1. Health Care Adaptations for the Child and Family
Chapter 22
Health Care Adaptations for the Child and Family

2. Objectives
List five safety measures applicable to the care of the hospitalized child.
Illustrate techniques of transporting infants and children.
Plan the basic daily data collection for hospitalized infants and children.
Identify normal vital signs of infants and children at various ages.
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3. Objectives (cont.)
Devise a nursing care plan for a child with a fever.
Discuss the techniques of obtaining urine and stool specimens from infants.
Position an infant for a lumbar puncture.
Calculate the dosage of a medicine that is in liquid form.
Demonstrate techniques of administering oral, eye, and ear medications to infants and children.
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4. Objectives (cont.)
Compare the preferred sites for intramuscular injection for infants and adults.
Discuss two nursing responsibilities necessary when a child is receiving parenteral fluids and the rationale for each.
Demonstrate the appropriate technique for gastrostomy tube feeding.
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5. Objectives (cont.)
Summarize the care of a child receiving supplemental oxygen.
Recall the principles of tracheostomy care.
List the adaptations necessary when preparing a pediatric patient for surgery.
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6. Admission to the Pediatric Unit—Nursing Responsibilities
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7. Informed Consent
Ensure the parent/guardian signing consent for any procedure understands the purpose and risks involved
Nurse acts as a patient advocate by ensuring the consent has been signed before the procedure
When possible, provide the patient with age-appropriate information
Give an example of a situation in which informed consent is necessary and communicate the information to a child.
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8. Identification
ID bracelet must be applied upon admission to the nursing unit
Parent/guardian is also given one to wear and the identification numbers must match what is on the child’s bracelet
ID bracelet must be verified before any medication, treatment, or procedure is provided
Discuss the importance of verifying ID bracelets on the child and the parent/guardian.
Discuss safety measures while applying the bands and for discharge.
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9. Essential Safety Measures in the Hospital Setting—the Do’s
Keep crib sides up at all times when the child is unattended in bed
Identify a child by ID bracelet and NOT by room or bed number
Use a bubble-top or plastic-top crib for infants and children capable of climbing over the crib rails
Give an example of a potentially dangerous situation if a child is not identified by an ID bracelet.
Audience Response Question #1
The mother of a 2-month-old patient is changing his diaper with the crib rail in the down position. The nurse observes the mother walk away from the crib without raising the rail. The nurse should:
1. Realize the mother feels comfortable regarding the safety of her child.
2. Instruct the mother that crib rails must be returned to the upward position any time the child is unattended in the crib.
3. Notify social services and the pediatrician.
4. Document the occurrence in the medical record.
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10. Essential Safety Measures in the Hospital Setting—the Do’s (cont.)
Place cribs so that children cannot reach sockets or appliances
Inspect toys for sharp edges and removable parts
Keep medications and solutions out of reach of the child
Prevent cross-infection; do not borrow items such as toys from one child and give to another without cleaning the toy per hospital policy first
Take proper precautions whenever oxygen is being administered
Give examples of how to minimize unsafe conditions within the hospital.
What is an example of a cross-infection situation?
Discuss precautions that should be instituted when administering oxygen.
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11. Essential Safety Measures in the Hospital Setting—the Don’ts
Do not allow ambulatory patients to use wheelchairs or stretchers as toys
Do not leave an active child in a baby swing, feeding table, or high chair unattended
Do not leave a small child unattended when out of the crib
Do not leave medications at the bedside
Do not prop nursing bottles or force-feed small children—risk of choking
Discuss these safety measures.
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12. Preparation Steps for Performing Procedures
Nursing actions prior to a procedure include
Verifying written order of health care provider
Gathering equipment
Identifying the patient
Explaining the procedure to the parent/child
Providing privacy
Performing hand hygiene
Utilizing standard/transmission-based precautions
Discuss when it is and is not appropriate for a parent or caregiver to assist in a medical/nursing procedure.
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13. Transporting, Positioning, and Restraining the Infant
Method depends on age, level of consciousness, and how far the child must travel
Older children are transported as adults are
Young children—cribs, wagons, pediatric-sized wheelchair, or gurney
Side rails are up
ID bracelet has been checked to ensure the correct child is being transported
The nurse documents time, method of transport, where child is transported, and who is accompanying child
What are some improper methods of transporting an infant?
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14. Transporting, Positioning, and Restraining the Infant (cont.)
Discuss Figure 22-4, A-D, on page 490.
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15. Verifying the Child Assessment
Children are different from adults.
Data collection is done to determine the level of wellness, the response to medication or treatment, or the need for referral.
