Chapter 21: Examples of common procedures in a hospitalized child

Question 1

Preparing an Infant for a Procedure

Answer 1

• describe procedure to the parents; what will happen and how long it will take
• encourage parents to stop you at any point if there is a question
• remind parents infants often cry for reasons other than discomfort but be honest about any discomfort the infant may experience with the procedure
• identify what restraints may be used and give an explanation as to why they are needed
• allow parents to decide whether they would like to be present for the procedure; may leave the room and come back immediately following the procedure

Question 2

Preparing a Toddler for a Procedure

Answer 2

• describe the procedure to the parents; what will happen, and how long it will take
• use play to demonstrate the procedure to the Toddler; encourage to demonstrate or practice on a doll or teddy bear
• use simple, concrete language to describe the procedure and how it might feel
• limit preparation to 5 to 10 minutes b/c of short attention span a toddler might have
• identify what restraints may be used and explain why they are needed
• allow parents to decide if they wanna be preset in the room for procedure; allow parents to stroke their child or speak soothingly to their child if remains in the room

Question 3

Preparing a Preschooler for a Procedure

Answer 3

• explain procedure in terminology the child can understand
• begin preparation immediately prior to the procedure so the child will not worry for hours or days
• use play to demonstrate the procedure; encourage to practice on a doll or teddy bear
• set limits for the child so they are aware of expectations: ex: tell her she can scream as much as she wants but must hold very still
• give legitimate choices whenever possible
• allow parents to choose whether to be present for the procedure; allow parents to stroke their child’s head or speak soothingly to child if they remain in the room
• use distraction techniques such as deep breathing, singing, or squeezing parent’s or nurse’s hand

Question 4

Preparing a School-age Child for a Procedure

Answer 4

• explain the procedure in terminology that the child can understand
• children in this stage have a good concept of time, so preparation can begin in advance of the procedure
• for the younger school-aged child, use play to demonstrate the procedure; have the child demonstrate on and practice positioning with doll or teddy bear
• allow child to touch and explore equipment to be used in the procedure
• involve the child in simple tasks during the procedure when possible
• set limits for the child so they are aware of expectations; ex: tell her she can yell and scream as much as she wants but must hold very still
• give legitimate choices to the child
• allow parents and the child to decide together whether parents will be present for the procedure; some school-age children may be modest about exposing body parts in front of family members
• allow parents to stroke their child or speak smoothly to their child if they remain in the room
• teach techniques such as deep breathing, counting, reciting a silly rhyme, or anything else that might help distract and relax the child during the procedure

Question 5

Preparing an Adolescent for a Procedure

Answer 5

• describe the procedure, explaining exactly what will happen and how long it will take
• encourage adolescent to stop you at any point if they have a question
• be honest
• describe potential risks and pain associated with the procedure, but don’t dwell on it
• allow adolescent to take as active as a role as possible in the procedure
• practicing positioning or demonstrating the equipment prior to the procedure helps give the adolescent a sense of control
• provide a peer video of procedure if possible
• if possible, allow to make choices as to when the procedure should take place
• allow adolescent option if they want the parent present
• offer tips for distraction such as deep breathing, relaxation, counting, or squeezing an object or parent’s hand

Question 6

Critical Nursing Action: Before a Procedure

Answer 6

1. think through the procedure in advance and anticipate problems
2. gather all equipment and check to make sure it functions properly
3. establish trust by getting to know the child first
4. through the use of play, allow the child to “perform” the procedure on her doll, teddy bear, or other appropriate surrogate
5. offer a coping strategy such as guided imagery or relaxation breathing
6. give the child realistic choices
7. be sure informed consent is signed
8. wash hands
9. let the child know it is “ok” to cry

Question 7

Critical Nursing Action: During a Procedure

Answer 7

• whenever possible, schedule all treatments away from the child’s bed or “safe area”
• expect the child to do well
• talk to the child; ask how he is doing
• keep child informed of the progress of the procedure
• use distraction techniques such as pop-up picture books, bubbles, “shutting off the pain switch”, or other techniques that have been practiced before the procedure
• when appropriate, give the child some control by allowing him to make some of the decisions
• involve the parent to provide comfort to the child, if the parent is able; sometimes a parent’s presence at the procedure may not be beneficial for the child

Question 8

Critical Nursing Action: After a Procedure

Answer 8

• praise the child for completing the procedure
• provide an opportunity for the child to verbalize feelings
• if the parents were not involved in the procedure, comment on a positive aspect involving the child during the procedure; ex: “Jill was able to help out and keep still when she was asked to do so! she did a great job!”
• give a reward (e.g. stickers, small toy, or previously agreed-on reward negotiated with parents)
• document the child’s response to the procedure and outcomes

Question 9

Distraction kit

Answer 9

set of materials that help divert the child’s attention to a more pleasant experience than the painful experience

