Transporting Infants and Children

Infants and children need to be transported within the unit and to areas outside the pediatric unit. Infants and small children can be carried for short distances within the unit, but for more extended trips the child should be securely transported in a suitable conveyance.

Small infants can be held or carried in the horizontal position with the back supported and the thigh grasped firmly by the carrying arm (Fig. 27-5, A). In the football hold, the infant is carried on the nurse’s arm with the head supported by the hand and the body held securely between the nurse’s body and elbow (Fig. 27-5, B). Both of these holds leave the nurse’s other arm free for activity. The infant also can be held in the upright position with the buttocks on the nurse’s forearm and the front of the body resting against the nurse’s chest. The infant’s head and shoulders are supported by the nurse’s other arm in case the infant moves suddenly (Fig. 27-5, C). Older infants are able to hold their heads erect but are still subject to sudden movements.

The method of transporting children depends on their age, condition, and destination. Older children are safe in wheelchairs or on stretchers. Younger children can be transported in their crib, on a stretcher, in a wagon with raised sides, or in a wheelchair with a safety belt. Stretchers should be equipped with high sides and a safety belt, both of which are secured during transport.

Special care is needed in transporting critically ill patients in the hospital. Critically ill children should always be transported on a stretcher or bed (rather than carried) by at least two staff members with monitoring continued during transport. A blood pressure monitor (or standard blood pressure cuff), pulse oximeter, and cardiac monitor/defibrillator should accompany every patient (Warren, Fromm, Orr, et al, 2004). Airway equipment and emergency medications should accompany the patient.

Restraining Methods and Therapeutic Holding

The Joint Commission (2001) defines restraint as “any method, physical or mechanical, which restricts a person’s movement, physical activity, or normal access to his or her body.” Before initiating restraints, the nurse completes a comprehensive assessment of the patient to determine whether the need for a restraint outweighs the risk of not using one. Restraints can result in loss of dignity, violation of patient rights, psychologic harm, physical harm, and even death. Consider alternative methods first and document them in the patient’s record. The nurse is responsible for selecting the least restrictive type of restraint (Table 27-5). Using less restrictive restraints is often possible by gaining the cooperation of the child and parents.

The two types of restraints used with children are classified as medical-surgical and behavioral restraints. When a standard or protocol states that immobilization is required 100% of the time as a part of the procedure or postprocedural care process, the restraint device is considered a part of routine care. For example, the postoperative use of elbow restraints after a cleft lip repair, if written in the protocol or standard of care and used for 100% of patients, would not fall under The Joint Commission or Centers for Medicare and Medicaid Services mandates concerning restraints.

Medical-surgical restraints are used for children with an artificial airway or airway adjunct for delivery of oxygen, indwelling catheters, tubes, drains, lines, pacemaker wires, or suture sites. The medical-surgical restraint is used to ensure that safe care is given to the patient. The potential risks of the restraint are offset by the potential benefit of providing safer care. Medical-surgical restraints may be instituted for any of the following reasons:

Medical-surgical restraints can be initiated by an individual order or by protocol; the use of the protocol must be authorized by an individual order. The order for continued use of restraints must be renewed each day. Patients are monitored at least every 2 hours.

Behavioral restraints are limited to situations with a significant risk of patients physically harming themselves or others because of behavioral reasons and when nonphysical interventions are not effective. Before initiating a behavioral restraint, the nurse should assess the patient’s mental, behavioral, and physical status to determine the cause for the child’s potentially harmful behavior. If behavioral restraints are indicated, a collaborative approach involving the patient (if appropriate), the family, and the health care team should be used. An order must be obtained as soon as possible, but no longer than 1 hour after the initiation of behavioral restraints. Behavioral restraints for children must be reordered every 1 to 2 hours, based on age. A licensed independent practitioner must conduct an in-person evaluation within 1 hour and again every 4 hours until restraints are discontinued. Children in behavioral restraints must be continuously observed and assessed every 15 minutes. Assessment components include signs of injury associated with applying restraint, nutrition and hydration, circulation and range-of-motion of extremities, vital signs, hygiene and elimination, physical and psychologic status and comfort, and readiness for discontinuation of restraint. The nurse must use clinical judgment in setting a schedule for when each of these parameters needs to be evaluated because every parameter must be assessed during each 15-minute physical assessment.