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16. Organizing the Infant Assessment
Select a warm, non-stimulating room
Expose only areas of body to be examined
Observe without touching first, with minimal touching next, and with invasive touch last to assess reflexes and blood pressure
Talk softly
Utilize pacifier to comfort infant
Swaddle/hold after assessment complete
Utilize parent teaching opportunities
Document findings
Discuss why these organizational steps are important in the infant assessment process.
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17. Basic Data Collection Observation Growth and development
How does the child look?
Growth and development
Are child’s size and actions age-appropriate?
Level of interaction between child and environment
Is child’s behavior withdrawn, normal for age and development, or inappropriate?
Is the child tipping his head or rubbing his ears?
Is child maintaining a rigid body posture in order to breathe?
Are there any obvious bruises (especially in various stages of healing) or cuts?
How clean is the child?
Give examples of situations in which the nurse must assess and observe growth and development.
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18. The History Survey
Allows the nurse to teach parents about child’s needs as well as injury and illness prevention
Should include questions about complementary and alternative medicine, over-the-counter medications, and immunization history
Should also include
Child’s health and eating habits
Sleeping
Toileting
Activity patterns
Use of special words or gestures in order to communicate with others
Give an example of information gained during the history in which the nurse can teach the parents injury prevention.
What is the rationale for the nurse obtaining eating, toileting, sleeping, and activity patterns?
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19. The Physical Survey
Head-to-toe review upon admission and then at least once per shift or clinic visit
Vital signs
Temperature
Weight
Blood pressure
Pulse
Respiration rate
Hydration status
Heart sounds
Lung sounds
Bowel sounds
Skin—rashes/lesions
Tachycardia is often the first sign of shock or body stress in infants and children.
Hypotension could be a late sign of shock because of a compensatory mechanism that is activated early—this is an emergency!
Mottled skin on the extremities is not unusual.
Infants have a large body surface area and high metabolic rate that are prone to fluid loss and hypothermia as well as cold stress.
Hydration status:
Sunken fontanel could indicate dehydration.
Bulging fontanels could indicate increased intracranial pressure (ICP). In an older child and adult, increased ICP is manifested by increased systolic BP, widening pulse pressure, irregular respirations, and bradycardia. In an infant, increased ICP might only be manifested by a decreased level of consciousness.
Audience Response Question #2
A child's weight is 57 pounds upon admission. The nurse converts this to ________ kilograms.
1. 23
2. 26
4. 114
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20. Pulse Rate
Apical pulse advised for children younger than 5 years of age
Radial pulse used for children older than 5 years of age
Pulse rate increases as temperature increases
Discuss the importance of obtaining an apical pulse for one full minute.
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21. Blood Pressure (BP) The width of the cuff should be ⅔ of the upper arm
Electronic BP machines do not require auscultation with stethoscope
Normal BP is lower in children than in adults
Can secure BP cuff over brachial, popliteal, or femoral artery
A BP reading taken when an infant is crying may not be accurate
What methods are used to obtain a BP of the brachial, popliteal, or femoral arteries?
Discuss the reason for inaccurate BP readings of children who are crying.
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22. Pathogenesis of Fever and the Use of Antipyretics
Infection stimulates immune substances to work along with prostaglandins to stimulate the hypothalamus to raise body temperature
Triggers vasoconstriction, shivering, and decreased peripheral perfusion
Decreases body heat loss while maintaining homeostasis
Antipyretic medications inhibit prostaglandin production
Fever increases metabolic demand on the heart and lungs
Discuss the pathophysiology regarding increased metabolic rate and fever and the increased demand on the heart and lungs.
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23. Hyperthermia
An increase in core body temperature occurs with central nervous system impairment
Prostaglandins are not involved
Homeostasis mechanism is bypassed
Treatment involves vigorous cooling measures
Discuss the difference between fever and hyperthermia.
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24. Techniques to Measure Body Temperature
Discuss Skills 22-3 and 22-4 on page 496.
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25. Techniques to Measure Body Temperature (cont.)
Usually done in one of five places
Oral
Axillary
Temporal artery
Tympanic
Core (not widely recommended due to increase risk of rectal mucosal tearing)
Describe where these temperatures are measured on the body.
Audience Response Question #3
The nurse assesses the tympanic temperature of a 4-week-old as 95.9º F. The nurse should:
1. document the temperature.
2. notify the physician.
3. have another nurse reassess.
4. take an axillary temperature.
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26. Pain The fifth vital sign Must be addressed in the plan of care
Refer to Chapter 12 for pain in the newborn and Chapter 21 for pain in the child/adolescent.
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27. Weight Provides a means of determining progress
Necessary to determine safe medication dosages
Review techniques to use based on the age of the infant or child.
