Procedures and Treatments

1
Procedures and Treatments

• Chapter 5

2
Nurses Role

• The nurse is responsible for following facility
  policies and ensuring patient safety before,
  during, and after all procedures and treatments.

3
Preparation

• The emotional support and information that the
  nurse offers often help to decrease anxiety for
  the child and family.

4
Psychological or Emotional Support

• It is important for the nurse to explain the
  procedure and purpose of the procedure or
  treatment to the caregiver.
• When the caregivers anxiety and concerns
  decrease, the child in turn often will have less
  anxiety.

5
Psychological or Emotional Support

• The child who is old enough to understand the
  procedure must have the procedure explained and
  be encouraged to ask questions and should be
  given complete answers.

6
Psychological or Emotional Support

• Infants can be soothed and comforted before and
  after the procedure.
• Children should always be listened to and have
  their questions answered.

7
Psychological or Emotional Support

• Take charge in a kind, firm manner that tells
  them the decision is not in their hands.
• Nurses have conflicting feelings about the merit
  of giving some reward after a treatment.

8
Legal Safety Factors

• Orders should be clarified when needed.
• The child must always be identified by checking
  the ID band and the child or caregiver state the
  childs name.

9
Legal Safety Factors

• If consent is needed, the form is completed,
  signed, and witnessed.
• The procedure is discussed with the child and
  family caregiver, and questions are answered.

10
Legal Safety Factors

• Wash hands before and after any procedure.
• The nurse gathers supplies and equipment and
  review the steps for beginning the procedure.
• Safety for the child is priority.
• Standard precautions are followed.

11
Follow-Up for Procedures

• When the procedure is completed, the child is
  left in a safe position with siderails raised and
  bed lowered.
• For the older child, the call light is put within
  reach.
• Comforting and reassuring the child is important.

12
Follow-Up for Procedures

• Concerns or questions are discussed.
• Specimens are labeled with the patients name,
  identifying information, and the type of specimen
  in the container.
• Facility policies are followed.

13
Follow-Up for Procedures

• Documentation includes the procedure, the childs
  response, and the description and characteristics
  of any specimen obtained.

14
Performing Procedures R/T Position

• Safety is the nurses most important
  responsibility when performing procedures related
  to positioning a child.
• Comfort must be a priority when using restraints
  or transporting.

15
Restraints

• Restraints should never be used as a form of
  punishment.
• When possible, restraining by hand is the best
  method.

16
Restraints

• However, mechanical restraints must be used to
  secure a child during IV infusions, to protect a
  surgical site from injury such as cleft lip and
  cleft palate, or when restraint by hand is
  impractical.

17
Restraints

• Close and conscientious observation is a
  necessary part of nursing care.
• Be alert to family concerns when the child is in
  restraints.
• Explanations will help the family understand and
  be cooperative.

18
Mummy Restraints

• Mummy restraints are used for an infant or small
  child. Fig. 5-2 on pg 85.
• This device is a snug wrap that is effective when
  performing a scalp venipuncture, inserting a
  nasogastric tube, or performing other procedures
  that involve only the head or neck.

19
Mummy Restraints

• Papoose boards are used with toddlers or
  preschoolers.

20
Clove Hitch Restraints

• Clove hitch restraints are used to secure an arm
  or leg, most often when a child is receiving an
  IV infusion.
• Made of soft cloth formed in a figure 8.
• Checked and loosened at least every 2 hours.

21
Clove Hitch Restraints

• This restraint should be secured to the lower
  part of the crib or bed, not to the side rail, to
  avoid possible injury when the siderail is raised
  or lowered.

22
Elbow Restraints

• Elbow restraints are made of muslin in two
  layers.
• Pockets wide enough to hold tongue depressors are
  placed vertically in the width of the fabric.

23
Elbow Restraints

• It is wrapped around the childs arm and tied
  securely to prevent the child from bending the
  elbow.
• Must fit the child properly
• Should not be too high under the axillae.
• The may be pinned to the childs shirt to keep
  them from slipping.