Restraints with ties must be secured to the bed or crib frame, not the side rails. Suggestions for increasing safety and comfort while the child is in a restraint include leaving one finger breadth between skin and the device (Fig. 27-6) and tying knots that allow for quick release. The nurse can also increase safety by ensuring the restraint does not tighten as the child moves and decreasing wrinkles or bulges in the restraint. Placing jacket restraints over an article of clothing; placing limb restraints below waist level, below knee level, or distal to the IV; and tucking in dangling straps also increase safety and comfort.

An alternative approach for temporary restraint is therapeutic holding. Therapeutic holding is the use of a secure, comfortable, temporary holding position that provides close physical contact with the parent or caregiver for 30 minutes or less (Fig. 27-7). The use of restraints can often be avoided with adequate preparation of the child; parental or staff supervision of the child; or adequate protection of a vulnerable site, such as an infusion device. The nurse needs to assess the child’s development, mental status, potential to hurt others or self, and safety. The nurse should carefully consider alternative measures to using restraints. Some examples of alternative measures include bringing a child to the nurses’ station for continuous observation, providing diversional activities, or encouraging the participation of the parents.

Femoral Venipuncture

The nurse places the child supine with the legs in a frog position to provide extensive exposure of the groin area. The infant’s legs can be effectively controlled by the nurse’s forearms and hands (Fig. 27-10). Only the side used for the venipuncture is uncovered so that the practitioner is protected should the child urinate during the procedure. Apply pressure to the site to prevent oozing from the site.

Animation—Central Venous Access via Femoral Vein

Extremity Venipuncture

The most common sites of venipuncture are the veins of the extremities, especially the arm and hand. A convenient position is to place the child in the parent’s (or assistant’s) lap, with the child facing the parent and in the straddle position. Next, place the child’s arm for venipuncture on a firm surface, such as a treatment table. The nurse can partially stabilize the child’s outstretched arm and have the parent hug the child’s upper body, preventing movement; the nurse can then use the parent’s arm to immobilize the venipuncture site. This type of restraint also comforts the child because of the close body contact and allows each person to maintain eye contact (Fig. 27-11).

Animation—IV Line Placement

Lumbar Puncture

Pediatric lumbar puncture (LP) sets contain smaller spinal needles, but sometimes the practitioner will specify a different size or type of needle. The technique for LP in infants and children is similar to that in the adult, although modifications are suggested in neonates, who have less distress in a side-lying position with modified neck extension than in flexion or a sitting position.

Animation—Lumbar Puncture, Infant

Children are usually easiest to control in the side-lying position, with the head flexed and the knees drawn up toward the chest. Even cooperative children need to be held gently to prevent possible trauma from unexpected, involuntary movement. They can be reassured that, although they are trusted, holding will serve as a reminder to maintain the desired position. It also provides a measure of support and reassurance to them.

The child is placed on the side with the back close to the edge of the examining table on the side from which the practitioner is working. Maintain the child’s spine in a flexed position by holding the child with one arm behind the neck and the other behind the thighs (Fig. 27-12, A). The flexed position enlarges the spaces between the lumbar vertebrae, which facilitates access to the spinal fluid space. It is helpful to wrap the legs before positioning to decrease leg movement.

An alternate position used with small infants and some older children is the sitting position. The child is placed with the buttocks at the edge of the table and with the neck flexed so that the chin rests on the child’s chest or the nurse’s shoulder. The nurse’s hands immobilize the infant’s arms and legs (Fig. 27-12, B).

