Selected Caring Interventions

1. Selected Caring Interventions Restraining Methods, Specimen Collection, Med Administration Chapter 45

2. Restraint Guidelines (1265) • Make sure restraining is the last resort and use least restrictive device or method • Often eliciting help of parent can minimize the chances of having to restrain a child • Child in restraint must be checked at least as often as protocol requires—depends on whether it is behavioral or nonbehavioral restraint • If restraint is part of procedure all of the time and for all patients, it does not fall under restraint guidelines.

3. Nonbehavioral Restraints • Needed to ensure safe care—benefit outweighs risk. Specifically used in cases of: • Risk for interruption of O2 tx or airway patency • Risk of harm from dislodging tubes, wires, sutures • Patient confusion, agitation, unconsciousness • Developmental inability to understand instructions

4. Behavioral Restraint • Used in situations when there is significant risk of patient harming self or others and where nonphysical methods have not worked. • Order must be obtained within the hour • Child must be continuously observed and reassessed every 15 minutes • If need for restraint lasts less than 30 minutes, therapeutic holding is best

5. Types of Restraints • Jacket—for chairs or to keep patient flat • Mummy—blanket or papoose • Limb—arm, leg, elbow • Sheets and pillowcases

6. Therapeutic Holding • Temporary, secure, comfortable holding position • Allows close contact with parent—in some cases parents assist with holding • Can be used with many types of procedures that typically take less than 30” such as IV starts, venipunctures, tube insertion, lumbar punctures. • With some procedures, local anesthesia or oral sedatives can also be used.

7. Obtaining Urine Specimens (1267) • For regular UA—collection bag for infants, cup or hat for children. Gain cooperation by challenging child to show you color of their urine. • Clean-catch usually reserved for children who can follow directions and are potty-trained • Sterile specimens should be obtained by catheterization (may use feeding tube) or bladder needle aspiration (MD) • 24 hour collection—bags, indwelling caths, or a child who can be depended on

8. Obtaining Stool Specimens (1270) • Collected for culture, O & P, rotovirus, C-diff, blood, fat, etc. • With infants, apply urine bag to prevent contamination of stool with urine • For children, use bedpan or hat. If child also needs to void, have child do this first if possible to prevent contamination.

9. Obtaining Blood Specimens (1271) • May be taken from finger, heel, arm • Usually requires therapeutic holding • With venipunctures, make sure elbow is restrained • For fingersticks, give child choice of finger • Allow closeness of parent and sucking sweet pacifier for infants who need heelsticks. Warm heel x 3”; use sides of heel, not middle • Make sure bandage is applied • Have “2 try” policy with most experienced going first

10. Obtaining Respiratory Specimens (1272) • Includes sputum (TB, RSV), throat (strep), nasopharyngeal (pertussis), and nasal washings (RSV) • Almost always requires therapeutic holding; hands over head method is very effective • Usually need to gag child to get good throat culture • Sputum can be obtained by coughing, gastric washing, or tracheal suction • Different collection devices for different sites

11. Medication Administration (1273) • Know action, SEs, and safe dosage ranges • Be aware of child’s immature liver and kidneys and less circulating plasma protein that can increase chances of toxicity. • Most dosages are calculated by mg/kg (most common) or BSA (most accurate) • Always check with HCP if dosage is out of range • Be aware of institutional policies re: double-checking of dosages • Make sure to use 2 methods of ID

12. Oral Administration • Preferred because less invasive; however, is less predictable than injectable routes • Usually use liquid forms rather than solids to reduce aspiration risk. If liquid not available, then crush med unless it is time-released or coated • Syringe is most reliable way to give med; may use nipple for infant

13. Oral cont’d • Do not put in formula or in essential food • If child is uncooperative, try to find out reason and explain to child if developmentally appropriate. Sometimes parent may give med. • If holding is required, avoid putting child on back (see pic on p. 1275) • See Atraumatic Care for ideas to enhance cooperation

14. IM Administration • Use TB syringe for volumes less than 1 mL • Use smallest needle (25 to 30g) if needle is no longer than 1”. If longer, use 22-25g to enhance stability. May need 20-22g if med is viscous. • Lengths range from ½ to 1 ½ inches depending on size and age. • Always change needle prior to injection. • Never give injection to sleeping child.

15. IM cont’d • Use Z-track to lock med and prevent leak into subq; do not use air bubble. • Acceptable amounts for injection depend on size of child, but vary between 0.5 and 2 mL. • Because most children will be uncooperative and to prevent injury, holding will be needed so plan appropriately—parent may or may not want to help • Bunch up or spread, depending on size of child • Use 90 degree angle to minimize trauma and pain • Always aspirate

16. IM Sites • Vastus lateralis is preferred site for infants • Ventrogluteal is acceptable for all ages and is less painful than vastus • Deltoid can be used beginning at 18 months. • Make sure you know how to measure to locate sites (Table 45-4, p. 1276 and 1277) • What do you do if child wants to see needle?

17. Subq and Intradermal • Technique very similar to adults • Sites are same as adults • Use 26-30g ½ or 5/8 inch for subq; 3/8 to ½ inch for ID • Inject small volumes up to 0.5 mL • 45 or 90 degree angle for subq; 10-15 degree angle for ID • No need to aspirate

18. IV Administration • Be sure you know rate, compatibility, and dilution of med to be given • IV rates are slower than adults—usually between 10 and 50 mL/h • Double check IV drugs with another nurse • Always use a pump—its usually a policy

19. IV Administration cont’d • Angiocath size is usually 22 or 24g • Sites on p. 1286, Figure 45-17 • IV starter should be experienced! Some places have a policy about # of sticks • For emergencies with vascular collapse, intraosseous route may be used in children < 6 years

20. Other Routes—Rectal, Optic, Otic, Nasal • Biggest problem is gaining cooperation • Rectal—use little finger; hold cheeks together • Optic—same as adults; if clenching lids, put drop in inner corner • Otic—warm drops; pull pinna down and back in children < 3 yrs; up and back > 3 yrs. • Nasal—if drops, hyperextend neck off of bed; with spray, angle away from septum