mm
and should be made at the outer aspect of the heel.
 Explain
rectal, optic,
otic, and nasal
administration
 RECTAL ADMINISTRATION
The rectal route for administration of medications is useful when a child is
unable to take oral medications due to vomiting, altered gastrointestinal
motility, or altered mental status.

Advantages to medication administration via the rectal route include no need to

coax a child to swallow unpleasant tasting medications, and relative ease of
accessibility for giving medications during an emergency if the patient is
unconscious or vomiting and there is no venous access.
Some of the drugs available in suppository form are acetaminophen, aspirin,
sedatives, analgesics (morphine), antiemetics, and laxatives
 RECTAL ADMINISTRATION
Absorption by rectal mucosa is dependent on several factors, including gut motility,
amount of time that the drug remains in the rectum, and amount of stool present at time
of drug administration.
The difficulty in using the rectal route is that unless the rectum is empty at the time of
insertion, the absorption of the drug may be delayed, diminished, or prevented by the
presence of feces.
If the patient is neutropenic, immunosuppressed, or thrombocytopenic, the rectal route
may be contraindicated due to risk of introducing bacteria into the bloodstream.
When preparing to administer medication by the rectal route, first remove the wrapping on
the suppository and lubricate the suppository with warm water (water-soluble jelly may
hinder medication absorption).
Have the child lie on the side with top leg flexed; alternatively, the child can lie prone.
Provide developmentally appropriate distraction for the child during the procedure.
Rectal suppositories are traditionally inserted with the apex (pointed end) foremost.
Reverse contractions or the pressure gradient of the anal canal may help the suppository
slip higher into the canal.
Using a gloved hand or finger cot, quickly but gently insert the suppository into the rectum
beyond both of the rectal sphincters.
Then hold the buttocks together firmly to relieve pressure on the anal sphincter until the
urge to expel the suppository has passed, which occurs within 5 to 10 minutes.
 NURSING TIP
To reduce unpleasant sensations when administering medications:
Eye: Apply finger pressure to the lacrimal punctum at the inner aspect of the eyelid for
1 minute to prevent drainage of medication to the nasopharynx and the unpleasant
“tasting” of the drug.
Ear: Allow medications stored in the refrigerator to warm to room temperature before
instillation.
Nose: Position the child with the head hyperextended to prevent strangling sensations
caused by medication trickling into the throat rather than up into the nasal passages.
 Optic, otic, and nasal administration
There are few differences in administering eye, ear, and nose medication to children
and to adults.
The major difficulty is in gaining children’s cooperation.
Older children need only an explanation and direction.
Although the administration of optic, otic, and nasal medication is not painful, these
drugs can cause unpleasant sensations, which can be eliminated with various
techniques.
To instill eye medication, place the child supine or sitting with the head

administration
extended and ask the child to look up. Use one hand to pull the lower eyelid
downward; the hand that holds the dropper rests on the head so that it may move
synchronously with the child’s head, thus reducing the possibility of trauma to a

optic
struggling child or dropping medication on the face.
When the lower eyelid is pulled down, a small conjunctival sac is formed; apply
the solution or ointment to this area rather than directly on the eyeball.
If applying an ointment, start at the inner canthus and move outward. Another
effective technique is to pull the lower eyelid down and out to form a cup effect,
into which the medication is dropped.
Take care not to touch the tip of the dropper to the eyeball. Gently close the
eyelids to prevent expression of the medication. Wipe excess medication from
the inner canthus outward to prevent contamination to the contralateral eye.
in infants One approach is to place the drops in the nasal corner where the
eyelids meet. The medication pools in this area, and when the child opens the
eyelids, the medication flows onto the conjunctiva.
IF BOTH EYE OINTMENT AND DROPS ARE ORDERED, GIVE DROPS

