care of the sick or hospitalized child

8/13/2019 Care of the Sick or Hospitalized Child

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Care of the Sick or Hospitalized Child

GENERAL PRINCIPLES

FAMILY-CENERE! CARE

Family-centered care provides a framework for health care providers to ensure all aspectsof care and the care environment are designed and focused toward family needs and

concerns. The patient and family members are active members of the care team. The

family is recognized and cares for the hospitalized child with full information, support,and respect.

The goal of family-centered care is to maintain or strengthen the roles and ties of the

family with the hospitalized child to promote normality of the family unit.

"e#efits for Pare#ts a#d Child

Care and teaching are in keeping with specific family needs and strengths.

Family roles and close family interactions during time of stress are enhanced.

Minimizes separation aniety. !ecreases reactions of protest, denial, and despair.

"ncreases sense of security for the child.

Family needs to care for their child physically and emotionally are fulfilled.

#arents feel useful and important, rather than dependent and peripheral.

!ecreases parental guilt feelings.

"ncreases parents$ competence and confidence in caring for the sick child.

Families of children with special needs share comfort and support from one

another.

%reater absorption of staff teaching by the family.

!iminishes posthospitalization reactions.

I$ple$e#tatio# Strate%ies

"mplementation of family-centered care will depend on regulations of the particularhealth care setting as well as the capabilities of the individual family unit. &eview the

policies and regulations regularly with the input of children or adolescents and family

members. 'amples of activities that can facilitate and strengthen family ties include(

Taking a family history and listening for specific family)cultural needs and

preferences.

*llowing rooming-in for parents of young children.

+aving parents participate in the child$s physical care.

*cknowledging that parents are not visitors having fleible visiting regulations

for family members, including siblings. +aving pictures of family members available at the hospital.

'ncouraging telephone contact.

/sing family tape recordings.

'ncouraging the child and family members to participate in health care provider

or team rounds when appropriate. +aving patient and parental input during the

development of the daily medical plan can be beneficial.


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*cknowledging that there are varying types of family units. 'nsure that the child$s

usual caregiver 0who may not always be a parent1 or legal guardian is included in

the decision-making process as appropriate.

Role of the N&rse

o create a# e#'iro#$e#t co#d&ci'e to $ai#tai#i#% fa$il( stre#%th)i#te%rit() a#d it(* he #&rse sho&ld+

o +elp to maintain a positive nurse-parent-child relationship. *void actions

that may cause parents to feel threatened by the nurse.

o Facilitate a supportive marital relationship, allowing for differences in

style and needs.

o "nclude siblings in planning and intervention as appropriate to their age

and the situation.

o 2upplement the family$s abilities and role in achieving the common goal

of the child$s welfare.

o assist pare#ts ,ith decisio# $aki#% ao&t ,he# to sta( ,ith their child

a#d ,he# to e a,a(*o The parents$ presence is especially important if the child is age 3 or

younger, especially anious, upset, or in medical crisis.

o The parents$ decision is influenced by needs of other family members, as

well as by 4ob, home responsibilities, and personal needs.

o The nurse should try to alleviate guilty feelings of parents who are unable

to stay with their child.

o de'elop tr&sti#%) %oal-directed relatio#ships ,ith fa$ilies*

o 5btain a thorough nursing history that provides information to assess

broad consideration of strengths, relationships, and concerns include

family and individual stage of development, cultural, spiritual, social,

material, and financial areas.o #lan with the family toward mutual, realistic goals.

o &ecognize and acknowledge the care and consideration the child receives

from the parents.

o oser'e the pare#t-child relatio#ship a#d e ale to+

o 'valuate the degree of participation and effectiveness of the parents in

physical and emotional care.

o 5bserve the parents$ attitudes, skills, and techni6ues and the child$s

behavior and response to them.

o *ssess what teaching needs to be done.

o !etect and respond to actual and potential problems in the parent-child

relationship. o teach pare#ts k#o,led%e) dersta#di#%) a#d skills #ecessar( to fctio#

effecti'el( ,ith the hospitalized child* he #&rse sho&ld+

o Carefully assess the learning needs, learning styles, and potential barriers

to understanding and skill development assist families that need languageinterpretation.

o #erform nursing techni6ues safely and efficiently.


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o Mutually with parents, assess and interpret the behavior of the hospitalized

child, so appropriate understanding and intervention are reached.

o *ssess the child$s and parents$ understanding of essential medical care and

wellness-focused information.

o "nterpret and reinforce what health care providers have told parents.

*nswer 6uestions thoroughly and honestly as knowledge and nurse rolepermit. &efer core 6uestions about diagnosis and prognosis to the health

care provider most involved with the area of concern.

o 'plain medical procedures and diagnostic tests and the preprocedure

preparations re6uired.

o #rovide health teaching and anticipatory guidance concerning medically

related information and wellness behaviors, parenting and child-rearingmatters, and crisis intervention and community resources.

o help pare#ts adapt to the sit&atio# a#d to de'elop their o,# feeli#% of

'al&e ( copi#% ,ith the child.s ill#ess a#d deri'i#% $ea#i#% thro&%h the

diffic&lt e/perie#ces the( are faci#%*

o 7e aware of common parental reactions to the stress eperienced byfamilies of children who have severe or chronic illness respond or refer toother discipline as indicated 0ie, child psychiatry or child life personnel1.

o 7e aware that defense mechanisms, if used in moderation, are constructive

and may facilitate optimal coping.

o +elp parents recognize and value their own feelings and the feelings of

significant others.

o "dentify parental support systems as well as adaptive and maladaptive

coping.

o 7e perceptive of parents$ physical and emotional needs and limitations.

*s possible, help prevent parents becoming fatigued.

'ncourage parents to leave and take a break. o assist fa$ilies) as appropriate) i# deali#% ,ith #or$ati'e fa$il(

de'elop$e#tal tasks*

o 7e aware that the child$s hospitalization is commonly only one of many

stresses a family eperiences at a given time. 5thers may include(

"nterpersonal problems.

/nemployment, 4ob change. &ecent changes in dwelling place and conse6uent disruption.

#roblems associated with childcare and discipline.

Concurrent illness of other family members.

Financial constraints, lack of insurance.

Transportation issues 0no car, limited public transportation1. 8anguage barriers.

o 9eep in mind that the family unit and family members individually have

strengths and resources to be discovered and contributed.

o Consciously identify and separate your feelings and 4udgments about the

situation from those of the child and family the goal is to draw onindividual and family strengths to meet needs and solve problems as a

family unit.


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2ummer camp is an eciting eperience for children.

They learn about nature and themselves they eperience independence and group

living they get a change of pace from their usual routines.

Many camps are set up for children with chronic or handicapping conditions

where their special needs are met and they have an opportunity to learn, play, and

socialize with other people who are much like themselves. "n these settings, the nurse serves the role of camp counselor, confidant, and

provider of care.

Hospital or E/te#ded-Care Facilit(

"npatient facilities have special programs to facilitate the age and development

related needs of infants, children, and youth.

;ursing care is directed toward the child and family members.


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Foster neonate-sibling relationships as appropriate.

"dentify areas of infant deprivation or overstimulation. #lan a schedule of

appropriate stimulation 0ie, hold and rock every > to ? hours, eye contact1.

#rovide sensory-motor stimulation as appropriate.

*llow individuality to begin to emerge.

#rovide consistent caretakers when possible.

Yo% I#fa#t 45 to 7 Mo#ths6

Pri$ar( Co#cer#s

2eparation=mother and father are learning to identify and meet the needs of their

infant. The infant is learning to make his needs known and to trust the mother to

meet them.

2ensory-motor deprivation.

;eeds=security, motor activity, comforting measures.

Reactio#s

2eparation aniety is different from that of an older child because the younginfant sees the primary caregiver as an etension of himself.

!evelopment of trust is disturbed when the infant is separated from his mother

and when illness or hospitalization interferes with meeting the infant$s needs.

"nterference with development of a basic sense of trust has lifelong implications.

N&rsi#% I#ter'e#tio#s

'ncourage the parents to balance their responsibilities and minimize separation,

staying with the infant and providing care for their baby.


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'ncourage the parents$ presence and nurturing of their baby.

Foster the parents$ confidence and competence in this new role.

'ncourage the parents and family to ad4ust their schedules and home routines.

%et to know the infant through the parents, avoid overshadowing the parents.

The infant is beginning to develop purposeful activities and to strive towardindependence. #rovide opportunities and encouragement for this development tocontinue, and provide ways for infant to use newly ac6uired skills.