Specimens and spinal fluid pressure are obtained, measured, and sent for analysis in the same manner as for the adult patient. Take vital signs as ordered, and observe the child for any changes in level of consciousness, motor activity, or other neurologic signs. Post-LP headache may occur and is related to postural changes; this is less severe when the child lies flat. Headache is seen much less frequently in young children than in adolescents.

Bone Marrow Aspiration or Biopsy

The position for a bone marrow aspiration or biopsy depends on the chosen site. In children the posterior or anterior iliac crest is most frequently used, although in infants the tibia may be selected because it is easy to access the site and hold the child.

If the posterior iliac crest is used, the child is positioned prone. Sometimes a small pillow or folded blanket is placed under the hips to facilitate obtaining the bone marrow specimen. Children should receive adequate analgesia or anesthesia to relieve pain. If the child might awaken, he or she may need to be held, preferably by two people—one person to immobilize the upper body and a second person to immobilize the lower extremities.

Urine Specimens

Older children and adolescents can use a bedpan or urinal or can be trusted to follow directions for collection in the bathroom. However, they may have special needs. School-age children are cooperative but curious. They are concerned about the reasons behind things and are likely to ask questions regarding the disposition of their specimen and what one expects to discover from it. Self-conscious adolescents may be reluctant to carry a specimen through a hallway or waiting room and appreciate a paper bag for disguising the container. The presence of menses may be an embarrassment or a concern to teenage girls; therefore it is a good idea to ask them about this and make adjustments as necessary. The specimen can be delayed or a notation made on the laboratory slip to explain the presence of red blood cells.

Skill—Urine Specimen Collection

Preschoolers and toddlers are usually unable to void on request. It is often best to offer them water or other liquids that they enjoy and wait about 30 minutes until they are ready to void voluntarily.

Children will better understand what is expected if the nurse uses familiar terms, such as “pee-pee,” “wee-wee,” or “tinkle.” Some have difficulty voiding in an unfamiliar receptacle. Potty chairs or a potty hat placed on the toilet is usually satisfactory. Toddlers who have recently acquired bladder control may be especially reluctant, since they undoubtedly have been admonished for “going” in places other than those approved by parents. Enlisting the parents’ help usually leads to success. For infants and toddlers who are not toilet trained, special urine collection bags with self-adhering material around the opening at the point of attachment are used. To prepare the infant, the genitalia, perineum, and surrounding skin are washed and dried thoroughly, since the adhesive will not stick to a moist, powdered, or oily skin surface. The collection bag is easiest to apply if attached first to the perineum, progressing to the symphysis pubis (Fig. 27-13). With girls the perineum is stretched taut during application to ensure a leakproof fit. With boys the penis and sometimes the scrotum are placed inside the bag. The adhesive portion of the bag must be firmly applied to the skin all around the genital area to avoid leakage. For low-birth-weight infants, small bags with adhesive that is gentle to the skin are available.* The diaper is carefully replaced. The bag is checked frequently and removed as soon as the specimen is available, since the moist bag may become loosened on an active child. For some types of urine testing, such as specific gravity, ketones, glucose, and protein, the nurse can aspirate urine directly from the diaper. If the urine is not tested within 30 minutes, the specimen is refrigerated or placed in a sterile container with a preservative.

Urine obtained from disposable diapers can be tested accurately for glucose, ketones, protein, blood, and urea. Superabsorbent disposable diapers may absorb all urine and may also produce a false crystalluria. Specific gravity measurements are accurate for up to 4 hours provided that the disposable diapers are kept folded. Urine samples collected by the cotton ball method were accurate for pH and specific gravity and were atraumatic to the skin of newborns (Burke, 1995).

At times parents may be asked to bring a urine sample to a health care facility for examination, especially when infants are unable to void during an outpatient visit. In this instance parents need instructions on applying the collection device and storing the specimen. Ideally, the specimen should be brought to the designated place as soon as possible. If there is a delay, the sample should be refrigerated and the lapsed time reported to the examiner.