24
Jacket Restraints

• Jacket restraints are used to secure the child
  from climbing out of the bed or a chair or to
  keep the child in a horizontal position.
• Must be the correct size.
• Should be checked frequently to prevent slipping
  and choking on the neck of the jacket.

25
Jacket Restraints

• Ties must be secure to the bed frame, not the
  sides, so the jacket is not pulled when the side
  are moved up and down.

26
Transporting

• Safety is the biggest concern.
• Carry the infant or place him or her in a crib or
  bassinet.
• Often in pediatric settingswagons are used for
  transport..

27
Transporting

• The toddler may be transported in a crib.
• Strollers or wheelchairs are used when the child
  is able to sit.
• Older children are placed on stretchers or in
  their beds.

28
Transporting

• A child who is in traction, which cannot be
  removed, can go to the playroom or other areas in
  the hospital in this manner.

29
Holding

• When a child is held, it is most important to be
  sure the child is safe and feels secure.
• Most common methods are the horizontal, upright
  position and the football hold.
• When holding an infant, always support the head
  and back.
• Fig. 5-3 pg. 86.

30
Sleeping

• Infants should be positioned on their backs or
  supported on their sides for sleeping, which has
  decreased the incidence of crib death of SIDS.
• The nurse teaches and reinforces this
  information.

31
Performing Procedures R/T Elevated Body Temp.

• Normal body temperature varies from 97.6º F
  (36.4 º C) orally to 100.3º F (37.9º C) rectally.
• Should be maintained below 101º F (38.3º C)
  orally or 102º F ( 38.9º C) rectally, although
  the health facility or practitioner may set lower
  limits.

32
Performing Procedures R/T Elevated Body Temp.

• Methods used to reduce fever include maintaining
  hydration, administering acetaminophen.
• Ineffectiveness in reducing fever and the
  discomfort they cause, tepid sponge baths are no
  longer recommended for reducing fever.

33
Performing Procedures R/T Elevated Body Temp.

• See Family Teaching Tips on Reducing Fever on pg.
  87.

34
Control of Environmental Factors

• If a child begins to shiver, whatever is being
  used to lower the temperature should be stopped.
• Shivering indicates the child is chilling, which
  will cause the body temperature to increase.

35
Cooling Devices

• A hypothermia pad or blanket lowers or maintains
  the body temp.
• The childs temp. is monitored closely and
  checked frequently with a regular thermometer.

36
Cooling Devices

• The blanket is always covered before being placed
  next to the childs skin.
• The baseline and temperature measurements are
  documented as well as information regarding the
  childs response to the treatment.

37
Performing Procedures R/T Feeding Nutrition

• The nurse is responsible for accurately
  documenting both a childs intake and output.
• If unable to consume adequate amounts of fluid or
  foods, gavage or gastrostomy feedings are given
  to meet the nutrient needs and promote normal
  growth.

38
Intake and Output

• In a well child setting, the caregiver can
  provide information about the childs usual
  patterns or intake and output.
• With the ill or hospitalized child, more exact
  measurements of fluid intake and output are
  required.

39
Intake and Output

• These measurements are recorded as often as every
  hour, and a running total is kept to closely
  monitor the child.
• Oral fluids, feeding tube intake, IV fluids, and
  foods that become liquid at room temperature are
  all measured and recorded..

40
Intake and Output

• Urine, vomitus, diarrhea, gastric suctioning, and
  any other liquid drainage are measured and
  considered output.

41
Intake and Output

• To measure the output of an infant wearing a
  diaper, the wet diaper is weighed and the weight
  of the dry diaper is subtracted before the amount
  is recorded.

42
Gavage Feedings

• Gavage feedings provide nourishment directly
  through a tube passed into the stomach.
• If gavage feedings are not well tolerated, the
  nurse should report it and await alternate
  orders.

43
Gavage Feedings

• Whether the tube is inserted nasally or orally,
  the measurement is the same from the tip of the
  childs nose to the earlobe and down to the tip
  of the sternum (Fig. 5-6 pg. 88)

44
Gavage Feedings

• The length is marked on the tube with tape or a
  marking pen.
• The end of the tube to be inserted should be
  lubricated with sterile water or water-soluble
  lubricating jelly, never an oily substance
  because of the danger of oil aspiration into the
  lungs.