0lder I#fa#t 48 to 59 Mo#ths6

Pri$ar( Co#cer#s

7eginning definition of self=infant is aware of a growing ability to influence his

environment.

2eparation=infant becomes more possessive of the parents and clings to them at

the time of separation.

Reactio#s #assivity toward environment.

2eparation aniety=tolerance is limited fear of strangers, ecessive crying,

clinging, and overdependence on the parents.


+ave the mother stay and care for her child.

&elieve some of tensions and loneliness with transference ob4ect 0ie, blanket,

toy1.

#repare the child for procedures. !etailed eplanations are usually unnecessary

due to limited understanding. The procedures should be performed in another

room or a treatment room let the parents soothe the child afterward. #rovide for sensory stimulation and motor development appropriate for age.

#rovide opportunities for the child to continue using ac6uired skills, such asfeeding self and drinking from a cup.

The child needs opportunity to foster increased independence, curiosity and

eploration, locomotion, and language skills. /se infant seats, swing give room

to move around in crib, playpen, or floor use color, teture, and sound physicalstroking, rocking, and talking.

oddler 4A%es 5 to :6

Pri$ar( Co#cer#s

2eparation aniety=relationship with mother is intense. 2eparation represents theloss of family and familiar surroundings, resulting in feelings of insecurity, grief,

aniety, and abandonment. The toddler$s emotional needs are intensified by the

parents$ absence.

Changes in rituals and routines, all of which are important to sense of security,

become a source of concern.


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"nability to communicate=beginning use and understanding of language affords

child limited communication between self and the world. The child has limited

capacity to understand reality, passage of time. 8oss of autonomy and independence=egocentric view of life helps the child

develop a sense of autonomy. The child sees self as a separate being with some

potential control of own body and environment. 7ody integrity=incomplete and inaccurate understanding of the body results in

fear, aniety, frustration, and anger.

!ecrease in mobility=restricting mobility causes frustration. The child wants to

keep moving for the pleasure it gives as well as for the feeling of independence,the opportunity to learn about the world, and the route it provides for coping with

frustrations that cannot be verbally epressed. #hysical interference with this

freedom results in a sense of helplessness.

Reactio#s

Protest+

o +as urgent desire to find mother.o 'pects that they will answer cries, " want mommy " want daddy.

o Fre6uently cries and shakes crib.

o &e4ects attention of nurses.

o


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5btain from the parents key words in communicating with the child. Find out

about nonverbal behavior as well. Familiar toys, blankets, pillowcases, and family

pictures can reinforce the child$s sense of security. *llow the child to make choices when possible.

*rrange physical setting to encourage independence. *llow the child to eplore

his environment. 'nsure an age-appropriate and safe environment. ;o balloons atthe bedside.

*n adhesive bandage may give the child a security of wholeness after an

in4ection.

&eplace lost mobility with another form of motion, such as moving about in a

wheelchair, cart, or bed. 'ercise restrained etremity. #rovide opportunities for

the child to release energy suppressed by decreased mobility 0ie, by pounding,

throwing1. #rovide opportunities to continue learning about world throughsensory modalities, such as water play and diversional play.

!ischar%e;if roo$i#%-i# has #ot occ&rred d&ri#% hospitalizatio#) pare#ts

$&st e prepared for the possile post-hospital eha'ior of their toddler*

he( ,ill #eed s&pport i# dersta#di#% a#d ha#dli#% these eha'iors* hechild $a( do a#( of the follo,i#%+

o 2how lack of affection or resist close physical contact. #arents may

interpret this as re4ection.

o &egress to an earlier stage of development.

o Cling to parents, unable to tolerate any separation from them show

ecessive need for love and affection.

Appropriate pare#tal respo#se to the child.s eha'ior is 'ital if relatio#ships

are to e reestalished*

o 'tra love and understanding will help restore the child$s trust.

o +ostility and withdrawal of love will cause the child$s further loss of trust,

self-esteem, and independence.o Continue with previously established routines at home. Continue to set

limits.

Preschool Child 4A%es : to


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7ody image and integrity=hospitalization and intrusive procedures provide a

multitude of threats of both bodily mutilation and loss of identity, which are 4ust

beginning to develop along with the ac6uisition of autonomy. "mmobility=mobility is the child$s dominant form of self-epression and

adaptation to the environment. The child has great urge for locomotion and

eercise of large muscles. "t represents the main epression of emotion andrelease of tension.

8oss of control=this influences the preschooler$s perception of and reaction to

separation, pain, and illness.

Reactio#s

&egression=child temporarily stops using newly ac6uired skills in an attempt to

retain or regain control of a stressful situation. #reschooler may return to behavior

of infant or toddler.

&epression=child may attempt to eclude the undesirable and unpleasant stresses

from consciousness.

#ro4ection=preschooler may transfer own emotional state, motives, and desiresto others in environment.

!isplacement or sublimation=emotions are permitted to be directed and

epressed in other situations, such as art or play.

"dentification=the child assumes characteristics of the aggressor in an attempt to

reduce fear and aniety and to feel in control of the situation.

*ggression=hostility is direct and intentional physical epression takes

precedence over verbal epression.

!enial and withdrawal=the child is able to ignore interruptions and disavow any

thought or feeling that would result in a painful eperience.

Fantasy=a mental activity to help the child bridge the gap between reality and

fantasy because of lack of eperience. The preschooler may simply show similar behaviors 0protest, despair, denial1 to

those of the toddler although the stage of protest is usually less aggressive anddirect.


Minimize stress of separation by providing for parental presence and participation

in care. 2trive to shorten the hospital stay. +elp parents understand whathospitalization means to the child.

"dentify defense mechanisms apparent in the child and help him through the

stressful situation by accepting, showing love and concern, and being alert to

readiness to relin6uish them. 2et limits for the child. 8et him know that someone is there. +elp the child

become master of something in the situation.

#rovide opportunity and encouragement for the child to verbalize.

Careful preparation for all procedures should be done on the child$s level of

development and comprehension. #rovide privacy during these procedures.

7e sure the child has opportunities for play. #lay is one important medium

through which the child can overcome fear and aniety. "ncorporate child life


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therapy into care as appropriate. * body outline, doll, and simple visual aids are

appropriate teaching tools. #rovide self-epression, role reversal through puppets,

dolls, and drawings.

'ncourage activities with other children, especially those in similar

circumstances.

#rovide consistency in nursing personnel and approach to care. 'ncourage the child to participate in his own care and hygiene as appropriate.

#rovide a safe, age-appropriate environment.

!eal specifically with castration and mutilation fears. "f the child is having

surgery, describe eactly which body part will be repaired. #rovide pictures andother visual aids to reinforce teaching.


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5btain a thorough nursing history, including information regarding health and

physical developments, hospitalizations, social and cultural background, and

normal daily activities. /se this information to plan care. #rovide order and consistency in the environment whenever possible.

'stablish and enforce reasonable policies to protect the child and to increase his

sense of security in the environment. *rrange the environment to allow for as much mobility as possible 0ie, make sure

articles are appropriately placed move the bed if the child is immobilized1.

&espect the child$s need for privacy, and respect modesty during eaminations,

bathing, and other activities.

/se treatment rooms whenever possible when performing painful or intrusive

procedures. 9eep the room as safe territory.

+elp young children identify problems and 6uestions 0often through play1. Then

help them find the answers.

#rovide information about the illness and hospitalization based on assessment of

what facts the child needs and wants and how this information can be made

readily understandable. :iew all nursing care activities as teaching situations. 'plain the function of

e6uipment, and allow the child to handle it. Teach scientific terminology for body

parts, procedures, and e6uipment. #rovide visual aids whenever possible.


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7egin discharge planning early, including plans for physical and emotional needs.

*lert families to possible behavioral changes, including phobias, nightmares,

regression, negativism, and disturbances in eating and learning.

Adolesce#t

Pri$ar( Co#cer#s

#hysical illness, eposure, and lack of privacy may cause increased concern about

body image and seuality.

2eparation from security of peers, family, and school may cause aniety.

"nterference with struggle for independence and emancipation from parents is a

concern.

The adolescent may be threatened by helplessness and may see illness as a

punishment for feelings not mastered or for breaking rules imposed by parents or

physicians.

"llness and hospitalizations may interfere with peer associations, self-concept,

seuality, and independence.

Reactio#s

*niety or embarrassment related to loss of control.

"nsecurity in strange environment.

"ntellectualization about disease details to avoid addressing actual concerns. They

may know others with the same chronic type of illness who have died may fear

the future or feel guilty they have survived.

&e4ection of treatment measures, even if previously accepted.

*nger 0may be directed toward parents or staff1 because goals are being thwarted.

!epression.