Stool Specimens

Stool specimens are frequently collected from children to identify parasites and other organisms that cause diarrhea, to assess gastrointestinal function, and to check for occult (hidden) blood. Ideally, stool should be collected without contamination with urine, but in children wearing diapers, this is difficult unless a urine bag is applied. Children who are toilet trained should urinate first, flush the toilet, and then defecate into the toilet or a bedpan (preferably one that is placed on the toilet to avoid embarrassment) or a commercial potty hat.

Stool specimens should be large enough to obtain an ample sampling, not merely a fecal fragment. Specimens are placed in an appropriate container, which is covered and labeled. If several specimens are needed, mark the containers with the date and time and keep them in a specimen refrigerator. Exercise care in handling the specimen because of the risk of contamination.

Blood Specimens

Whether the specimen is collected by the nurse or by others, the nurse is responsible for making certain that specimens, such as serial examinations and fasting specimens, are collected on time and that the proper equipment is available. Collecting, transporting, and storing specimens can have a major impact on laboratory results.

Venous blood samples can be obtained by venipuncture or by aspiration from a peripheral or central access device. Withdrawing blood specimens through peripheral lock devices in small peripheral veins has varying degrees of success. Although it avoids an additional venipuncture for the child, attempting to aspirate blood from the peripheral lock may shorten the life of the device. However, the nurse can use central lines to withdraw blood samples (see Fig. 27-14, Evidence-Based Practice box, and Atraumatic Care box). When using an IV infusion site for specimen collection, consider the type of fluid being infused. For example, a specimen collected for glucose determination would be inaccurate if removed from a catheter through which glucose-containing solution was being administered.

The needed specimens are quickly collected, and pressure is applied to the puncture site with dry gauze until bleeding stops. The arm should be extended, not flexed, while pressure is applied for a few minutes after venipuncture in the antecubital fossa to reduce bruising. The nurse then covers the site with an adhesive bandage. In young children, adhesive bandages pose an aspiration hazard, so avoid using them or remove the adhesive bandage as soon as the bleeding stops. Applying warm compresses to ecchymotic areas increases circulation, helps remove extravasated blood, and decreases pain.

Arterial blood samples are sometimes needed for blood gas measurement, although noninvasive techniques, such as transcutaneous oxygen monitoring and pulse oximetry, are used frequently. Arterial samples may be obtained by arterial puncture using the radial, brachial, or femoral arteries, or from indwelling arterial catheters. Assess adequate circulation before arterial puncture by observing capillary refill or performing the Allen test, a procedure that assesses the circulation of the radial, ulnar, or brachial arteries. (See Blood Gas Determination, Chapter 31.) Because unclotted blood is required, use only heparinized collection tubes or syringes. In addition, no air bubbles should enter the tube because they can alter blood gas concentration. Crying, fear, and agitation affect blood gas values; therefore make every effort to comfort the child. Pack the blood samples in ice to reduce blood cell metabolism and take it to the laboratory immediately.

Take capillary blood samples from children by finger stick. A common method for taking peripheral blood samples from infants younger than 6 months of age is by a heel stick. Before the blood sample is taken, warm the heel for 3 minutes and cleanse the area with alcohol. Holding the infant’s foot firmly with the free hand, the nurse then punctures the heel with an automatic lancet device. An automatic device delivers a more precise puncture depth and is less painful than using a lance (Vertanen, Fellman, Brommels, et al, 2001). A surgical blade of any kind is contraindicated. An example of a safe device is the BD Quickheel Safety Lancet. The Tenderfoot Preemie device* was compared with the Monolet lancet and was found to be safer than the lancet and required fewer heel punctures, less collection time, and lower recollection rates (Kellam, Sacks, Wailer, et al, 2001). Shepherd, Glenesk, Niven, and colleagues (2005) reported the Tenderfoot device was more effective and safer than a lancet for newborn screening tests. Although obtaining capillary blood gases is a common practice, these measures may not accurately reflect arterial values.