FIRST, WAIT 3 MINUTES, AND THEN APPLY THE OINTMENT TO

ALLOW EACH DRUG TO WORK. WHEN POSSIBLE, ADMINISTER EYE

OINTMENTS BEFORE BEDTIME OR NAPTIME BECAUSE THE

CHILD’S VISION WILL BE BLURRED TEMPORARILY

DRUG ALERT
Ear drops are instilled with the child in the prone or supine position and the head turned
to the appropriate side. To avoid uncomfortable stimulation of vertigo, ensure that ear
medications are at room temperature before instilling.
For children younger than 3 years of age, the external auditory canal is straightened by Ear
gently pulling the pinna downward and straight back.
The pinna is pulled upward and back in children older than 3 years of age.
To place the drops deep into the ear canal without contaminating the tip of the dropper,
admi
place a disposable ear speculum in the canal and administer the drops through the
speculum. Position the bottle so that the drops fall against the side of the ear canal. After nistra
instillation, the child should remain lying on the unaffected side for a few minutes.
Gentle massage of the area immediately anterior to the ear facilitates the entry of drops
into the ear canal.
tion
The use of cotton pledgets prevents medication from flowing out of the external canal.
However, they should be loose enough to allow any discharge to exit from the ear.
Premoistening the cotton with a few drops of medication prevents the wicking
action from absorbing the medication instilled in the ear.
 Nose drops are instilled in the same manner as in the adult patient. Remove

administration
mucus from the nose with a clean tissue or a washcloth.
 Unpleasant sensations associated with medicated nose drops are minimized
when care is taken to position the child with the head extended well over

Nose
the edge of the bed or pillow. Depending on size, infants can be positioned
in the football hold , in the nurse’s arm with the head extended and
stabilized between the nurse’s body and elbow and the arms and hands
immobilized with the nurse’s hands, or with the head extended over the
edge of the bed or a pillow.
 After instillation of the drops, the child should remain in position for 1
minute to allow the drops to come in contact with the nasal surfaces.
 Identify
aerosol
therapy and
nursing care
 Aerosol Therapy
Aerosol therapy can be an effective method for administering medication directly into the
airway. Bronchodilators, steroids, mucolytics, and antibiotics, suspended in particulate form,
can be inhaled so that the medication reaches the small airways.
This route of administration can be useful in avoiding the systemic side effects of certain drugs
and in reducing the amount of drug necessary to achieve the desired effect.
Many children with airway diseases, such as asthma, use aerosol therapies on a regular basis, it
is important for families to have an understanding of the home plan of care, including drugs to
use for maintenance and drugs to use for rescue.
Breath sounds and work of breathing should be assessed before and after treatments
 FAMILY TEACHING AND HOME CARE
The nurse usually assumes responsibility for preparing families to administer
medications at home.
The family should understand why the child is receiving the medication and the effects
that might be expected, as well as the mount, frequency, and length of time the drug is to
be administered.
Instruction should be carried out in an unhurried, relaxed manner, preferably in an area
away from a busy ward or office.
Instruct the caregiver carefully regarding the correct dosage.
To allow an opportunity to demonstrate their understanding of the skills required, caregivers
should always perform return demonstration before returning home.
This is essential when the drug has potentially serious consequences from incorrect dosage,
such as insulin or digoxin, or when more complex administration is required, such as
parenteral injections.
When teaching a parent to give an injection, the nurse must ensure that the caregivers have
adequate time for instruction and practice.
Home modifications are often necessary because the availability of equipment or assistance
can differ from the hospital setting.
The nurse should clarify with parents the time that the drug is to be administered.
This is particularly significant if a drug must be given at equal intervals throughout a 24-hour
period
 Medications can be aerosolized or nebulized with air or with oxygen-enriched gas. The metered-dose
inhaler (MDI) is a self-contained, handheld device that allows for intermittent delivery of a specified
amount of medication. Many bronchodilators are available in this form and are successfully used by
children with asthma.
A spacer device attached to the MDI can help with coordination of breathing and aerosol delivery. It also
allows the aerosolized particles to remain in suspension longer. For nebulized administration, a handheld
nebulizer discharges a medicated mist through a mouthpiece or a small plastic mask,
which the child holds over the nose and mouth. To avoid particle deposition in the nose and pharynx, the
child is instructed to take slow, deep breaths through an open mouth during the treatment. For home use, an
air compressor is necessary to force air through the liquid medication to form the aerosol.
Compact, portable units can be obtained from health equipment companies.