"ncreased dependency on parents and staff. !enial or withdrawal.

!emanding or uncooperative behavior 0usually an attempt to assert control1.

Capitalization on gains from illness or pain.


+elp parents to prepare the adolescent for elective hospitalization.

*ssess the impact of illness on the adolescent by considering factors such as

timing, nature of illness, new eperiences imposed, changes in body image, and

epectations for the future. 7e aware of misconceptions.

"ntroduce the adolescent to the hospital staff and to regular routines soon after

admission. 5btain a thorough nursing history that includes information about hobbies,

school, family, illness, hospitalization, food habits, seuality, recreational

activities, and drug and alcohol eposure or addictions.

'ncourage adolescents to wear their own clothes, and allow them to decorate their

beds or rooms to epress themselves.

+ave drawers and closets available to store personal items.

*llow the adolescent access to a telephone.


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*llow adolescents control over appropriate matters 0ie, timing of bath, selection

of food1.

&espect their need for periodic isolation and privacy.

+ave a supervised recreational and activities program available that is planned by

a professional childcare worker.

*ccept the adolescent$s level of performance. *llow regression with epectationof growth.

"nvolve adolescent patients in planning care so they will be more accepting of

restrictions and receptive to health teaching. Focus on capabilities rather than

limitations. *dolescent should be accepted as a vital member of the health careteam. The adolescent$s consent should be obtained for procedures and surgery.

'plain clearly all procedures, routines, epectations, and restrictions imposed by

illness. "f necessary, clarify the adolescent$s interpretation of illness and

hospitalization. #lan separate teaching sessions for parents. %ive tours of theoperating room and recovery room or special procedure room preoperatively to

the child and his family.

Facilitate verbal re4ection of treatment measures to protect the adolescent fromharming himself physically by stopping treatment.

*ssess the adolescent$s intellectual skills, and provide necessary information to

allow for problem solving to deal with illness and hospitalization.

&ecognize positive and negative coping behaviors as attempts to ad4ust to a

threatening situation. *ttempt to deal with feeling that caused the behavior as well

as with the behavior itself.

7e a good listener. Maintain a sense of humor. 7e honest and respectful with the

adolescent and his family.

#rovide opportunities such as writing, artwork, and recreational activities to allow

nonverbal adolescents to epress themselves.

Foster interaction with other hospitalized adolescents and continuation of peerrelationships with outside friends.

'stablish regular group meetings to allow patients to meet with staff members and

with each other to comment and ask 6uestions about their hospital eperiences.

2et necessary limits to encourage self-control and ensure the rights of others.

+elp adolescents work through seual feelings. *void behavior that could be

interpreted as provocative or flirtatious.

!escribe and interpret the needs and reactions of the hospitalized adolescent to his

parents. 'mphasize the adolescent$s need to be respected as a uni6ue individual,

separate from his parents. *ssist the parents to cope with the illness and hospitalization as well as to deal

effectively with the adolescent$s response to related stress. 'ncourage continuation of education. Contact school tutors if necessary.

2tress the confidential nature of conversations between nurse and patient,

physician and patient.

#rovide employers with absence from work paperwork if necessary.

*ssess for signs and symptoms of drug or alcohol withdrawal.


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7ecause many adolescents use the "nternet, review information that the patient

might have found on the "nternet regarding diagnosis and treatment to ensure they

have found credible and accurate information.

PE!IARIC AC=E CARE N=RSING

&efer to the previous section on the impact of hospitalization on the developmental stageof the child. "n addition to the stress of hospitalization and the illness itself, the child mustdeal with multiple providers and the noious environment( high noise level, loss of sleep,

bright lights, random and unpredictable procedures, and the drastic change from normal

routine.

The parental role changes when their child is admitted to the intensive care unit 0"C/1,from that of parents of a well child to one of parents of a critically ill child. To ease this

transition, parents need to be informed about their child$s current condition, care plan,

and the future. They also need to feel needed and vital in their child$s recovery.

E$otio#al S&pport to Child

"f possible, familiarize the child with the setting or unit before admission. #rovide immediate physical care that communicates competence, caring, and

strength and facilitates trust.

7e alert to behavioral changes that may indicate physical distress.

Facilitate parent-child interaction facilitate fre6uent family visits.

*sk the parents about the child$s own way of responding to emotional stress. /se

particular comforts that are most soothing to the child.

2upport parents so they will be best able to support their child. *sk a social

worker to visit the family to ensure the parents have a plan regardingtransportation, daycare for siblings, and sleeping arrangements if they have come

to the facility from out of town.

Foster rest and prolonged periods of sleep. Time activities to reduce interruptionsdim lights to allow for ade6uate sleep whenever possible, cluster caregivingactivities.

!o everything possible to reduce the amount of pain the child must endure

anticipate and prevent aniety and pain provide comfort measures and

therapeutic distractions as appropriate. *dminister aniety-reducing or pain-reducing medications as ordered, and determine effectiveness. &e6uest topical

anesthetics 0eg, lidocaine A.3B and prilocaine A.3B1 prior to venipuncture and

in4ections when appropriate. Consider conscious sedation, and assist according tostandards and procedures.

#rovide age-appropriate stimulation when indicated by the child$s condition 0T:,

games, books, and toys1. 'ncourage child life therapy whenever appropriate. #rovide opportunities for the child to epress his fears and concerns.

"f possible, avoid eposing an alert child to the death or resuscitation of another

child. "f the child is eposed, provide ade6uate and developmentally appropriate

eplanation. +elp the child epress his own feelings and work through the

eperience.

#repare the child and his family for transfer from the "C/ by implementing a

nursing care plan similar to one that the child will eperience on a regular unit


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0eg, decrease fre6uency of monitoring of vital signs, encourage independence1.

%ive a thorough report to the receiving nurse during transfer.

E$otio#al S&pport to the Fa$il(

0rie#t pare#ts to the it a#d its ,aiti#% areas* Clarif( 'isiti#% policies a#d

hospital e/pectatio#s*o "f the admission to the "C/ is epected, familiarize the parents with the

"C/ before the admission.

o "f the admission is unepected and sudden, the eperience can be

traumatic for the family. Care to reduce fears, stress, and aniety is ofprime importance for the family.

'ncourage liberal visiting hours and unlimited phone calls from the parents to the

"C/.

*ssure the parents that everything possible is being done for their child.

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*sk the parents to discuss any medical information they find on the "nternet to

ensure accuracy.

HERAPE=IC PLAY AN! CHIL! LIFE PR0GRAMS

#lay is a central mechanism in which children cope. Through play, children

communicate, learn, and master a traumatic eperience such as hospitalization.Many hospitals have established programs with a specially trained staff whose 4ob it is toconcern themselves solely with the social and emotional welfare of every pediatric

patient. 2uch programs are called by a variety of names, including Child 8ife,

Children$s *ctivities, &ecreational Therapy, #lay Therapy, and others.

Collaboration between nurses and child life specialists etends the benefits of theseapproaches across time and settings of care.

Goals of Child Life Pro%ra$s

o pre'e#t so$e of the e$otio#al pai# a#d fear associated ,ith ill#ess a#d

hospitalizatio#*

o

Child life workers may assume primary responsibility or a supportive rolein the preparation of patients for hospitalization, surgery, or particularprocedures.

o "n many hospitals, child life workers arrange preadmission tours, puppet

shows, and similar activities to which all children who are plannedpediatric admissions are invited.

o pro'ide a co$fortale) accepti#%) a#d #o#threate#i#% e#'iro#$e#t ,here

the child $a( pla( a#d i#teract ,ith other childre# a#d ,ith a# ad&lt ,ho is

#ot i#'ol'ed ,ith health care*

o "deally, there is a separate child life playroom in every unit. +owever,

there may be only an open area at the end of the corridor or in the middle

of the unit.o %enerally, there is a specific regulation that no medical procedures 0even a

relatively benign one such as taking a child$s temperature1 are to be carriedout in the play area.

o "n many settings, children are encouraged to have their meals in the

playroom. %enerally, they not only en4oy the opportunity to eat withothers, but also seem to eat better.

o pro'ide the child ,ith a# opportit( for choice*

o The child may choose whether he wishes to come to the playroom. 5nce

there, the child may choose what to do.

o * variety of craft and play materials, including real and miniature medical

e6uipment, are available.o 2hould the child choose to sit and watch or be held and rocked, these

activities are seen as acceptable choices.

o Certain items 0puzzles, games1 may be brought back to the child$s room

for use when the playroom is closed.

o #ortable T:s and video games may be available.

o pro'ide a co#ti#&i#% ed&catio#al pro%ra$*


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o "n some settings, teachers are paid by the hospital and are an integral part

of the child life program. "n others, teachers are provided by the local

public schools, and they work in close cooperation with the child lifedepartment.

o "n most hospitals, the educational program includes special activities for

preschoolers and toddlers as well as a program of infant stimulation thatmay be in collaboration with physical and occupational therapists.