The most serious complications of infant heel puncture are necrotizing osteochondritis from lancet penetration of the underlying calcaneus bone, infection, and abscess of the heel. To avoid osteochondritis, the puncture should be no deeper than 2 mm and should be made at the outer aspect of the heel. The boundaries of the calcaneus can be marked by an imaginary line extending posteriorly from a point between the fourth and fifth toes and running parallel with the lateral aspect of the heel and another line extending posteriorly from the middle of the great toe and running parallel with the medial aspect of the heel (Fig. 27-15). Repeated trauma to the walking surface of the heel can cause fibrosis and scarring that may interfere with locomotion.

No matter how or by whom the specimen is collected, children, even some older ones, fear the loss of their blood. This is particularly true for children whose condition requires frequent blood specimens. They mistakenly believe that blood removed from their body is a threat to their lives. Explaining to them that their body continuously produces blood provides them a measure of reassurance. When the blood is drawn, a comment such as, “Just look how red it is. You’re really making a lot of nice red blood,” confirms this information and affords them an opportunity to express their concern. An adhesive bandage gives them added assurance that the vital fluids will not leak out through the puncture site.

Children also dislike the discomfort associated with venous, arterial, or capillary punctures. Children have identified these procedures as the ones most frequently causing pain during hospitalization and an arterial puncture as being one of the most painful of all procedures experienced. Toddlers are most distressed by venipuncture, followed by school-age children and then adolescents. Consequently, nurses need to institute pain reduction techniques to lessen the discomfort of these procedures. (See Pain Management, Chapter 7.)

Respiratory Secretion Specimens

Collection of sputum or nasal discharge is sometimes required for diagnosis of respiratory infections, especially tuberculosis and respiratory syncytial virus (RSV). Older children and adolescents are able to cough as directed and supply sputum specimens when given proper directions. The nurse must make it clear to them that a coughed specimen, not mucus cleared from the throat, is needed. It is helpful to demonstrate a deep cough. Infants and small children are unable to follow directions to cough and will swallow any sputum produced; therefore gastric washings (lavage) may be used to collect a sputum specimen. Sometimes a satisfactory specimen can be obtained using a suction device such as a mucus trap if the catheter is inserted into the trachea and the cough reflex elicited. A catheter inserted into the back of the throat is not sufficient. For children with a tracheostomy, a specimen is easily aspirated from the trachea or major bronchi by attaching a collecting device to the suction apparatus.

Nasal washings are usually obtained to diagnose an infection of RSV. The child is placed supine, and 1 to 3 ml of sterile normal saline is instilled with a sterile syringe (without needle) into one nostril. The contents are aspirated using a small, sterile bulb syringe and are placed in a sterile container. Another method uses a syringe with 5 cm (2 inches) of 18- to 20-gauge tubing. The saline is quickly instilled and then aspirated to recover the nasal specimen. To prevent any additional discomfort, all of the equipment should be ready before beginning the procedure.

Other respiratory secretion collection methods include nasopharyngeal swabs to diagnose Bordetella pertussis and throat cultures. The nurse swabs both the tonsils and the posterior pharynx when obtaining a throat culture. The swab stick is inserted into the culture tube. Some culture kits require squeezing an ampule to release the culture medium.

Determination of Drug Dosage

Nurses must have an understanding of the safe dosage of medications they administer to children, as well as the expected action, possible side effects, and signs of toxicity. Unlike with adult medications, there are few standardized pediatric dosage ranges, and with a few exceptions, drugs are prepared and packaged in average adult-dosage strengths.

Factors related to growth and maturation significantly alter an individual’s capacity to metabolize and excrete drugs. Immaturity or defects in any of the important processes of absorption, distribution, biotransformation, or excretion can significantly alter the effects of a drug. Newborn and premature infants with immature enzyme systems in the liver (where most drugs are broken down and detoxified), lower plasma concentrations of protein for binding with drugs, and immaturely functioning kidneys (where most drugs are excreted) are particularly vulnerable to the harmful effects of drugs. Beyond the newborn period, many drugs are metabolized more rapidly by the liver, necessitating larger doses or more frequent administration. This is particularly important in pain control, when the dosage of analgesics may need to be increased or the interval between doses decreased.