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28. Height Infants Children Birth to 2 years 2 to 18 years
Measured lying on a flat surface
Children
2 to 18 years
Measured in a standing position
Discuss proper procedures to measure height of infants and children.
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29. Head Circumference Measured on all infants and toddlers
Place tape measure slightly above eyebrows, above ear, and around occipital prominence
What is the importance of head circumference measurement?
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30. Collecting Specimens Verify physician order
Obtain lab requisitions, correct containers, and supplies
Collect specimen
Label clearly and attach proper forms
Send to laboratory according to hospital policy
Record in nurses’ notes and on intake and output record what specimens were obtained and, where appropriate, the amount of output
What is the importance of proper documentation when obtaining and sending a specimen to the lab?
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31. Examples of Specimens Urine Stool Blood Cerebral spinal fluid Wounds
Body fluids, such as peritoneal fluid or fluid from surgical drain
It is important to follow hospital protocols in the collection and handling of any laboratory specimen
Urine should not be collected from a disposable diaper as chemicals in the diaper will alter the results
Review the techniques for obtaining specimens listed.
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32. Physiological Responses to Medications in Infants and Children
Understanding the differences in drug absorption, distribution, metabolism, and excretion between children and adults is essential to provide safe pediatric medication administration
Age is the most important variable in predicting response to any drug therapy
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33. Absorption of Medications in Infants and Children
Gastric influences
Intestinal influences
Topical medications (ointments)
Parenteral medications
How might medications be absorbed differently when administered by these various routes?
What factors need to be considered in the pediatric patient prior to administering any medications?
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34. Metabolism of Medications in Infants and Children
Most are metabolized in the liver
Drugs generally metabolize more slowly, especially because the liver and enzymes do not function at a mature level until 2 to 4 years of age
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35. Excretion of Medications in Infants and Children
Many medications depend on the kidney for excretion
If younger than 1 year of age, the immature kidney function prevents effective excretion of drugs from the body
Combination of
Slow stomach emptying
Rapid intestinal transmit time
Unpredictable liver function
Inability to effectively excrete medications via the kidney
Can result in altered responses and places the child at risk for toxicity
Discuss the pathophysiology regarding excretion of medications via the renal system.
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36. Administering Medications to Infants and Children
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37. Nursing Responsibilities
Observe for toxic symptoms whenever medications are administered
Document positive and negative responses
Every medication administered should have the safety of the dose prescribed calculated before administration
Give an example of toxic symptoms the nurse might assess in a child.
What are some examples of negative responses to medications?
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38. Parent Teaching
Is essential to ensure compliance when the child is sent home with medications
Teaching should include
The importance of administering and completing the medications as prescribed
Techniques of measuring and administering each dose
Techniques for encouraging child compliance
Importance of writing and following a schedule for medication administration
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39. Methods of Drug Administration
Oral
Preferred route
Parenteral
Nosedrops, eardrops, eyedrops
Rectal
Subcutaneous and intramuscular injections
Intravenous
Long-term venous access devices
Saline lock
Peripheral
PICC
Central
Hickman, Groshong, and Broviac catheters
Implanted ports
Review the various techniques and safety measures for each method and for each age group.
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40. Calculating Drug Doses
Body surface area
Milligrams per kilogram (mg/kg)
Dimensional analysis
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41. Formula for Dimensional Analysis
Unit × Dosage wanted Dosage on hand Unit to give
Provide measurements and allow students to calculate medication using the dimensional analysis method.
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42. Safety Alert Maximum volume for IM administration Infants—0.5 mL
Toddlers—1 mL
School-age/adolescent
Deltoid—1 mL
Vastus lateralis—2 mL
Discuss why this is important to follow.
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43. Total Parenteral Nutrition
Also known as hyperalimentation
Provides nutritional needs to those who cannot use the gastrointestinal tract for nourishment for a prolonged period of time
Allows highly concentrated solutions of protein, glucose, and other nutrients to infuse into a large vessel
It is important for the nurse to monitor and report the following
Hypoglycemia
Hyperglycemia
Electrolyte imbalances
Give an example of a child’s situation that requires TPN.
Discuss the pathophysiology regarding hyperglycemia, hypoglycemia, and electrolyte imbalances.
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44. Nursing Care of a Child Receiving Parenteral Fluids
Observe the child hourly for
Low volume in the bag or the need to refill the burette
The rate of flow of the solution
Pain, redness, or swelling at the needle insertion site
Moisture at or around the needle insertion site
Accurate I&O is kept for all children receiving IV fluids
Discuss the importance of monitoring the child every hour.
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45. Nursing Care of a Child Receiving Parenteral Fluids (cont.)