DRUG ALERT
To administer oral, nasal, or optic medication when only one person is available to hold the
child, and the child is unable to cooperate, use the following procedure:

• Place child supine on a flat surface (e.g., bed, couch, floor).

• Sit facing child so child’s head is between operator’s thighs and child’s arms are under
operator’s legs.
• Place lower legs over child’s legs to restrain lower body, if necessary.
• To administer oral medication, place a small pillow under child’s head to reduce risk of
aspiration.
• To administer nasal medication, place a small pillow under child’s shoulders to aid flow of
liquid through nasal passages

NURSING TIP
 If parents have difficulty reading or if there is a language barrier, use colors and/or
pictures to convey instructions.
For example, mark each drug with a color and place the appropriate color on a
calendar chart or on a drawing of a clock to identify when the drug needs to be
given. If a liquid medication and syringe are used, also mark the syringe at the place
the plunger needs to be with color-coded tape. Several websites and phone
applications are available to help create patient-specific medication calendars.

NURSING TIP
 Describe When a child has an indwelling feeding tube or a
gastrostomy, oral medications are usually given via
that route.
nasogastric,
An advantage of this method is the ability to
administer oral medications around the clock
orogastric, and without disturbing the child.
A disadvantage is the risk of occluding, or clogging,
gastrostomy the tube, especially when giving viscous solutions
through small-bore feeding tubes.

administration The most important preventive measure is adequate

flushing after the medication is instilled
 ALTERNATIVE FEEDING TECHNIQUES
Some children are unable to take nourishment by mouth because of anomalies of the
throat, esophagus, or bowel; impaired swallowing capacity; severe debilitation;
respiratory distress; or unconsciousness.
These children are frequently fed by way of a tube inserted orally or nasally
into the stomach (orogastric [OG] or NG gavage) or duodenum-jejunum
(enteral gavage) or by a tube inserted directly into the stomach
(gastrostomy) or jejunum (jejunostomy). Such feedings may be intermittent
or by continuous drip.
 APPLYING EVIDENCE TO PRACTICE
Nasogastric, Orogastric, or Gastrostomy
Medication Administration in Children

