Procedures and Treatments Chapter 30

1. Procedures and TreatmentsChapter 30

2. OBJECTIVES 1. Describe nursing responsibilities when preparing the child for a procedure or treatment. 2. Describe nursing responsibilities after the child undergoes a procedure or treatment. 3. Explain different types of restraints, their uses, and safety measures to consider in children. 4. Describe appropriate positioning of the child for holding, transporting, and sleeping. 5. List methods of reducing an elevated body temperature in children. 6. Explain the reason for monitoring accurate intake and output measurements when caring for children. 7.  Discuss the reasons and procedure for inserting a feeding tube and administering a gavage feeding. 8. Explain the use of gastrostomy feeding in children and how it is different from gavage feeding. 9. Describe oxygen administration methods and safety considerations for children. 10. Describe nasal or oral suctioning to improve the child’s respiratory function. 11. Explain basic components of tracheostomy care for the child. 12. Discuss the use of hot or cold therapy in children in relationship to circulation. 13. Describe nursing care for three types of ostomies that are created in children with problems related to elimination. 14. Explain how and why nose and throat specimens may be collected from the child. 15. Describe four methods of urine specimen collection. 16. Explain the method of stool collection for the child. 17. Discuss the role of the nurse in assisting with procedures related to blood collection, lumbar puncture, and diagnostic tests and studies in children.

3. Nurse’s Role in Preparation and Follow-Up • Includes following guidelines set by the healthcare institution • The preparation before the procedure • The follow-up needed when the procedure is completed • Also responsible for following facility policies and ensuring patient safety before, during, and after all procedures and treatments

4. Nurse’s Role in Preparation and Follow-Up (cont.) • Preparation for procedures • Supporting the child and family • Follow the facility’s policies to ensure that legal requirements and safety precautions are met • Psychological or emotional support • Source of comfort to children for painful procedures • Explain the procedure and its purpose to the caregiver to help decrease anxiety

5. Nurse’s Role in Preparation and Follow-Up (cont.) • Psychological or emotional support (cont.) • Explain the procedure to the child in a manner appropriate for the child’s age and level of development • Encourage the child to ask questions and give complete answers • Toddlers understanding will be limited • Use diversion • Allow to cry

6. Nurse’s Role in Preparation and Follow-Up (cont.) • Preparation for procedures (cont.) • Legal and safety factors • Ensuring an order is written for the procedure • Identifying the child • Consent on chart if needed • Hand washing • Gather needed supplies and equipment • Safety for child is a priority • Following standard precautions

7. Nurse’s Role in Preparation and Follow-Up (cont.) • Follow-up for procedures • Leave child in a safe position • Comfort and reassure the child • Answer caregiver questions • Remove and dispose of equipment and supplies properly • Label, prepare, and document specimens according to agency policy • Document the procedure and the child’s response • Follow facility policies

8. Question Tell whether the following statement is true or false. Before performing a procedure the nurse must validate the child’s identity. You can do this by simply asking the child if they are (name the child who is supposed to have the procedure).

9. Answer False Rationale: Always identify the child before any treatment or procedure; check the child’s ID band and verify that information by having the child or caregiver state the child’s name.

10. Performing Procedures Related to Position • Safety is the most important nursing responsibility when performing procedures related to positioning a child • Using restraints • Often needed for protection • Should never be used as a form of punishment • Joint Commission’s guidelines and standards for the use of restraints must be followed • Restraining by hand best method

11. Performing Procedures Related to Position (cont.) • Using restraints (cont.) • 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 • Mummy restraints and papoose boards • Mummy restraints are snug wraps used to restrain an infant or small child during a procedure. • Papoose boards are similar restraints used for toddlers or preschoolers

12. Performing Procedures Related to Position (cont.) • Using restraints (cont.) • Clove Hitch restraints are used to secure an arm or leg, most often when a child is receiving an IV infusion. The restraint is made of soft cloth formed in a figure eight. Padding under the restraint is desirable if the child puts any pull on it. Loosen the restraint and check the site at least every 1 to 2 hours • Elbow restraints wrapped around the child’s arm and tied securely to prevent the child from bending the elbow

13. Performing Procedures Related to Position (cont.) • Using restraints (cont.) • Jacket restraints are used to secure the child from climbing out of bed or a chair, or to keep the child in a horizontal position • Crib top restraints are clear plastic coverings attached to the top of the crib. This type of restraint is used for older infants and toddlers who are able to stand and climb to prevent them from climbing over the side of the bed and falling

14. Performing Procedures Related to Position (cont.) • Holding • Child needs to feel safe and secure • 3 most common methods of holding a child • Horizontal position • Upright position • Football hold • Always support the infant’s head and back