Various formulas involving age, weight, and body surface area (BSA) as the basis for calculations have been devised to determine children’s drug dosages. Because the administration of medication is a nursing responsibility, nurses need to have not only knowledge of drug action and patient responses, but also resources for estimating safe dosages for children. Children’s dosages are most often expressed in units of measure per body weight (mg/kg). Some medications, such as chemotherapy, are more precisely dosed using BSA. The ratio of BSA to weight varies inversely with length; therefore the infant who is shorter and weighs less than an older child or adult has relatively more BSA than would be expected from the weight. BSA is based on the West nomogram and is easily determined using conversion programs widely available on the Internet.

Oral Administration

The oral route is preferred for administering medications to children because of the ease of administration. Most are dissolved or suspended in liquid preparations. Although some children are able to swallow or chew solid medications at an early age, solid preparations are not recommended for young children because of the danger of aspiration.

Most pediatric medications come in palatable and colorful preparations for added ease of administration. Some have a slightly unpleasant aftertaste, but most children swallow these liquids with little if any resistance. The nurse can taste a minute amount of an oral preparation to see whether it is palatable or bitter. Complaints of dislike from the child can be accepted and the taste camouflaged whenever possible. Most pediatric units have preparations available for this purpose (see Atraumatic Care box).

Intramuscular Administration

Subcutaneous and Intradermal Administration

Subcutaneous and intradermal injections are frequently administered to children, but the technique differs little from the method used with adults. Examples of subcutaneous injections include insulin, hormone replacement, allergy desensitization, and some vaccines. Tuberculin testing, local anesthesia, and allergy testing are examples of frequently administered intradermal injections.

Techniques to minimize the pain associated with these injections include changing the needle if it pierced a rubber stopper on a vial, using 26- to 30-gauge needles (only to inject the solution), and injecting small volumes (<0.5 ml). The angle of the needle for the subcutaneous injection is typically 90 degrees. In children with little subcutaneous tissue, some practitioners insert the needle at a 45-degree angle. However, the benefit of using the 45-degree angle rather than the 90-degree angle remains controversial.

Although subcutaneous injections can be given anywhere there is subcutaneous tissue, common sites include the center third of the lateral aspect of the upper arm, the abdomen, and the center third of the anterior thigh. Some practitioners believe it is not necessary to aspirate before injecting subcutaneously; for example, this is an accepted practice in the administration of insulin. Automatic injector devices do not aspirate before injecting.

When giving an intradermal injection into the volar surface of the forearm, the nurse should avoid the medial side of the arm, where the skin is more sensitive.

Intravenous Administration

The IV route for administering medications is frequently used in pediatric therapy. For some drugs it is the only effective route. This method is used for giving drugs to children who:

Evidence-Based Practice—Frequency of Changing Intravenous Administration Sets

Chapter 28 discusses insertion sites and observation of the IV infusion under Parenteral Fluid Therapy and Venous Access Devices. The nurse needs to consider several factors in relation to IV medication. When a drug is administered intravenously, the effect is almost instantaneous and further control is limited. Most drugs for IV administration require a specified minimum dilution and/or rate of flow, and many are highly irritating or toxic to tissues outside the vascular system. In addition to the precautions and nursing observations commonly related to IV therapy, factors to consider when preparing and administering drugs to infants and children by the IV route include:

Before any IV infusion, check the site of insertion for patency. Never administer medications with blood products. Only one antibiotic should be administered at a time. Extra fluids needed to administer IV medications can be problematic for infants and fluid-restricted children. Syringe pumps are often used to deliver IV medication because they minimize fluid requirements and more precisely deliver small volumes of medication compared with large-volume infusion pumps. Regardless of the technique, the nurse must know the minimum dilutions for safe administration of IV medications to infants and children.