PAIN MANAGEMEN

Ge#eral Co#sideratio#s

#ain eperienced by infants and children is not effectively identified or managed

in many cases.

There are still misunderstandings about the ways pain is eperienced and

epressed by infants and children.

7ehavioral and physiologic cues are used to assess pain in infants. 2pecial rating

tools are available to involve children in assessing the intensity of their pain,including the #ain 'perience "nventory, C&"'2 ;eonatal #ostoperative #ain

Measurement 2cale, 5ucher #ain &ating 2cale, ;umerical or :isual *nalog

2cale, and the F*C'2 #ain &ating 2cale.

FACES Pai# Rati#% Scale* 4>hale() L*) ? >o#%) !* @5B* Esse#tials of pediatric#&rsi#% @


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Preoperati'e eachi#%

*ll preparation and support must be based on the child$s age, developmental

stage, and level personality past history and eperience with health professionalsand hospitals background including religion, socioeconomic circumstances,

culture, and family attitudes and dynamics.

"n6uire as to what information the child has already received. !etermine what the child knows or epects identify family myths and possible

misunderstandings.

Additio#al %&ideli#es i# preparatio# i#cl&de+

o /se illustration or model of a child$s body, concrete eamples, and simple

terms 0not medical 4argon1.

o "dentify changes that may occur as a result of the procedure, both in body

and daily routine.

o %ive eplanations slowly and clearly, saving aniety-producing aspects

until the end. &epeat as needed.

o Make use of the child$s creative ability and logical thinking powers to aid

in preparation for procedures.o "nvolve parents, as indicated, depending on the situation.

o *llow and encourage the child to participate as able.

o 2uggest ways for the child to cope=crying is okay.

o 5ffer constant reassurance speak in a calm manner.

o +ave the child tell you what they understand from your teaching. &epeat

and correct information as necessary.

5rient the patient and his family to the unit, room, location of playroom,

operating room, and recovery room, and introduce them to other children, parents,and some personnel. Make arrangements for the child to meet the anesthesiologist

as well as the operating room nurse and recovery room nurse.

Allo, a#d e#co&ra%e 2&estio#s* Gi'e ho#est a#s,ers*o 2uch 6uestions will give the nurse a better understanding of the child$s

fears and perceptions of what is happening.

o "nfants and young children need to form a trusting relationship with those

who care for them.

o The older the child the more reassuring information can be.

#rovide opportunity for the child and his parents to work out concerns and

feelings 0play, talk1. 2uch supportive care should result in less upset behavior andmore cooperation.

#repare the child for what to epect postoperatively 0ie, e6uipment to be used or

attached to child, where the child will wake up, how the child will feel, what the

child will be epected to do, diet, any physical restrictions1.

Ph(sical Preparatio#

*ssist with necessary laboratory studies. 'plain to the child what is going to

happen before the procedure and how he may respond. %ive continual support

during the procedure.

2ee that the patient has nothing by mouth 0;#51. 'plain to the child and his

parents what ;#5 means and the importance of it. #lace signs on the patient$s


21/67

hospital door indicating the ;#5 status to ensure that nonfamily members and

nonstaff members do not give the patient food.

Assist ,ith fe'er red&ctio#*

o Fever will result from some surgical problems 0eg, intestinal obstruction1.

o Fever increases risk of anesthesia and need for fluids and calories.

*dminister appropriate medications as prescribed. 2edatives and drugs to dry thesecretions are often given on the unit preoperatively.

'stablish good hydration. #arental therapy may be necessary to hydrate the child,

especially if the child is ;#5, vomiting, or febrile.

I$$ediate Postoperati'e Care

Mai#tai# a pate#t air,a( a#d pre'e#t aspiratio#*

o #osition the child on side or abdomen to allow secretions to drain and to

prevent the tongue from obstructing the pharyn.

o 2uction any secretions present. *void causing a gag refle or spasm

during suctioning.

Make fre2&e#t oser'atio#s of %e#eral co#ditio# a#d 'ital si%#s*Postoperati'e protocols $a( 'ar( per proced&re a#d facilit(*

o Take vital signs every 3 minutes until the child is awake and his

condition is stable.

o ;ote temperature, respiratory rate and 6uality, pulse rate and 6uality,

blood pressure, skin color.

o


22/67

*fter undergoing simple surgery and receiving a small amount of anesthesia, the child

may be ready to play and eat in a few hours. More complicated and etensive surgery

debilitates the child for a longer period of time.

Co#ti#&e to $ake fre2&e#t a#d ast&te oser'atio#s i# re%ard to eha'ior)

co$fort le'el a#d pai# co#trol) 'ital si%#s) dressi#%s or operati'e site) a#d

special apparat&s 4I*1* li#es) chest t&es) o/(%e#6*o ;ote signs of dehydration=dry skin and membranes sunken eyes poor

skin turgor sunken fontanelle, poor urine output in an infant.

o &ecord any passage of flatus or stool and bowel sounds. 5bserve for

intestinal ileus because crying children swallow air, which may cause

gastric distention.

o &ecord vomiting time, amount, and characteristics.

*ssess behavior for signs of pain, and medicate appropriately.

Record i#take a#d o&tp&t acc&ratel(*

o #arenteral fluids and oral intake.

o !rainage from gastric tubes or chest tubes, colostomy, wound, and urinary

output.o #arenteral fluid is evaluated and prescribed by considering output and

intake. "t is usually maintained until the child is taking ade6uate oralfluids.

Ad'a#ce diet as tolerated) accordi#% to the child.s a%e a#d the health care

pro'ider.s directio#s*

o First feedings are usually clear fluids if tolerated, advance slowly to full

diet for age. ;ote any vomiting or abdominal distention.

o 7ecause anoreia may occur, offer what the child likes, in small amounts

and in an attractive manner.

Pre'e#t i#fectio#*

o 9eep the child away from other children or personnel with respiratory orother infections.

o Change the child$s position every A to ? hours prop infants with a blanket

roll.

o 'ncourage the child to cough and breathe deeply let the infant cry for

short periods of time, unless contraindicated. 5ffer older children

incentive spirometry every hour while awake.

o 9eep operative site clean=change dressing as needed keep the diaper

away from the wound.

o 'nforce diligent handwashing by family members and staff before any

contact with the patient.

o !o not cohort surgical patients with patients with a proven or presumptiveinfection.

o *dminister prophylactic antibiotics as ordered.

#rovide good general hygiene, and opportunities for eercise and diversional

activity encourage sleep and rest.

#rovide emotional support and psychological security. &eassure the child that

things are going well if there are complications, offer honest information based


23/67

on the patient$s health and developmental level and the parents$ willingness to

share this information with their child. Talk about going home if appropriate.

7egin early to prepare for discharge( teach special procedures, provide written

instructions, and arrange for community nurse referral.

HE !YING CHIL!The nursing role is to assist the child and family to cope with the eperience in such away that it will promote growth rather than destroy family integrity and emotional well-

being.

Reco%#ize the Sta%es of !(i#%

Sta%es of !(i#% as Ide#tified ( !r* Elizaeth ler-Ross

SAGE N=RSING C0NSI!ERA0NS

I* !e#ial) shock) diselief *ccept denial, but function within a reality

sphere. !o not tear down the child$s 0or

family$s1 defenses. 7e aware that denial usually breaks down in

the early morning when it may be dark and

lonely.

7e certain that it is the child or family who is

using denial, not the staff.

II* A#%er) ra%e) hostilit( *ccept anger and help the child epress it

through positive channels.

7e aware that anger may be epressed toward

other family members, nursing staff,

physicians, and other persons involved.

+elp families recognize that it is normal for

children to epress anger for what they are

losing.

III*"ar%ai#i#% 4fro$ No) #ot

$e) to Yes) $e) &t6

&ecognize this period as a time for the child

and family to regain strength.

'ncourage the family to finish any unfinished

business with the child. This is the time to dothings such as take the promised trip or buy

the promised toy.I1*!epressio# 4he child a#dJor

fa$il( e/perie#ces sile#t %rief

a#d $o&r#s past a#d f&t&re

losses*6

&ecognize this as a normal reaction and

epression of strength.

+elp families to accept the child who does

not want to talk and ecludes help. This is the

usual pattern of behavior.

&eassure the child that you can understand


24/67

his or her feelings.