15. Performing Procedures Related to Position (cont.) • Transporting • Safety of the child is the biggest concern • Best to carry the infant or place him or her in a crib or bassinet • Toddlers-use crib with high side rails or a high-topped crib, strollers or wheelchairs, wagons • Older children-stretchers, beds • Always use seat belts or safety straps

16. Performing Procedures Related to Position (cont.) • Positioning for sleep • Infants on their backs or supported on their sides • Decreases incidence of crib death or sudden infant death syndrome • Teach and reinforce this information to family caregivers

17. PERFORMING PROCEDURES RELATED TO ELEVATED BODY TEMPERATURE • “Normal” body temperature varies from 97.6 F orally to 100.3 F rectally; should remain below 101 F orally or 102 F rectally (follow MD orders)-higher temp may produce febrile seizures • Methods used to reduce fever include maintaining hydration by encouraging fluids and administering acetaminophen • Tepid sponge baths no longer recommended for reducing fever (ineffectiveness, and discomfort) • Family caregivers need instructions on fever reduction for home care

18. PERFORMING PROCEDURES RELATED TO ELEVATED BODY TEMPERATURE (cont.) • Control of environmental factors • Removing excess coverings • Changing to lightweight clothes • Removing clothes • Lowering the room temperature • Applying cool compresses to the forehead • If shivering occurs stop what you are doing to reduce the body temperature • Shivering indicates the child is chilling, causes body temperature to increase

19. PERFORMING PROCEDURES RELATED TO ELEVATED BODY TEMPERATURE (cont.) • Cooling devices • Hypothermia pad or blanket-always cover before placing next to the child (absorbs moisture) • Document • Child’s baseline temperature and additional temperature measurements • Information regarding the child’s response to the treatment

20. Question When lowering a child’s temperature and shivering occurs you must stop what you are doing to lower the temperature. This is because shivering a. Is very uncomfortable for a child with a fever b. Is the body’s mechanism for raising the temperature c. Means you have lowered the temperature to fast d. Lowers the temperature faster

21. Answer b. Is the body’s mechanism for raising the temperature Rationale: If a child begins to shiver, whatever method is being used to lower the temperature should be stopped. Shivering indicates the child is chilling, which will cause the body temperature to increase.

22. Performing Procedures Related to Feeding and Nutrition • Intake and output measurements • Accurately measuring and recording intake and output are especially important • Oral fluids, feeding tube intake, IV fluids, and foods that become liquid at room temperature (e.g., frozen foods such as popsicles) are all measured and recorded as intake • Urine, vomitus, diarrhea, gastric suctioning, and any other liquid drainage are measured and considered output • Document color and characteristics • Weigh diapers

23. Performing Procedures Related to Feeding and Nutrition (cont.) • Gavage feeding • Also called enteral tube feeding (surgery, chronic, or serious condition)-How? (nose or mouth) • Can be intermittent (bolus feeding) or continuous • If gavage or enteral feedings are not well tolerated, report it and await alternate orders from the provider • Verifying positioning of the feeding tube by inserting air (using an Asepto syringe) and listening with a stethoscope for sounds in the stomach is considered an unreliable method of checking for tube placement and is no longer recommended

24. Performing Procedures Related to Feeding and Nutrition (cont.) • Gavage feeding (cont.) • Document • Type and amount of contents aspirated by the nurse • Amount of feeding given and name of formula • The child’s tolerance for the procedure • The positioning of the child after completion

25. Performing Procedures Related to Feeding and Nutrition (cont.) • Gastrostomy feeding • Surgically inserted through the abdominal wall into the stomach • Used in children who must receive tube feedings over a long period of time • Meticulous care of the wound site is necessary to prevent infection and irritation • Gastrostomy button may be inserted for long-term feedings (more desirable cosmetically, simple to care for, & cause less skin irritation)

26. Performing Procedures Related to Feeding and Nutrition (cont.) • Gastrostomy feeding (cont.) • Aspirate, measure, and replace the residual stomach contents at the beginning of the procedure • Following the feeding, flush the tube with water to clear the tubing and prevent the feeding solution from occluding the tube • After each feeding, place the child on the right side or in Fowler’s position

27. PERFORMING PROCEDURES RELATED TO RESPIRATION • Oxygen administration • Oxygen is administered to treat symptoms of respiratory distress or when the oxygen saturation level in the blood is below normal • Depending on the child’s age and oxygen needs, many different methods are used to deliver oxygen (nasal, mask, hood, tent) • Explain the procedure and equipment to the child and the caregiver • Teach the family caregiver about oxygen administration, equipment, and safety measures, esp. in home situations