45
Gavage Feedings

• Elevate the head and place a rolled-up diaper
  behind the neck.
• Turn the head and align the body to the right.
• After inserting the tube, verify its position by
  aspirating stomach contents or be inserting 1 to
  5 mL of air and listening to the gurgling sounds.
  

46
Gavage Feedings

• If stomach contents are aspirated, these should
  be measured and replaced and, in a very small
  infant, subtracted from the amount ordered for
  that particular feeding.

47
Gavage Feedings

• If the tube is left in position, it should be
  secured to the infants nose using adhesive tape.
  (Fig. 5-8).
• The feeding syringe is inserted into the tube and
  the feeding, which has been warmed to room temp,
  is allowed to flow by gravity.

48
Gavage Feedings

• The entire feeding should take 15 to 20 minutes
  after which the infant must be burped and
  positioned on the right side for at least 1 hour
  to prevent regurgitation and aspiration.

49
Gavage Feedings

• The type and amount of contents aspirated by the
  nurse, the amount of formula fed, the infants
  tolerance for the procedure, and the positioning
  of the infant after completion should be recorded
  on the chart.

50
Gavage Feedings

• The feeding tube and any leftover formula should
  be discarded at the completion of the procedure.

51
Gastrostomy Feedings

• Children who must receive tube feedings over a
  long period may have a gastrostomy tube
  surgically inserted through the abdominal wall
  into the stomach under general anesthesia.
• (Fig. 5-9 pg. 89).

52
Gastrostomy Feedings

• Meticulous care of the wound site is necessary to
  prevent infection and irritation.
• Until healing is complete, the area must be
  covered with a sterile dressing.
• The child may need to be restrained to prevent
  pulling.

53
Gastrostomy Feedings

• The residual stomach contents are aspirated,
  measured, and replaced at the beginning of the
  procedure.
• Head and shoulders are elevated during the
  feeding.
• After each feeding, the child is placed on the
  right side or in Fowlers position.

54
Gastrostomy Feedings

• When regular oral feedings are resumed, the tube
  is surgically removed, and the opening usually
  closes spontaneously.

55
Oxygen Administration

• Oxygen administered by nasal cannula or prongs,
  mask, or via an oxygen hood.
• Oxygen tents may also be used to deliver oxygen.
• It is more difficult to maintain oxygen
  concentration in a tent because it is opened many
  times throughout the day.

56
Oxygen Administration

• Whatever equipment is used to administer oxygen,
  the procedure and equipment must be explained to
  the child and the caregiver.
• When oxygen is to be discontinued, it is done so
  gradually.

57
Oxygen Administration

• Equipment is checked frequently to ensure proper
  functioning, cleanliness, and correct oxygen
  content.
• Exposure to high concentrations of oxygen can be
  dangerous to small infants and children with
  other respiratory diseases.

58
Oxygen Administration

• The nurse teaches the family caregiver regarding
  oxygen administration, equipment, and safety
  measures.
• See Family Teaching Tips (O2 Safety) pg. 91 On
  your own!!!

59
Nasal/Oral Suctioning

• Excess secretions in the nose or mouth can
  obstruct the infant or childs airway and
  decrease respiratory function.
• Coughing often clears the airway.
• If unable, the nurse must remove secretions by
  suctioning.

60
Nasal/Oral Suctioning

• A bulb syringe is used to remove secretions from
  the nose and mouth (Fig. 5-11 pg. 91).
• Sterile normal saline drops may be used to loosen
  dried nasal secretions.

61
Tracheostomy

• A tracheostomy is a surgical procedure in which
  an opening is made into the trachea so that a
  child with a respiratory obstruction can breathe.
• The trach tube is suctioned to remove mucous and
  secretions and to the keep the airway patent.

62
Tracheostomy

• Must be cleaned often to decrease the possibility
  of infection.
• A tracheostomy collar or mist tent provides
  moisture and humidity.