Key components to remember when providing intravenous therapies
The developmental level of the child
IV placement
Preparation of the child prior to insertion
Related nursing actions
Protection of the IV site
Mobility considerations
Safety needs
Review nursing guidelines for IV therapy at various stages of development in Table 22-5, pages
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46. Preventing Medication Errors
6 Rights of Medication Administration
Patient
Drug
Dose
Time
Route
Documentation
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47. Factors to Consider for Pediatric IVs
Developmental characteristics
Site where IV is to be inserted
Preparation of child
Family Involvement
Related nursing actions
Protection of IV site
Mobility Considerations
Safety needs
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48. Avoiding Drug Interactions
Selected drug-environment interactions
Phototoxicity
Selected drug-drug interactions
Phenytoin (Dilantin) and antacid
Selected drug-food interactions
Iron supplement and egg yolks
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49. Nutrition, Digestion, and Elimination
Gavage feeding
Given when infant cannot take food or fluids by mouth but the gastrointestinal tract is functioning
Places nutrients directly into the stomach so that natural digestion can occur
What is the proper technique when administering a gavage feeding?
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50. Nutrition, Digestion, and Elimination (cont.)
Gastrostomy
Tube surgically placed through the abdominal wall into the stomach
Used in infants or children who cannot have food by mouth because of anomalies or strictures of the esophagus, severe debilitation, or coma
Brown or green drainage may indicate that the tube has slipped from the stomach into the duodenum. This can cause an obstruction and is reported immediately.
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51. Nutrition, Digestion, and Elimination (cont.)
Enema
Administration is essentially the same as with adults
Modifications include
Type
Amount
Distance of insertion
Isotonic solutions
Tap water is contraindicated
Plain water is hypotonic to the blood and could cause a rapid fluid shift and overload if absorbed through the intestinal wall
Give examples of isotonic solutions.
What is a potential complication when administering a tap-water enema? Fluid overload
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52. Respiration Tracheostomy
An artificial airway (a plastic tube) placed in the trachea through the neck
Nursing care is essential to the survival of the child
The tube can become plugged by mucus or other secretions and cause the child to suffocate
Tube prohibits vocalization
Discuss Figure on page 521.
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53. Respiration (cont.) Indications for suctioning Complications
Noisy breathing
Bubbling of mucus
Moist cough or respirations
Complications
Tracheoesophageal fistula
Stenosis
Tracheal ischemia
Infection
Atelectasis
Cannula occlusion
Accidental extubation
Signs and symptoms to observe
Restlessness
Rising pulse rate
Fatigue
Apathy
Dyspnea
Sternal retractions
Pallor
Cyanosis
Inflammation or drainage around insertion site
Review the technique for correctly performing suctioning.
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54. General Considerations for the Child Receiving Oxygen Therapy
Signs of respiratory distress include increased pulse rate and respirations
Restlessness
Flaring nares
Intercostal an substernal retractions
Cyanosis
Children with dyspnea often vomit, which increases the danger of aspiration
Maintain clear airway by suctioning if needed
Organize nursing care to minimize interruptions
Observe children carefully because vision may be obstructed by mist and young children are unable to verbalize their needs
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55. General Considerations for the Child Receiving Oxygen Therapy (cont.)
Safety considerations
Infection prevention and control
Prolonged exposure to high concentrations
Therapy is terminated gradually
Discuss Figure on page 524.
Review safety considerations when administering oxygen.
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56. Management of an Airway Obstruction
Abdominal Thrusts
Works on the principle that forcing the diaphragm up causes residual air in the lungs to be forcefully expelled, resulting in popping the obstruction out of the airway
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57. Procedure for Clearing an Airway Obstruction
Discuss the proper procedure for treating a child/infant with an airway obstruction.
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58. Preoperative and Postoperative Care
Children require both physical and psychological preparation at their level of understanding
Clarify any misunderstandings the child may have
Infants should not be maintained on NPO status for longer than 4 to 6 hours; provide a pacifier to assist in meeting developmental need for sucking
Postoperative
Nursing interventions are aimed at assisting the child to master a threatening situation and minimize physical and psychological complications
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59. Body Art, Body Jewelry, Tattoos
Most body jewelry designed to stay in place
Can cover with occlusive dressing
May need to remove if in area of surgery
Flexible plastic retainer may help keep holes open
Nipple rings removed for mammogram
MRI—most body jewelry is not ferromagnetic
Tattoos or permanent cosmetics at risk for developing edema or burning during MRI
Document presence of any tattoos
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60. Question for Review
What is the nursing responsibility in the monitoring of IV therapy for the pediatric patient?
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61. Review Objectives Key Terms Key Points Online Resources
Review Questions
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