28. PERFORMING PROCEDURES RELATED TO RESPIRATION (cont.) • Nasal/oral suctioning • Use a bulb syringe to remove secretions from the nose and mouth (may need sterile normal saline) • Nasotracheal suctioning with a sterile suction catheter may be needed if secretions cannot be removed by other methods • Tracheostomy care • Tracheostomy tube is suctioned to remove mucus and secretions and to keep the airway patent • Plastic or metal tubes require frequent cleaning to prevent infection • Tracheostomy prevents the child from being able to cry or speak

29. PERFORMING PROCEDURES RELATED TO CIRCULATION • Heat therapy • Local application of heat • Increases circulation by vasodilation, promotes muscle relaxation, speeds the formation and drainage of superficial abscess • Artificial heat should never be applied to the child’s skin without a specific order • 20 minutes at a time • Monitor closely • Document the application type, start time, therapy duration, and the skin’s condition before and after the application • Moist heat-warm compress or soak • Dry heat-electric heating pad, K-pad (hot water bottles are not recommended)

30. PERFORMING PROCEDURES RELATED TO CIRCULATION (cont.) • Cold therapy • Provider must order the use of cold applications • Inspect child’s skin before and after application • 20 minute intervals • Document the application type, start time, therapy duration, and the skin’s condition before and after the application • Procedure manual • Dry cold-ice bag & commercial instant cold pack • Moist cold-compress, soak, bath

31. PERFORMING PROCEDURES RELATED TO ELIMINATION • Enema administration • Can be a treatment or a preoperative procedure • The type and amount of fluid, as well as the distance the tube is inserted, vary according to age • Ostomy care • Preventing skin breakdown is a priority • Check ostomy bags for leakage, empty them frequently, and change the bags when needed • Document output

32. PERFORMING PROCEDURES RELATED TO ELIMINATION (cont.) • Types of ostomies • Colostomy • Bringing a part of the colon through the abdominal wall to create an outlet for fecal material elimination, temporary or permanent • Ileostomy • A similar opening in the small intestine • Urostomy • Created to help in the elimination of urine

33. Question Before beginning a gavage or gastrostomy feeding it is necessary to check the placement of the tube. What method of tube placement is considered unreliable? a. Inserting air into tube and listening for sound b. Do x-ray to check placement c. Aspiration for stomach contents d. Ask the patient to talk

34. Answer a. Inserting air into tube and listening for sound Rationale: Verifying positioning of the feeding tube by inserting air (using an Asepto syringe) and listening with a stethoscope for sounds in the stomach is considered an unreliable method of checking for tube placement and is no longer recommended. An x–ray is most reliable; aspirating stomach contents is acceptable; chest x-rays do not verify placement of tube in stomach.

35. Performing Procedures for Specimen Collection • Nose and throat specimens • Help diagnose infection • Procedure • Swab back of nose or throat • Swab placed in culture tube • Transported to lab • Epiglottitis-if suspected Do Not do a throat culture (could cause possible trauma and airway occlusion)

36. Performing Procedures for Specimen Collection (cont.) • Urine specimens • Collection bag • Clean catch-midstream • Catheterization-often uses a small sterile feeding tube to collect a sterile specimen • 24-hour urine collection-kept on ice until completed • For infants or toddler that is not potty trained, a sterile cotton ball may be placed in diaper • Stool specimens-must not be contaminated with urine

37. ASSISTING WITH PROCEDURES RELATED TO COLLECTION OF BLOOD AND SPINAL FLUID • Blood collection • Blood specimens are obtained either by pricking the heel, great toe, earlobe, or finger, or by venipuncture. • Lumbar puncture • Explain procedure in an age appropriate manner • Restrain the child (using age appropriate positions)-see page 675, Figure 30-11 • Sterile dressing is applied when the procedure is complete

38. ASSISTING WITH PROCEDURES RELATED TO COLLECTION OF BLOOD AND SPINAL FLUID (cont.) • Lumbar puncture (cont.) • Child must remain quiet for 1 hour after the procedure • Document • Vital signs • Level of consciousness • Motor activity frequently for several hours after the procedure

39. Assisting with Procedures Related to Diagnostic Tests and Studies • Diagnostic studies include • X-rays • Computed tomography (CT) scans and magnetic resonance imaging (MRI) scans • Arteriograms and intravenous pyelograms • Bone or brain scans • Electrocardiograms (EKGs) • Electroencephalograms (EEGs) • Cardiac catheterizations

40. Assisting with Procedures Related to Diagnostic Tests and Studies (cont.) • Teaching and preparing the child and the caregiver • Requesting and scheduling the tests or studies • Completing required paperwork; ensuring consents are signed • Ensuring that NPO status is maintained • Clarifying and documenting any allergies • Supporting, comforting, and restraining the child • Performing and documenting care after the procedure