63
Tracheostomy

• The tracheosotmy prevents the child from being
  able to cry or speak, so the nurse must closely
  monitor and find alternative methods of
  communicating with the child.

64
Performing Procedures R/T Circulation

• The nurse is responsible for applying the
  treatment, closely monitoring the effects of the
  treatment, and documenting those observations.

65
Heat Therapy

• Application of heat increases circulation by
  vasodilation and promotes muscle relaxation,
  thereby relieving pain and congestion.
• Speeds the formation and drainage of superficial
  abscesses.

66
Heat Therapy

• Closely monitored, and none should receive heat
  treatments longer than 20 minutes at a time
  unless specifically ordered by the provider.
• Moist heat produces faster results.
• Should not use the microwave because may unevenly
  heat the towels.

67
Heat Therapy

• Dry heat-- electric heating pad, and a K-pad,
  should be covered with a pillowcase before use on
  the child.
• Hot water bottles are not recommended due to
  injuries.

68
Heat Therapy

• Documentation includes the application type,
  start time, therapy duration, and the skin
  condition before and after the application.

69
Cold Therapy

• A provider must order the use of cold
  applications.
• May help prevent swelling, control hemorrhage,
  and provide an anesthetic effect.
• Intervals of about 20 minutes are recommended for
  both dry cold and moist cold treatments.

70
Cold Therapy

• Skin must be inspected before and after the cold
  application to detect skin redness or irritation.
• Documentation includes the application type,
  start time, therapy duration, and the skins
  condition before and after the application.

71
Enema

• Administer an enema as treatment for some
  disorders or before a diagnostic or surgical
  procedure.
• The procedure can be uncomfortable and
  threatening, so it is important for the nurse to
  discuss the procedure with the child before
  giving the enema.

72
Enema

• The type and amount of fluid, as well as the
  distance the tube is inserted, vary according to
  age.
• The tube is well lubricated with a water-soluble
  jelly before insertion.

73
Enema

• With an explanation before the procedure, the
  older child can usually hold the solution.
• A bedpan or bathroom should be available before
  the enema is started.

74
Ostomies

• A colostomy is made by bringing a part of the
  colon through the abdominal wall to create an
  outlet for fecal material elimination.
• Can be temporary or permanent.

75
Ostomies

• An ileostomy is a similar opening in the small
  intestine.
• The drainage contains digestive enzymes so the
  stoma must be fitted with a collection device to
  prevent skin irritation and breakdown.

76
Ostomies

• Teach care for the stoma and skin with any
  ostomy.
• Preventing skin breakdown is a priority.
• Output from any ostomy is recorded accurately.

77
Ostomies

• A urostomy may be created to help in the
  elimination of urine.
• Ostomies bags should be checked for leakage,
  emptied frequently, and changed when needed.

78
Performing Procedures For Specimen Collection

• Standard precaution are followed in collecting
  and transporting specimens, no matter what the
  source of the specimen.

79
Nose and Throat Specimens

• To collect a specimen, the nose or the back of
  the throat and tonsils are swabbed with a special
  collection swab.
• The swab is placed directly into a culture tube
  and taken to the lab for analysis.

80
Nose and Throat Specimens

• To diagnose RSV (respiratory syncytial virus), a
  nasal washing may be done.
• A small amount of saline is instilled into the
  nose then the fluid is aspirated and placed into
  a sterile specimen container.

81
Urine Specimens

• Cotton balls can be placed in the diaper of an
  infantthe urine squeezed from the cotton ball
  can be collected and used for many urine tests.
• Because toddlers and young children cannot
  usually void on command, they should be offered
  fluids 15 to 20 minutes before the urine specimen
  is needed.

82
Urine Specimens

• The nurse uses the word the child knows to
  identify urination, such as pee-pee or potty,
  so the child will understand.
• Offer privacy if applicable.

83
Urine Specimens

• Infant of child is positioned so that the
  genitalia are exposed and the area can be
  cleansed.
• On the male patient, the tip of the penis is
  wiped with a soapy cotton ball, followed by a
  rinse with a cotton ball saturated with sterile
  water.