• appropriate for any age
• use before, during, and after procedure
• can also suggest holding someone’s hand really tight, say “ouch” really loud, count to 10 or count backwards, sing a song, or pretend to be somewhere else

Question 10

The environment

Answer 10

• use designated treatment rooms
• child’s inpatient room should be kept as a “safe” area whenever possible
• optimal lighting for a procedure should be bright and focused on safety but otherwise without glare

Question 11

Preparing the Parent

Answer 11

• relieve parental anxiety so they can help prepare and reassure the child or youth
• provide an explanation of what they will see and hear
• use simple explanations that are developmentally appropriate to explain how, why, where, and when

Question 12

Using Developmentally Appropriate Words

Answer 12

• for children beginning language skills: simple terms that are familiar such as “go potty”, “owie”, and “boo-boo”
• for concrete thinker who takes what is said literally: Do Not use words that may frighten the child (eg. “dye in your vein”, “shot in the arm”, :cut out the tonsils”, and “take your temperature”; USE “special medicine in your vein”, “special medicine in your arm”, “make your tonsils better”, and “check to see if your temperature is working”
• for all children, be honest and they will learn to trust you

Question 13

Informed Consent

Answer 13

involves providing the patient with the necessary knowledge to make a decision regarding health care
-implies that the person understands the benefits and risks of treatment or the refusal of treatment
-person must be legally able to give consent by virtue of his age; legal age is 18; exception is made for an adolescent younger than 18 that is married, parent, self-supporting, or member of military
-most children, legal or parent guardian is the person who gives consent for care
>required before diagnostic procedures, medical treatments, or surgical procedures; also for immunizations, or any treatment with inherent risks

Question 14

Legal Alert: Informed Consent

Answer 14

• must be obtained before a procedure is performed
• physician’s responsibility to explain the procedure and the risks and benefits of treatment
• alternatives to the prescribed treatment should be discussed
• it is a legal document denoting that the emancipated minor or parent understands the nature of the procedure, risks, and benefits
• nurse serves as a witness to the signature

Question 15

Common Procedures

Answer 15

• IV lines
• Peripheral IV lines
• Central Venous Access
• Peripherally Inserted Central Catheter
• Vascular Access Port
• Measuring Intake and Output
• X-ray Exams
• Specimen Collection
• Enteral Tube Feedings
• Orogastric and Nasogastric Feedings Tubes
• Gastrostomy Feedings Tubes
• Ostomies

Question 16

IV Lines

Answer 16

• in the hospital, children may require IV therapy for:
• fluid maintenance or replacement
• before diagnostic testing
• blood product replacement
• medication administration or
• postoperatively

Question 17

Peripheral IV Lines

Answer 17

-a peripheral line with a normal saline lock is used to keep the vein open for the possibility of future IV therapy, or for the child who requires intermittent medication administration
>the tubing is capped at the end with an injection cap that allows for multiple punctures; once the medication is disconnected from this tubing and the line flushed, the child can ambulate unencumbered by the IV pole and tubing
-follow hospital’s protocol for flushing the peripheral intermittent infusion device
-the normal saline lock is secured to prevent accidental dislodgement
-for younger child who has a normal saline lock inserted in the dorsum of the hand, a cover with cling wrap may be necessary to prevent the child from manipulating or pulling out the normal saline lock

Question 18

Central Venous Access

Answer 18

• for long-term IV access
• the IV catheter is inserted into a large vein (vena cava, subclavian, jugular, or femoral vein)
• Broviac, Hickman, and Groshong catheters are used for access
• catheters are multi-lumen and accommodate more than one IV therapy
• after insertion, chest x-ray to confirm proper positioning
• with this device, child is not subjected to multiple IV “sticks”
• easily accessed for medication and fluid administration; also blood draws

Question 19

Peripherally Inserted Central Catheter (PICC)

Answer 19

• can be left in place up to 4 months
• inserted above the antecubital fossa into the median, cephalic, or basilic vein and threaded into the superior vena cava
• used for long-term antibiotic and analgesic therapy
• may also be threaded into the head of the clavicle; considered a midline placement and often used for antibiotic therapy
• hospitals protocol for PICC line flushing and dressing changes

Question 20

Vascular Access Port

Answer 20

-central venous access device that is implanted under the skin and used for long-term fluid or medication administration
-the Infuse A-Port/Port-A-Cath is not visible and no dressing is required; child may be restricted from contact sports but can swim or shower without restrictions
>to access the device, the nurse palpates for placement, cleanses the area, and uses the Huber needle to puncture the port’s central diaphragm

Question 21

Risk of Infection

Answer 21

with any area in which the skin barrier is compromised, adhere to sterile techniques for dressing changes over IV sites and to monitor for signs and symptoms of infection (change in temperature, erythema, edema, or pain at the IV site and tenderness on palpation)