1* Accepta#ce *ssist families to provide significant loving

human contact with their child and oneanother.

7e aware that dying children, their families, and the staff will all progress through

these stages, not necessarily at the same time. Children eperience the stages with much variation. They tend to pass more

6uickly through the stages and may merge some of these stages.

The nursing goal is to accept the child and his family at whatever stage they are

eperiencing, not to push them through the stages.

/nderstand the meaning of illness and death at various stages of growth and

development.

Sta%es i# the !e'elop$e#t of a Child.s Co#cept of !eath

AGE 0F

CHIL! SAGE 0F !E1EL0PMEN

Child &p to

a%e :

o *t this stage, the child cannot comprehend the

relationship of life to death because the child has notdeveloped the concept of infinite time.

o The child fears separation from protecting and

comforting adults.o The child perceives death as a reversible act.

Preschool

child*

o *t this age, the child has no real understanding of the

meaning of death the child feels safe and secure withparents.

o The child may view death as something that happens

to others.o The child may interpret the separation that occurs

with hospitalization as punishment the painful tests andprocedures that the child is sub4ected to support this idea.

o The child may become depressed because of not

being able to correct these wrongdoings and regain the grace

of adults.

o The concept may be connected with magical thoughts

of mystery.

School-a%e

child

o The child at this age sees death as the cessation of

life child understands that he or she is alive and can become

not alive child fears dying.

o The child differentiates death from sleep. /nlike

sleep, the horror of death is in pain, progressive mutilation,and mystery.

o The child is vulnerable to guilt feelings related to

death because of difficulty in differentiating death wishes and

the actual event.

o The child believes death may be caused by angry

feelings or bad thoughts.

o The child learns the meaning of death from own


25/67

personal eperiences, such as the death of pets, family

members, and public figures.

o Television and movies have contributed to the

concept of death and understanding of the meaning of illness.

There may be more knowledge in the meaning of the

diagnosis and an awareness that death may occur violently.Adolesce#t o The adolescent comprehends the permanence of death

as the adult does, although the adolescent may not

comprehend death as an event occurring to persons close toself.

o The adolescent wants to live=sees death as thwarting

pursuit of goals( independence, success, achievement,physical improvement, and self-image.

o The adolescent fears death before fulfillment.

o The adolescent may become depressed and resentful

because of bodily changes that may occur, dependency, and

the loss of social environment.o The adolescent may feel isolated and re4ected because

adolescent friends may withdraw when faced with impending

death of a friend.

o The adolescent may epress rage, bitterness, and

resentment especially resents the fact that fate is to die.

"e a,are of other factors that i#fl&e#ce a child.s perso#al co#cept of death*

0f partic&lar i$porta#ce are+

o The amount and type of direct eposure a child has had to death.

o Cultural values, beliefs, and patterns of bereavement.

o &eligious beliefs about death and an afterlife.

Meet with the parents separately from the child and discuss their wishes regardingdissemination of information to their child.

Co$$icate ,ith the Child ao&t !eath

&esearch indicates that children generally can cope with more than adults will allow andthat children appreciate the opportunity to know and understand what is happening to

them. "t is important that the child$s 6uestions be answered simply, but truthfully, and that

they be based on the child$s particular level of understanding. The following responseshave been suggested by 'asom in The !ying Child and may be useful as a guide(

Preschool-A%e Child


26/67


27/67

o The primary responsibility for communicating with the parents should be

designated to one nurse.

o "nformation regarding the parents$ concerns should be communicated to all

staff members and should be included in the patient$s care plan.

Accept pare#tal feeli#%s ao&t the child.s a#ticipated death) a#d help pare#ts

deal ,ith these feeli#%s*o "t is not unusual for parents to reach the point of wishing the child dead

and to eperience guilt and self-blame because of this thought.

o The parents may withdraw emotional attachments to the child if the

process of dying is lengthy. This occurs because the parents complete

most of the mourning process before the child reaches biologic death.

They may relate to the child as if he were already dead.

Pro'ide a#ticipator( %&ida#ce re%ardi#% the child.s act&al death a#d

i$$ediate decisio#s a#d respo#siilities after,ard*

o !escribe what the death will probably be like and how to know when it is

imminent. This is necessary to dispel the horrifying fantasies that many

parents have. &eassure the parents that all measures will be taken to keepthe child comfortable at the time of death. 0;ote( certain diseases, despite

appropriate medical interventions, may cause an uncomfortable or painfuldeath. #arents should be promised complete comfort for their child only if

this epectation is realistic1

o Clarify the parents$ wishes about being present at the child$s death, and

respect their desires. 2ee if they want to hold the child=before, during, or

after the death.

o "f appropriate, allow the parents to discuss their feelings about issues such

as autopsy and organ donation in order that they may make appropriate

decisions. !o not make them feel guilty if they do not consent.

o "f necessary, assist the parents to think about funeral arrangements. 7e aware of factors that affect the family$s capacity to cope with fatal illness,

especially social and cultural features of the family system, previous eperiences

with death, present stage of family development, and resources available to them.

Contact the appropriate clergy if the family desires. Contact other etended family

members for support if they wish.

!uring final hours, do not leave the family alone, unless they re6uest it.

'ncourage parents and siblings to share their thoughts with the dying child.

#rovide information on bereavement support groups, usually available through

hospital or church.

PE!IARIC PR0CE!=RES

RESRAINS

#rotective measures to limit movement are mechanisms for restraining children. They can

be a short-term restraint to facilitate eamination and minimize the child$s discomfort

during special tests, procedures, and specimen collections. &estraints can also be used fora longer period of time to maintain the child$s safety and protection from in4ury.


28/67

(pes of restrai#ts*

Ge#eral Co#sideratio#s

#rotective devices should be used only when necessary and after all other

considerations are ehausted, never as a substitute for careful observation of the

child.

#rotective devices cannot be used on a continuous basis without an order.

Continuous use re6uires 4ustification and full documentation of the type of

restraint used, reason for use, and the effectiveness of the restraint used. 5ngoing

monitoring, documentation, and renewal of the order are re6uired.

The reason for using the protective device should be eplained to the child and his

parents to prevent misinterpretation and to ensure their cooperation with the

procedure. Children often interpret restraints as punishment.


29/67

Teach the child and his family about specific devices they may be using in the

hospital 0ie, side rails1 and after discharge 0ie, mitts, elbow restraints1.

*ny protective device should be checked fre6uently to make sure it is effective

and is not causing any ill side effects. "t should be removed periodically to

prevent skin irritation or circulation impairment. #rovide range of motion and skin

care routinely. #rotective devices should always be applied in a manner that maintains proper

body alignment and ensures the child$s comfort.

*ny protective device that re6uires attachment to the child$s bed should be

secured to the bed springs or frame, never the mattress or side rails. This allowsthe side rails to be ad4usted without removing the restraint or in4uring the child$s

etremity.

*ny re6uired knots should be tied in a manner that permits their 6uick release.

This is a safety precaution.


30/67

2eparate the corners of the bottom portion of the sheet, and fold it up toward the

child$s neck.

Tuck both sides of the sheet under the child$s body.

2ecure by crossing one side over the other in the back and tucking in the ecess,

or by pinning the blanket in place.

Special Preca&tio#s

Make certain the child$s etremities are in a comfortable position during this procedure.

Kacket !e'ice

The 4acket device is a piece of material that fits the child like a 4acket or halter. 8ongtapes are attached to the sides of the 4acket 0see Figure ?>-A, page >IJ1. Kacket device

restraints are used to keep the child in a wheelchair, high chair, or crib.

N&rsi#% Actio#

#ut the 4acket on the child so the opening is in the back.

Tie the strings securely. #osition the child in wheelchair, high chair, or crib.

Sec&re the lo#% tapes appropriatel(+

o /nder the arm supports of a chair.

o *round the back of the wheelchair or high chair.

o To the springs or frame of a crib.

Special Preca&tio#s

Children in cribs must be observed fre6uently to make certain they do not become

entangled in the long tapes of the 4acket device.

"elt !e'iceThe belt device is eactly like the 4acket method of restraining, ecept that the material

fits the child like a wide belt and buckles in the back 0see Figure ?>-A, page >IJ1.

Elo, !e'ice

The elbow device is a plastic device that fits around the arm at the elbow bend and issecured with a :elcro strap. This type of restraint prevents fleion of the elbow. "t is

especially useful for pediatric patients receiving a scalp vein infusion, those with eczema

or other skin rashes, and those following a cleft lip repair, eye surgery, or any other typeof procedure or surgery in which touching the upper etremities, head, or neck should be

prevented.