Several methods of venous access are available and include the peripheral lock device, central venous catheters, and implanted infusion ports. (See Venous Access Devices, Chapter 28.)

Nasogastric, Orogastric, or Gastrostomy Administration

When a child has an indwelling feeding tube or a gastrostomy, oral medications are usually given via that route. An advantage of this method is the ability to administer oral medications around the clock without disturbing the child. A disadvantage is the risk of occluding, or clogging, the tube, especially when giving viscous solutions through small-bore feeding tubes. The most important preventive measure is adequate flushing after the medication is instilled (see Nursing Care Guidelines box).

Rectal Administration

The rectal route for administration is less reliable but sometimes used when the oral route is difficult or contraindicated. It is also used when oral preparations are unsuitable to control vomiting. Some of the drugs available in suppository form are acetaminophen, aspirin, sedatives, analgesics (morphine), and antiemetics. The difficulty in using the rectal route is that, unless the rectum is empty at the time of insertion, the absorption of the drug may be delayed, diminished, or prevented by the presence of feces. Sometimes the drug is later evacuated, securely surrounded by stool.

Remove the wrapping on the suppository, and lubricate the suppository with water-soluble jelly or warm water. Rectal suppositories are traditionally inserted with the apex (pointed end) foremost. Reverse contractions or the pressure gradient of the anal canal may help the suppository slip higher into the canal. Using a glove or finger cot, quickly but gently insert the suppository into the rectum, beyond both of the rectal sphincters. Then hold the buttocks together firmly to relieve pressure on the anal sphincter until the urge to expel the suppository has passed, which occurs within 5 to 10 minutes. Sometimes the amount of drug ordered is less than the dose available. The irregular shape of most suppositories makes the process of dividing them into a desired dose difficult if not dangerous. If it must be halved, it should be cut lengthwise. However, there is no guarantee that the drug is evenly dispersed throughout the petrolatum base.

If medication is administered via a retention enema, the same procedure is used. Drugs given by enema are diluted in the smallest amount of solution possible to minimize the likelihood of being evacuated.

Optic, Otic, and Nasal Administration

There are few differences in administering eye, ear, and nose medication to children and to adults. The major difficulty is in gaining children’s cooperation. Older children need only explanation and direction. Although the administration of optic, otic, and nasal medication is not painful, these drugs can cause unpleasant sensations, which can be eliminated with various techniques.

To instill eye medication, place the child supine or sitting with the head extended and ask the child to look up. Use one hand to pull the lower lid downward; the hand that holds the dropper rests on the head so that it may move synchronously with the child’s head, thus reducing the possibility of trauma to a struggling child or dropping medication on the face (Fig. 27-19). When the lower lid is pulled down, a small conjunctival sac is formed; apply the solution or ointment to this area, rather than directly on the eyeball. Another effective technique is to pull the lower lid down and out to form a cup effect, into which the medication is dropped. Gently close the lids to prevent expression of the medication. Wipe excess medication from the inner canthus outward to prevent contamination to the contralateral eye.

Instilling eye drops in infants can be difficult because they often clench the lids tightly closed. One approach is to place the drops in the nasal corner where the lids meet. The medication pools in this area, and when the child opens the lids, the medication flows onto the conjunctiva. For young children, playing a game can be helpful, such as instructing the child to keep the eyes closed to the count of three and then open them, at which time the drops are quickly instilled. Ointment can be applied by gently pulling down the lower lid and placing the ointment in the lower conjunctival sac.

Ear drops are instilled with the child in the prone or supine position and the head turned to the appropriate side. For children younger than 3 years of age, the external auditory canal is straightened by gently pulling the pinna downward and straight back. The pinna is pulled upward and back in children older than 3 years of age (see Fig. 6-24). To place the drops deep into the ear canal without contaminating the tip of the dropper, place a disposable ear speculum in the canal and administer the drops through the speculum. After instillation, the child should remain lying on the unaffected side for a few minutes. Gentle massage of the area immediately anterior to the ear facilitates the entry of drops into the ear canal. The use of cotton pledgets prevents medication from flowing out of the external canal. However, they should be loose enough to allow any discharge to exit from the ear. Premoistening the cotton with a few drops of medication prevents the wicking action from absorbing the medication instilled in the ear.