Question 22

Measuring Intake and Output

Answer 22

-especially those with vomiting, diarrhea, fever, nasogastric suctioning, draining wounds, and burns; pre-surgical patients; and children with cardiac, renal, or respiratory illness
-measures intake for breastfed infant by recording “breastfed” (or by weighing the infant before and after the feeding and recording the increase in weight as ounces or milliliters consumed) on the intake sheet
>for infants with congestive heart failure or respiratory illness like bronchiolitis, the nurse asks about the length of time the feeding took to complete; expending too much energy in feeding may be deleterious to the child’s health
-gavage feeding (feeding a patient via a feeding tube passed through the nose into the stomach) feedings may be necessary for the child in congestive heart failure
-IV fluids may be required for the child struggling to breathe with a dyspneic respiratory condition
>for the child who wears diapers, the diaper can be weighed before and after use to determine urinary output
-diapers weighed on a gram scale, and output is determined by subtracting the weight of the dry diaper from the weight of a wet one
-each gram is equal to about 1 milliliter

Question 23

Method used to measure normal urinary output

Answer 23

1 to 2 mL/kg per hour

Question 24

X-ray Exams

Answer 24

• for diagnostic purposes
• essential when checking for placement of a chest tube, central line, or feeding tube
• for the younger child, the nurse may be asked to help position the child for an optimal view
• lead apron is worn to protect against unnecessary exposure to radiation
• pregnant woman should not assist b/c fetal tissue is sensitive to damage by x-rays

Question 25

Specimen Collection: Urine Sample

Answer 25

-to collect, may require catheterization or a clean-catch
>Catheterization: using sterile technique, can be traumatic experience, distracting techniques can be helpful in decreasing anxiety and fear, a lubricant with 2% lidocaine is used to eliminate discomfort
>Clean-catch: nurse places a urine collection bag around the perineal area after cleaning the perineum and surrounding skin; the infant is diapered and the bag is monitored for urinary output; urine must be removed from the bag and sent to the lab within 30 minutes of voiding

Question 26

Specimen Collection: Stool Sample

Answer 26

-for ova and parasites (O&P) to determine the causative agent for a diarrheal condition, or to check the presence of occult blood
-if potty trained, he can use the potty chair or the toilet with a collection hat under the seat
-if not potty-trained, stool from diaper is collected
>samples transferred into a collection cup using tongue blades
>O&P samples sent to the lab ASAP
-when lab services not available 24 hours a day, sample should be refrigerated ASAP

Question 27

Specimen Collection: Blood Sample

Answer 27

• can be traumatic event
• preparation and support
• distraction techniques prior to the venipuncture
• application of EMLA cream, a topical analgesia containing lidocaine and prilocaine, anesthetizes the skin before any painful procedure; cream is applied to the site, covered with a transparent dressing for 1 hour, and removed prior to the venipuncture

Question 28

Specimen Collection: Throat Culture

Answer 28

rapid strep test or a throat culture can be used to diagnose group A streptococci as the cause of sore throat; if positive, antibiotic is prescribed; if negative, a culture to grow the bacteria done to confirm the results

• throat culture more accurate than a rapid strep test, but may take several days to obtain results
• most children don’t tolerate throat cultures well; helpful to place the child on the parent’s lap facing forward and have the parent place one arm across the child’s chest and over his arms, and one hand on the child’s forehead
• nurse uses tongue blade to push tongue downward and swabs the posterior pharynx with two sterile cotton-tipped applicators

Question 29

Throat examinations: Epiglottitis

Answer 29

-throat examinations and cultures should NOT be performed one a child who has suddenly developed a high fever, is drooling, has severe sore throat, hoarseness, stridor, and sits in a tripod position
>this history indicates the possibility of epiglottitis
-eliciting the gag reflex, as happens with a throat culture, may cause the inflamed epiglottis to completely obstruct the airway

Question 30

Calculation of Daily Fluid Requirements

Answer 30

0-10 kg = 1000
11-20 kg= 50
>20 kg 20
ex: 50 kg
10          x             100 =1000
10          x             50= 500
30          x              20= 600
(this is 50kg)        (add this up to equal daily fluid requirement in 24 hours)

Question 31

Specimen Collection: Cerebrospinal Fluid

Answer 31

-lumbar puncture (LP) rules out sepsis or meningitis
-also be scheduled for children undergoing treatment for cancer
>prepares child for LP by telling the family and child for the reason for the procedure and teaching distraction methods to the child
>practice positioning with the child
>an hour before, EMLA cream can be applied at the designated site; makes less painful
>with the LP, a needle is inserted into the subarachnoid space at the level of L4 or L5 to withdraw cerebrospinal fluid (CSF) for analysis
>infant seated upright with head bent forward
>older child: must lie on his side with the head flexed, hips and knees flexed, and the back arched while being firmly held to make sure not to move
-CSF samples sent for culture, glucose, red blood cells, and protein
>After LP: vital signs taken, lay flat for 1 hour and drink fluids, may complain of headache or pain at the site, frequent neurological assessment to note changes in status
-complications such as nerve trauma, infection, bleeding, or pressure effects are rare