E2&ip$e#t

'lbow device.

2kin protective material for under the device 0long-sleeved shirt or gauze1.

N&rsi#% Actio#

Cover the elbow with a long-sleeved shirt or gauze if irritation or sweating is

epected.


31/67

#lace the child$s arm in the center of the elbow restraint.


32/67

N=RSING ALER

Mitts should be removed at least every ? hours to permit skin care and to allow the childto eercise fingers.

Cri op !e'ice

* crib top device is used to prevent an infant or small child from climbing over the crib

sides. 2everal types of commercial devices are available, including nets, plastic tops, and

domes. * crib top device should be applied to the crib of a child capable of climbing overthe crib sides 0usually between ages and ?1.

N=RSING ALER

"n all instances, it is essential to be certain that the crib sides are kept all of the way upand latched securely. There should be no space between the top of the crib sides and the

bottom of the crib top device.

Papoose "oard

* papoose board is the most cumbersome restraint device that may be used for

procedures of the head, chest, and abdomen. 2traps restrain the child or infant at the

forehead, lower arms, and thighs 0see Figure ?>-A, page >IJ1.

SPECIMEN C0LLECI0N

'valuation of specimens such as blood, urine, and stool is important in determining thestatus of the child. The nurse should be adept in the techni6ues for obtaining specimens,

as well as meticulous in labeling and recording them.

PR0CE!=RE G=I!ELINESAssisti#% ,ith "lood Collectio#

E=IPMEN

A>- to I-gauge short needle or scalp vein needle

2maller volume or micro blood-collecting tubes

2maller tourni6uet 0rubber band may be used with infant1

%loves per standard precautions

N&rsi#% Actio# Ratio#ale

Preparator( phase.

"mmobilize the child by placing in a mummy restraint ifnecessary 0see page >IE1.

.

"nfants and young children s6uirm. "them allows easier access to the veni

also helps keep the child warm.

A.

#osition the patient. A.

These positions allow for optimal vistabilization of the patient.

a.Femoral venipuncture:#lace child on back with legs in

froglike position. #lace your hands on the child$s knees.

a.Cover perineum to protect site in c


33/67

b

.

External jugular venipuncture:#lace the child in mummy

restraint and lower head over the side of the bed or table.

Turn head to side and stabilize. 02ee accompanyingfigure.1

b.Crying will make eternal 4ugular

causes blood to flow more readily.

c.Antecubital fossa venipuncture:#lace the child in a supine

position. The nurse stands on the side opposite the site tobe used 0across from the person drawing the specimen1.

The nurse positions her right arm across the upper part of

the child$s chest and grasps the shoulder at the aillaposition. The nurse$s left arm is placed across the lower

part of the child$s chest and is used to etend the child$s

arm at the wrist 0see accompanying figure1.

c.The nurse$s hands are used to straig

the child$s arm still arms are used stability of child$s upper body.

d.Infantheel, toe, or digital puncture:-3 minutes.

A

.

The femoral and 4ugular veins are la

7ecause intravascular pressure is gre

oozing, and hematoma formation ma'ternal pressure prevents this from

a.ugular venipuncture:


34/67

place the patient in an upright sitting position. !o not

apply ecessive pressure that may compromise circulation

or respiration.

vein.

>

.

.

Crying and thrashing about may initi

Follo,-&p phase

.

Check the patient fre6uently for hour after the procedure

for oozing, bleeding, or evidence of a hematoma.

.

&eapply pressure and report if oozin

A

.

&ecord carefully and accurately(

a. 2ite of venipuncture

b. +ow the patient tolerated procedure

c. 7leeding stopped or continued and for how long

d. Test for which the specimen was collected as well as

the place to which it was sent for analysis and the

time at which it was sent.

PR0CE!=RE G=I!ELINES

Collecti#% a =ri#e Speci$e# fro$ the I#fa#t or Yo% Child

E=IPMEN

Collecting device=plastic, disposable urine bag or collector 0+ollister, /-7ag,

double chamber1

Cleansing agent

D-ED minutes

before the procedure, if no contraindications.

.

To increase urine

production.A

.

#osition the patient so genitalia are eposed by placing child

on back with legs in a froglike position. *ssistance may beneeded to hold the legs of the young child in proper position.

A

.

#roper positioning will

facilitate cleansing andallow for properplacement of

collection device.

>

.


35/67

A

.

Cleanse genital area. A

.

This method of

cleansing the female

will preventcontamination of the

genitalia from the anus

and will preventcontamination of the

urine specimen

obtained. !uring thecleansing, be gentle to

avoid any in4ury or

possible stimulation of

urination.

a.Female:/sing cotton balls, dip into cleansing agent, wipelabia ma4ora from top to bottom 0clitoris to anus1 only once

with each cotton ball. &epeat this once more.


36/67

. voided.


37/67

.

Check diaper for wetness. "f the child has

4ust voided, report this or report last

voiding time. *t least hour should passwithout voiding.

.

To perform a successful bladder

aspiration, enough urine must be present

to distend the bladder up above the pubicsymphysis=so bladder is accessible.

A

.

#osition child on back on the eamination

table. +ead should be toward the nurse,feet toward the health care provider

performing the aspiration. 2pread child$s

legs apart in a froglike position. #lace yourhands on the child$s knees.

A

.

This position allows the nurse to stabilize

the child. "t also gives a full view of thechild, making it easier to observe, talk to,

and soothe the child.

>

.

'nsure that the skin over the puncture site

is cleansed in an antiseptic manner.

>

.

To prevent infection from being

introduced into the bladder by inserting

the needle through unclean skin, whichwould contaminate the specimen.

Perfor$a#ce phase

.

The health care provider and nurse should

wear gloves and other protectivee6uipment 0gown, mask, and goggles1 if

necessary.

.

2tandard precautions.

A

.

.

To prevent urination during procedure,compress the infant$s urethra(

a. !ale:#ressure on penis.

b.Female:!igital pressure upward onurethra from rectum.

?

.

minutes

or until oozing ceases and coagulation has

taken place.

3.

*pply an adhesive bandage if necessary.&eapply diaper. +old and comfort the

child for a few minutes.

3.

+olding the child will help to restore andmaintain a good nurse-patient relationship

and will help the child to rela after a

frightening and painful procedure.

Follo,-&p phase

.

Check the child periodically for hour

after the procedure to see that bleeding oroozing has not occurred.

.

This is not likely if pressure was applied

properly after the procedure and thepatient was left 6uiet.

A

.

;ote time of first voiding after procedure.

;ote color of urine 0it may be pink1.

7loody urine should be reported to the

A

.

"t is important to note any changes in

voiding pattern after the procedure

because change might indicate in4ury. The


38/67

health care provider. first voided urine may be pink because of

a small amount of local capillary bleeding

at the time of the procedure.>

.

*ccurately describe and chart the

procedure, including(

a. Time of procedureb.


39/67

specimen container.

3

.

2end labeled specimen to the laboratory

promptly.

3

.

#rompt delivery to the laboratory

will prevent changes from occurringin the specimen that could alter the

test results.

Follo,-&p phase

.

*ccurately describe and record the following(

a. Time specimen was collected.

b. Color, amount, and consistency of stool 0noteany foul smell or blood-tinged stool1.

c. Type of specimen collected.

d. ;ature of test for which the specimen was

collected.e. Condition of the perineal and anal areas.

FEE!ING AN! N=RII0N;utritional re6uirements may increase while infant or child is ill, but the ability to feednaturally may be impaired by illness or the child$s response to illness. "f eisting feeding

patterns cannot be maintained, alternate methods may be necessary.

Ga'a%e Feedi#%

See Proced&re G&ideli#es

%avage feeding is a means of providing food by way of a catheter passed through

the nares or mouth, past the pharyn, down the esophagus, and into the stomach,

slightly beyond the cardiac sphincter. Feedings may be continuous or intermittent. %avage feedings can provide a method of feeding or administering medications

that re6uire minimal patient effort when the child is unable to suck or swallowade6uately 0eg, premature neonates under >A weeks$ gestation or under ,3ED gchildren with neurologic deficits or respiratory compromise1.

%avage feedings provide a route that allows ade6uate calorie or fluid intake they

can also provide supplemental or additional calories.

%avage feedings can prevent fatigue or cyanosis that is apt to occur from bottle-

feeding. They can provide supplements for an infant who is a poor bottle-feeder.

%avage feedings can provide a safe method of feeding hypotonic patients, patients

eperiencing respiratory distress 0respiratory rate greater than ED)minute1, patients

with uncoordinated suck and swallow, intubated patients, debilitated patients, andpatients with anomalies of the digestive tract.