84
Urine Specimens

• In the female patient, the labia majora are
  cleansed front to back using one cotton ball for
  each wipe.
• The labia minora are then exposed and cleansed.
• The area is rinsed with a cotton ball saturated
  with sterile water.

85
Urine Specimens

• The male and female genitalia are permitted to
  air-dry before collection methods are followed.
• Appropriate documentation includes the time of
  specimen collection, the amount and color of
  urine, the test to be performed, and the
  condition of the perineal area.

86
Collection Bag

• To collect a urine specimen from infants and
  toddlersa urine collection bag is used (Fig.
  5-13 pg. 94).
• Skin must be clean, dry, and free of lotions,
  oils, and powder.

87
Collection Bag

• The device is a small, plastic bag with a
  self-adhesive material to apply it to the childs
  skin.
• The paper backing is removed, and the adhesive
  surface is applied over the penis in the male and
  the vulva in the female.

88
Collection Bag

• Diaper is replace.
• The collection device should be removed as soon
  as the child voids.

89
Clean Catch

• If a urine specimen is needed for a culture, the
  older child may be able to cooperate in the
  collection of a midstream specimen.
• Genital area is cleaned, and the child urinates a
  small amount, stops the flow, then continues to
  void into a specimen container.

90
24-Hour Urine Collection

• The urine is kept on ice in a special bag or
  container during the collection time period.
• Entire amount of urine in 24 hour period.

91
Stool Specimens

• Stool specimens are tested for various reasons
  including the presence of occult blood, ova and
  parasites, bacteria, glucose, or excess fat.

92
Stool Specimens

• Using a tongue blade, the nurse puts on gloves,
  collects these specimens from a diaper or bedpan,
  and places them in clean specimen containers.
• Stool must not be contaminated with urine.

93
Stool Specimens

• Must be delivered to the lab promptly after being
  labeled.
• Documentation includes the time of specimen
  collection, stool color, amount, consistency and
  odor, the test to be performed and the skin
  condition.

94
Assisting with Procedures R/T Blood Spinal
Fluid

• The nurse might assist with the collection of
  blood samples or in holding and supporting a
  child during a lumbar puncture.

95
Blood Collection

• The nurse must be familiar with the general
  procedure to explain it to the child.
• Help hold or restrain the child during the
  procedure.

96
Blood Collection

• Blood specimens are obtained either by pricking
  the heel, great toe, earlobe, or finger or by
  venipuncture.
• In infants, the jugular or scalp veins are most
  commonly used sometimes the femoral vein is
  used (Fig. 5-14 pg. 95).
• In older children, the veins in the arm are used.

97
Lumbar Puncture

• When analysis of cerebrospinal fluid is
  necessary, a lumbar puncture is performed.
• The nurse must restrain the child in the position
  shown in Figure 5-15 pg. 95 until the procedure
  is completed.

98
Lumbar Puncture

• The nurse grasps the childs hands with the hand
  that has passed under the childs lower
  extremities and holds the child snugly against
  his or her chest.
• This position enlarges the intervertebral spaces
  for easier access with the aspiration needle.

99
Lumbar Puncture

• Important to hold still.
• Performed with strict asepsis.
• Sterile dressing applied.
• The child must remain quiet for 1 hour after the
  procedure.
• V/S, LOC, and motor activity should be monitored
  frequently for several hours after the procedure.
  

100
Assisting With Procedures R/T Diagnostic Tests
Studies

• The nurses role often is to teach and prepare
  the child and the caregiver for the procedures to
  be done.
• After orders have been written, the nurse
  requests and schedules the tests or studies to be
  done.

101
Assisting With Procedures R/T Diagnostic Tests
Studies

• The required paperwork is completed and consents
  are signed.
• If NPO prior to the study, the nurse ensures that
  the NPO status is maintained.
• Any allergies are clarified and documented on the
  consent and requisition forms.

102
Assisting With Procedures R/T Diagnostic Tests
Studies

• During the procedure the nurse might be called on
  to support and comfort or restrain the child.
• Following the procedure, the nurse performs and
  documents the care needed.