Question 32

Enteral Tube Feedings

Answer 32

when a child is unable to take adequate nutrition by mouth, an alternate feeding method is used to maintain and promote growth in the child
-nourished by oro- or nasogastric feeding tube or a gastrostomy tube
-feedings may be administered as a bolus or a continuous infusion
>bolus given relatively at the same rate as an oral feeding method to deliver formula in children who cannot tolerate oral feedings
>as continuous, placed on a feeding pump and regulated to be administered over a predetermined number of hours
-continuous often preferred with serious heart defects to decrease the workload of the heart while providing enteral nutrition
-to allow underweight infants or children to gain weight, a continuous feeding may be given during hours of sleep to boost calorie intake without interfering with a normal daily feeding/eating schedule

Question 33

Orogastric and Nasogastric Feeding Tubes

Answer 33

-for newborn infants requiring gavage feedings (a feeding done using a tube that is passed through the nares and into the stomach; food in liquid form, usually room temperature), the orogastric route is preferred because newborns are obligate nose breathers
>tube is inserted and then removed at the end of the bolus feed
>if the tube is to be left in place, the nasogastric route should be considered; nasogastric are preferred over total parenteral nutrition b/c they preserve the stomach’s mucosa, allow the digestive process to continue, and are cost-effective

Question 34

Psychosocial needs of the infant receiving gavage feedings

Answer 34

• the time taken to administer a gavage feeding can be used in the same way as in a regular feeding
• place infant comfortably in the mother’s arms with the head elevated
• provide infant with a pacifier to help stimulate an actual feeding
• non-nutritive sucking has been shown to increase weight gain and decrease crying and to allow for the normal muscular development of the mouth and tongue

Question 35

How to Administer a bolus feeding

Answer 35

once the placement of the tube is confirmed and the child is in position the nurse administers a bolus feeding of room-temperature formula via gravity through an appropriate sized syringe attached to the feeding tube

• the formula-filled syringe is held less than 12 inches above the infant
• when the feeding is complete, the tubing is flushed with tap water to prevent clogging of the lumen, the syringe is removed, and the feeding port is capped
• to decrease the chance of regurgitation, the infant is burped after the bolus is infused
• follow protocol for nasogastric gavage feedings
• the amount of water to flush should be only the amount required to successfully flush the length of tubing; excess may result in overfeeding

Question 36

Gastrostomy Feeding Tubes

Answer 36

when a child require enteral tube feedings over a longer period of time, such as those with oral feeding aversions or neurological dysfunction, a gastrostomy tube (GT) is an alternative to the nasogastric tube
-GT inserted through the abdominal wall into the stomach
-GT secured internally and externally with a variety of bumpers depending on the manufacturer
>after initial insertion, GT is left open to gravity drainage for 12 to 24 hours and the wound site observed for signs of infection
-stoma care and assessment important b/c of potential for leakage of gastric secretions onto the periostomal skin
>mark the tube with indelible ink to make it easy to observe for migration; must report vomiting, abdominal distention, or evidence of bile drainage or aspirate

Question 37

Ostomies

Answer 37

surgical opening from either the small or large bowel to the surface of the abdomen to allow for fecal elimination

• may be needed in cases from trauma, obstruction, disease, and infection
• may be needed temporarily to allow bowel sufficient time to heal
• may be needed permanently when the child’s condition does not allow for ostomy reversal

Question 38

Ostomy Care: Infants and Toddlers

Answer 38

• parents assumes all responsibility for the care
• nurse assists parents by clarifying misconceptions, addressing concerns about caring for the child with an ostomy, and providing teaching guidelines regarding ostomy care
• if child unable or unwilling to verbalize his feelings, the nurse may attempt to engage the child through the use of play or art by bringing crayons and paper to the child’s room and giving the child time to process the current events in his life; child may be able to express himself through art or play more readily than through words
• child-life specialist can help
• refer to support groups

Question 39

Ostomy Care: School-aged

Answer 39

• needs to learn all aspects of ostomy care, including removal and reapplication of the ostomy appliance and periostomal skin care
• must be aware of the signs and symptoms of potential complications to report to the school nurse or parents

Question 40

Ostomy Care: Adolescents

Answer 40

-nurses and parents must be aware of the special needs of all adolescents (peer group and self-acceptance, sexuality, and depression) and how those needs may be further affected in the presence of an ostomy