I#fa#t Ga'a%e Feedi#%

E=IPMEN

2terile rubber or plastic catheter, rounded-tip, size 3-A French 0*rgyle feeding

tubes1

Clear, calibrated reservoir for feeding fluid

3-D m8 syringe


40/67

2tethoscope

2terile water or normal saline

Tape=hypoallergenic

Feeding fluid, room temperature

#acifier


Preparator( phase

. #osition child on side or back with a rolled diaper

placed under shoulders. * mummy restraint may

be necessary to help maintain this position 0seepage >IE1.

. This position allows for easy passage of the

observation, and helps avoid obstruction of

A. Measure the distance from the tip of the patient$s

nose to ear to iphoid process of sternum and markthe length on the feeding tube with tape.

A. #remeasuring the catheter provides a guide

catheter.

>. +ave suction apparatus readily available. >. 2uctioning clears the airway and prevents aoccurs.

Perfor$a#ce phase

. 8ubricate catheter with sterile water or normal

saline solution.

. !o not use oil because of danger of aspirat

A. 2tabilize the patient$s head with one hand use theother hand to insert catheter.

A.

a.Insertion through nares:2lip the catheter into the

patient$s nostril and direct it toward the occiput ina horizontal plane along the floor of the nasal

cavity. !o not direct the catheter upward.

5bserve for respiratory distress.

a.This direction will follow the nares$ passa

#ositioning in nares may cause partial airroute if there is critical airway compromi

b

.

Insertion through the mouth:#ass the catheter

through the patient$s mouth toward the back of

his throat, with his head tilted slightly forward.>. "f the patient swallows, passage of the catheter

may be synchronized with the swallowing.

!o not push against resistance. %ently try rotating

the tube if resistance is met.

>. 2wallowing motions will cause esophageal

cardiac sphincter and facilitates passage of

occur with very little pressure.

?. "f there is no swallowing, insert the catheter

smoothly and 6uickly.

?. 7ecause of cardiac sphincter spasm, resista

#ause a few seconds, then proceed.

3. "n the infant, especially, observe for vagal

stimulation 0ie, bradycardia Nslow heart rateO andapnea1.

3. The vagus nerve pathway lies from the med

thora to the abdomen. *bove the stomachunite to form the esophageal pleus. 2timul

with the catheter will directly affect the carE.


41/67

Gavage tube in jejunum

Steps in preparing adhesive tape to retain gav

J. Test for correct position of the catheter in the

stomach(

J.

a."n4ect >-3 m8 air, via the catheter, into stomach.

*t the same time, listen for the typical growling

stomach sound with a stethoscope placed overthe epigastric region.

a.*ids in ensuring proper location of cathe

b

.

*spirate in4ected air from the stomach. b.This prevents abdominal distention.

c.*spirate small amount of stomach content.*spirate could be tested for acidity.

c.Failure to obtain aspirate does not indicatmay not be any stomach content or the ca

with the fluid.d.

5bserve and gently palpate the abdomen for thetip of the catheter. *void inserting the catheter

into the infant$s trachea. 0*n infant$s anatomy

makes it relatively difficult to enter the tracheabecause the esophagus is behind the trachea.1

d."f improper placement occurs and the catpatient may cough, fight, and become cya

immediately and allow the patient to rest

tube again.

e.Further secure the tube to the patient$s cheek by

using tape or 5psite. *void using paper tape,

which loosens if eposed to secretions orformula.

e.*dhesive should not loosen easily and sh

may be eposed to secretions.

. The feeding position should be right side lying,

with head and chest slightly elevated. *ttach thereservoir to catheter and fill with feeding fluid.

'ncourage the infant to suck on a pacifier during

feeding. +old the infant when possible.

. This position allows the flow of fluid to be

the pacifier will rela the infant, allowing fas provide for normal sucking needs. 2ucki

and provide a positive association between

I. *spirate the tube before feeding begins to assess

for residual contents and to remove any air.

I. This is done to monitor for appropriate flui

overfeeding that can cause distention. ;otif

large residual. !ocument any residual amoa."f over one-half of the previous feeding is

obtained by aspiration, withhold the net


42/67

feeding. !o not return aspirate to the stomach.

;otify the health care provider of the large

residual volume.b

.

"f a small residual of formula is obtained, return

it to the stomach and subtract that amount from

the total amount of formula to be given.!ocument any residual contents.

D

.

The flow of the feeding should be slow. !o not

apply pressure. 'levate the reservoir E- inches03-AD cm1 above the patient$s head.

D

.

The rate of flow is controlled by the size of

smaller the size, the slower the flow. "f the pressure of the fluid itself increases the rate

a.Feedings given too rapidly may interfere with

peristalsis, causing abdominal distention,

regurgitation and, possibly, emesis.

a.The presence of food in the stomach stim

digestive process to begin. *lso, when th

incompetence of the esophageal-cardiac sregurgitation.b

.

Feeding time should last approimately as long

as when a corresponding amount is given by

nipple, 3 m8)3-D minutes or 3-AD minutes total

time.

.


43/67

tolerated feeding, and activity before, during, and

after feeding.

Gastrosto$( Feedi#%

See Proced&re G&ideli#es %astrostomy feeding is a means of providing nourishment and fluids by way of a

tube that is surgically inserted through an incision made through the abdominal

wall into the stomach. "t is the method of choice for those re6uiring tube feedingsfor an etended period of time 0usually longer than ? to E months1.

%astrostomy feedings provide a safe method of feeding a hypotonic or debilitated

patient or one who cannot tolerate alternative methods. 2pecific indications mayinclude duodenal atresia, tracheoesophageal fistula, omphalocele, and neurologic

in4ury. %astrostomy feedings may provide a route that allows ade6uate calorie or

fluid intake in a child with chronic lung disease or in one who does not have

continuity of the %" tract, such as in esophageal atresia, chronic reflu, or

aspiration processes. %astrostomy tubes can also allow better decompression of the stomach 0because

of the large tube size1 after a surgical procedure.


Gastrosto$( Feedi#%

E=IPMEN


44/67

b.Measure volume.

c. &esidual fluid may be returned to

stomach or discarded, depending on theamount.

d.*ssess the skin around the tube for

ecoriation and signs and symptoms ofinfection.

>

.

* H-tube that is connected at the point

where reservoir and gastrostomy tube 4oinmay be used during feeding.

>

.

To provide simultaneous decompression

during feeding.

?

.

- ounce ND->D

m8O1 if the tube is to be clamped. *pply

clamp before water level reaches end ofreservoir.

a. This rinses tubing and will prevent

clogging.

b.8eave tube unclamped and open to

continuous elevation.

b.Feeding fluid is allowed to return to the

reservoir if the infant cries or changesposition, and thus decreases pressure in

the stomach.

E

.

Commonly, when oral feedings are

started, they are given simultaneously with

E

.

This allows the infant to learn or

reestablish the sucking-swallowing process


45/67


46/67

o #rocedure to follow if the tube falls out=cover site with sterile gauze

dressing, and call health care provider or proceed to emergency room.

o Troubleshooting for nonfunctioning e6uipment=ensure that the pump is

plugged in and turned on, tubing is unclamped, not kinked abdomen is not

distended.

o #roper phone numbers available to have as a resource or to obtainassistance.

#erform regular home visits to assess nutritional and hydration status of the child,

check tube placement and stoma site, and modify the care plan as needed.


Nasoeal a#d Nasod&ode#al Feedi#%s

E=IPMEN

2terile radiopa6ue silicone or polyvinyl naso4e4unal 0;K1 or nasoduodenal 0;!1

tube, >I inches 0 m1 0appropriate size for child1 may have weighted tip

Tape p+ paper or p+ probe

&eservoir 0syringe or bag1 for feeding

#ossibly, an infusion pump

Three-way stopcock

2yringe=D.3 m8 normal saline solution or sterile water

'6uipment for nasogastric 0;%1 tube insertion introducer catheter

Cardiac monitoring e6uipment


Preparator( phase

.

*pply cardiac monitoring leads.

.

To allow for continuous monitoring of

heart rate and rhythm. The vagus nerve

pathway lies from the medulla throughthe neck and thora to the abdomen.

*bove the stomach, the left and right

branches unite to form the esophagealpleus. 2timulation of these nerve

branches with the catheter will directly

affect the cardiac and pulmonary pleus.

A

.

Tube is generally inserted by a health care

provider 0with or without fluoroscopy1.

A

.

a. Measure from glabella 0prominent point

between eyebrows1 to the heel forestimated length.

b.Measure and mark the remaining length

of tubing and record.

b.This serves as a double-check to ensure

that the tube has not advanced fartherthan intended.