If administering tablets, crush tablet to a fine powder and dissolve drug in a small amount of
warm water.
Never crush enteric-coated or sustained-release tablets or capsules.
Avoid oily medications because they tend to cling to side of tube.
Do not mix medication with enteral formula unless fluid is restricted. If adding a drug:
Check with pharmacist for compatibility and appropriateness of route (some medications, such
as tacrolimus and ursodiol, cannot be given via enteral feeding route)
Shake formula well and observe for any physical reaction (e.g., separation, precipitation).
Label formula container with name of medication, dosage, date, and time infusion started.
 GAVAGE FEEDING
infants and children can be fed simply and safely by a tube passed into the
stomach through either the nares or the mouth. The tube can be left in place or
inserted and removed with each feeding.
In older children, it is usually less traumatic to tape the tube securely in place
between feedings.
For long-term enteral tube feedings, the tube should be removed and replaced
with a new tube according to hospital policy, manufacturer recommendations,
specific orders, and the type of tube used.
 Preparations
The equipment needed for gavage feeding includes the
following:
A suitable tube selected according to the child’s size, the viscosity of the solution being
fed, and anticipated duration of treatment
Water or water-soluble lubricant to lubricate the tube; sterile water is used for infants
Paper or other nonallergenic tape to mark the tube and to attach the tube to the infant’s
or child’s cheek (and nose, if placed through the nares)
PH paper to determine the correct placement in the stomach.
The solution for feeding.
 Procedure
Infants are easier to control if they are first wrapped in a mummy restraint.
Whenever possible, the infant should be held and provided with a means for
nonnutritive sucking during the procedure to associate the comfort of physical contact
with the feeding.
When this is not possible, gavage feeding is carried out with the infant or child lying
supine or on the right side; the head and chest should be elevated.
Feeding the child in a sitting position helps maintain placement of the tube in the
lowest position, thus increasing the likelihood of correct placement in the stomach.
Although the most accurate method for testing tube placement is radiography, this
practice is not always possible before each feeding.
Studies evaluating NG and OG tube length in
infants and children found that age-specific
methods for predicting the distance based on
height are more accurate estimates of internal
distance to the stomach.
A convenient morphologic measurement, the
nose-ear-midxiphoid-umbilicus (NEMU) span,
approached the accuracy of the age-specific
prediction equations and is easy to use in a
clinical setting.
GASTROSTOMY FEEDING
Feeding by way of gastrostomy, or G tube, is often used for children in whom
passage of a tube through the mouth, pharynx, esophagus, and cardiac sphincter
of the stomach is contraindicated or impossible.
It is also used to avoid the constant irritation of an NG tube in children who
require tube feeding over an extended period. A gastrostomy tube may be placed
with the child under general anesthesia or percutaneously using an endoscope
with the patient sedated and under local anesthesia.
Immediately after surgery, the catheter may be left open and attached to gravity
drainage for 24 hours or more.
Direct postoperative care of the wound site toward prevention of infection and irritation. Cleanse the
area with soap and water at least daily or as often as needed to keep the area free of drainage.
After healing, meticulous care is needed to keep the area surrounding the tube clean and dry to
prevent excoriation and infection.
Exercise care to prevent excessive pull on the catheter that might cause widening of the opening and
subsequent leakage of highly irritating gastric juices.
Use barrier ointments such as zinc oxide, petrolatum-based ointment, and nonalcohol skin barrier
film to control leakage; add absorptive powders and pectin-based skin barrier wafers if skin irritation
is present.
TOTAL PARENTERAL NUTRITION
Total parenteral nutrition (TPN) provides for the total nutritional needs of infants
and children whose lives are threatened because feeding by way of the
gastrointestinal tract is impossible, inadequate, or hazardous.
Total parenteral nutrition therapy involves IV infusion of highly concentrated
solutions of protein, glucose, and other nutrients.
The solution is infused through conventional tubing with a special filter attached
to remove particulate matter or microorganisms that may have contaminated the
solution The highly concentrated solutions require infusion into a vessel with
sufficient volume and turbulence to allow for rapid dilution
The wide-diameter vessels selected are the superior vena cava and innominate
or intrathoracic subclavian veins approached by way of the external or internal
jugular veins.
The major nursing responsibilities are the same as for any IV therapy and include control of
sepsis, monitoring of the infusion rate, and assessment of the patient.
The TPN solution must be prepared under rigid aseptic conditions, which is best accomplished
by specially trained technicians.
Nurses should change the TPN, lipids, and tubing on a frequent basis. More frequent tubing
changes are required for TPN and lipids because these solutions can increase risk of microbial
growth.
General assessments, such as vital signs, I&O measurements, and checking results of
laboratory tests, facilitate early detection of infection or fluid and electrolyte imbalance.
Additional amounts of potassium and sodium chloride are often required in
hyperalimentation; therefore observation for signs of potassium or sodium deficit or
excess is part of nursing care. This is rarely a problem except in children with reduced
renal function or metabolic defects.
Hyperglycemia may occur during the first day or two as the child adapts to the high-
glucose load of the hyperalimentation solution.
Describe
enema
 ENEMA
The procedure for giving an enema to an infant or child does not differ essentially from that for an
adult except for the type and amount of fluid administered and the distance for inserting the tube into
the rectum. Depending on the volume, use a syringe with rubber tubing, an enema bottle, or an enema
bag.
An isotonic solution is used in children. Plain water is not used because, being hypotonic, it can cause
rapid fluid shift and fluid overload.
The nurse should have the bedpan handy or, for ambulatory children, ensure that the bathroom is
available before beginning the procedure.

An enema is an intrusive procedure and thus can be threatening to children of all ages; therefore
developmentally appropriate preparation and distraction is especially important for the comfort of the
child.
OSTOMIES
Children may require stomas for various health problems. The most frequent
causes in infants are necrotizing enterocolitis and imperforate anus and, less
often, Hirschsprung disease.
Care and management of ostomies in older children differ little from the care of
ostomies in adult patients.
The major emphasis in pediatric care is preparing the child for the procedure and
teaching care of the ostomy to the child and family. The basic principles of
preparation are the same as for any procedure.