> #lace patient on right side with his hips > Facilitates passage of the tube. &estraints


47/67

. slightly elevated. %entle restraint or soft

mittens may have to be applied.

. prevent the infant from pulling out the

tube before the tip passes the pylorus. !o

not place on left side.?

.

The tube is inserted by threading the ;K or

;! vinyl catheter into a ;o. D French

feeding catheter and introducing boththrough the nostril into the stomach. The

feeding tube is then withdrawn, and the ;!

or ;K feeding tube is allowed to advancethrough the pylorus.

?

.

5ral insertion may cause increased

salivation, air swallowing, and

regurgitation. The ;% tube acts as anintroduction catheter and may not be

needed because ;! or ;K catheters come

with an internal guidewire to aid inplacement.

3

.

*void inserting the tube into the patient$s

trachea.

3

.

"f improper placement occurs and the

catheter enters the trachea, the patient

may cough, fight, and become cyanotic.&emove the catheter immediately and

allow the patient to rest before attempting

to insert the tube again.

E. Check intestinal aspirate for p+ every -Ahours. The infant may be positioned on

right side, back, or abdomen.


48/67

I

.

Medications may be given by way of ;!

and ;K tubes if prescribed. * three-way

stopcock will have to be placed at theconnection of the ;K tube and the line from

the feeding fluid. *lternative method for

administering oral medications is bypassing an oral-gastric or ;% feeding tube

in this way, the stomach and process of

digestion and absorption are not bypassed.

I

.

Flush tubing with small amounts of

normal saline solution or sterile water

after medication is administered to ensurethat the infant receives entire dosage

prescribed, to prevent any sediment from

remaining in the tubing, and to preventtube clogging. #ills should be crushed

finely.

Perfor$a#ce phase

.

;K feedings are generally given by

continuous slow drip.

.

Commonly preferred method to minimize

the satiety-hunger cycle and large-

volume instillation.A

.

The setup used is similar to the pediatric

".:. infusion using an infusion pump and

small 0DD-A3D m81 closed chamber for

reservoir.

A

.

a. &eservoir chamber and tubing should be

changed every -A? hours.

a. To prevent growth of bacteria.

b.&ecord input every hour. Fill reservoir as

needed, with no more than ? hours worth

of feeding fluid.

b.To ensure a constant flow and

minimize overinfusion directly into the

4e4unum or duodenum.>

.

Feeding is given at room temperature.

*void cold fluid, which may cause infant

discomfort. "f breast milk is used, gently

knead the reservoir periodically to misettled-out fat content.

Follo,-&p phase

.

7e constantly alert for mechanicalproblems(

.

Tube clogging due to inade6uate rinsing.Tube advancing too far into 4e4unum

check protruding tube measurement.

Fluid overload, causing aspiration.

a. Check for abdominal distention resulting

from the patient$s inability to handleingested amount of fluid by(

P#alpating abdomen.

P5bserving for ripple of intestines.

PMeasuring abdominal girth every >-hours.

PChecking residual formula in the

stomach every >- hours. P!iscarding or refeeding residual

formula as prescribed.

b.Check stools for occult blood and bloodglucose as ordered to determine tolerance

of feeding fluid.

c. Check emesis and stools for gross blood

and report to physician immediately=


49/67

may be a sign of necrotizing

enterocolitis.

A.

#osition the patient in recumbent position. A.

8ess likely for dumping syndrome tooccur.

>

.

5bserve the patient closely to avoid

potential dangers as the tube passes thepylorus.

>

.

!iarrhea as the tube passes through the

pylorus, it becomes stiff because of thechange in p+. * stiff tube has been

reported to cause intestinal perforation. "f

tube becomes clogged or dislodged, itmust be removed.

a. Close attention to amount, type,

concentration, and osmolality of feedingfluid is stressed.

b.Check heart rate and blood pressure.

?

.

+old, fondle, and give positive stimulation

to the patient, if conditions permit.

?

.

This procedure limits the normal

pleasures associated with feeding. Thepatient needs attention to oromotor needs.3

.

*ccurately document condition of the

patient and the procedure, including type

and amount of feeding given, amount of

residual and characteristics, and any signsof impending patient distress or problems.

;aso4e4unal 0;K1 or nasoduodenal 0;!1 feedings are means of providing full

enteral feedings by way of a catheter passed through the nares, past the pharyn,

down the esophagus, through the stomach, through the pylorus into the duodenum

or 4e4unum.

!uodenal or 4e4unal feedings may decrease the risk of aspiration and can

minimize regurgitation and gastric distention because the feeding bypasses the

stomach and pylorus.

;! and ;K feedings provide a route that allows for ade6uate calorie or fluid

intake 0a full enteral feeding1 by way of continuous drip.

;! or ;K feedings may also provide a route for administration of enteralmedications.

;! or ;K feedings can provide a method of feeding that re6uires minimal patient

effort when the child or infant is unable to tolerate alternative feeding methods

0low birth weight, increased respiratory effort, intubated patient1.

FL=I! AN! ELECR0LYE "ALANCE

"asic Pri#ciples

"nfants and small children have different proportions of body water and body fat

than adults.

"od( Fl&ids E/pressed as Perce#ta%e of "od( >ei%htFL=I! A!=L

Male 4O6Fe$ale 4O6I#fa#t 4O6Total body fluidsED 3? J3

"ntracellular ?D >E ?D

'tracellular AD >3

o The body water of a neonate is approimately DB of body weight

compared with that of an average adult man, which is approimately EDB.


50/67

o The normal neonate demonstrates a rapid physiologic decline in the ratio

of body weight to body water during the immediate postpartum period.

o #roportion of body water declines more slowly throughout infancy and

reaches the characteristic value for adults by about age A.

Co$pared ,ith ad&lts) a %reater perce#ta%e of the od( ,ater of i#fa#ts a#d

s$all childre# is co#tai#ed i# the e/tracell&lar co$part$e#t*o "nfants=approimately one-half of the body water is etracellular.

o *dults=approimately one-third of the body water is etracellular.

Co$pared ,ith ad&lts) the ,ater t&r#o'er rate per it of od( ,ei%ht is

three or $ore ti$es %reater i# i#fa#ts a#d s$all childre#*

o The child has more body surface in relation to weight.

o The immaturity of kidney function in infants may impair their ability to

conserve water.

'lectrolyte balance depends on fluid balance and cardiovascular, renal, adrenal,

pituitary, parathyroid, and pulmonary regulatory mechanism.

Co$$o# A#or$alities of Fl&id a#d Electrol(te Metaolis$

S="SANCEAN!

MAK0R

F=NCI0N

A"N0RMALIYCA=SE CLINICALMANIFESAI0N

LA"0RA!AA

>ater

Medium ofbody fluids,

chemical

changes, bodytemperature,

lubricant

:olume deficit o #rimary=

inade6uate water

intake

o 2econdary

=loss following

vomiting, diarrhea,

and %" obstruction

5liguria, weightloss, signs of

dehydration

including dry skinand mucous

membranes,

lassitude, sunkenfontanelles, lack of

tear formation,

increased pulse rate,

decreased bloodpressure

Concentraazotemia,

hematocr

hemogloband eryth

:olume ecess o Failure to

ecrete water in thepresence of normal

intake such as in

cardiac disease or

failure or renaldisease

o


51/67

rhythm,

muscle and

nerveirritability

diarrhea, prolonged

cortisone,

corticotropin ordiuretic therapy,

diabetic acidosis

o

2hift ofpotassium into the

cells such as occurs

with the healingphase of burns,

recovery from

diabetic acidosis

irritability,

abdominal distention

and, eventually,cardiac arrhythmias

normal in

situations

hypochloralkalosis

changes

#otassium ecess o 'cessive

administration of

potassium-

containing

solutions, ecessiverelease of potassium

due to burns, severekidney disease,

adrenal

insufficiency

:ariable, including

listlessness,

confusion, heaviness

of the legs, nausea,

diarrhea, 'C%changes and,

ultimately, paralysisand cardiac arrest

'levated

plasma le

Sodi&$

5smotic

pressure,muscle and

nerve

irritability

2odium deficit o


52/67

shock or cardiac

failure producing

tissue anoia

respiration flushed,

warm skin

weaknessdisorientation

progressive to coma

AD

o

p+

#rimarybicarbonate ecesso

8oss ofchloride through

vomiting, gastric

suction, or the useof ecessive

diuretics ecessive

ingestion of alkali

!epressedrespiration, muscle

hypertonicity,

hyperactiv

care of the sick or hospitalized child

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