Nose drops are instilled in the same manner as in the adult patient. Unpleasant sensations associated with medicated nose drops are minimized when care is taken to position the child with the head extended well over the edge of the bed or pillow (Fig. 27-20). Depending on size, infants can be positioned in the football hold (see Fig. 27-5, B); in the nurse’s arm with the head extended and stabilized between the nurse’s body and elbow, and the arms and hands immobilized with the nurse’s hands; or with the head extended over the edge of the bed or a pillow. After instillation of the drops, the child should remain in position for 1 minute to allow the drops to come in contact with the nasal surfaces. Insert nasal spray dispensers into the naris vertically and then angle them to avoid trauma to the septum and to direct medication toward the inferior turbinate.

Family Teaching and Home Care

The nurse usually assumes responsibility for preparing families to administer medications at home. The family should understand why the child is receiving the medication and the effects that might be expected, as well as the amount, frequency, and length of time the drug is to be administered. Instruction should be carried out in an unhurried, relaxed manner, preferably in an area away from a busy ward or office.

Instruct the caregiver carefully regarding the correct dosage. Some persons have difficulty understanding medical terminology, and just because they nod or otherwise indicate they understand, the nurse should not assume that the message is clear. It is important to ascertain their interpretation of a teaspoon, for example, and to be certain they have acceptable devices for measuring the drug. If the drug is packaged with a dropper, syringe, or plastic cup, the nurse should show or mark the point on the device that indicates the prescribed dose and demonstrate how the dose is drawn up into a dropper or syringe, measured, and the bubbles eliminated. If the nurse has any doubts about the parent’s ability to administer the correct dose, the parent should give a return demonstration. This is essential when the drug has potentially serious consequences from incorrect dosage, such as insulin or digoxin, or when more complex administration is required, such as parenteral injections. When teaching a parent to give an injection, the nurse must allot adequate time for instruction and practice.

Home modifications are often necessary because the availability of equipment or assistance can differ from the hospital setting. For example, the parent may need guidance in devising methods that allow one person to hold the child and safely give the drug.

The nurse should clarify with parents the time that the drug is to be administered. For instance, when a drug is prescribed in association with meals, the number of meals that the family is accustomed to eating influences the amount of drug the child receives. Does the family have meals twice a day or five times a day? When a drug is to be given several times during the day, together the nurse and parents can work out a schedule that accommodates the family’s routine. This is particularly significant if a drug must be given at equal intervals throughout a 24-hour period. For example, telling parents that the child needs 1 tsp of medicine four times a day is subject to misinterpretation, since the parents may routinely schedule the doses at incorrect times. Instead, a preplanned schedule based on 6-hour intervals should be set up with the number of days required for the therapeutic dosage listed. Modification should also be made to accommodate sleep schedules. Written instructions should accompany all drug prescriptions.

• Use a separate, specifically designed enteral feeding pump mounted on a separate pole for continuous-feeding solutions.

• Label all tubing of continuous enteral feeding with brightly colored tape or labels.

• Use specifically designed continuous-feeding bags to contain the solutions instead of parenteral equipment, such as a burette.

• Whenever access or connections are made, trace the tubing all the way from the patient to the bag to ensure the correct tubing source is selecting.

Gavage Feeding

Infants and children can be fed simply and safely by a tube passed into the stomach through either the nares or the mouth. The tube can be left in place or inserted and removed with each feeding. In older children it is usually less traumatic to tape the tube securely in place between feedings. When this alternative is used, the tube should be removed and replaced with a new tube according to hospital policy, specific orders, and the type of tube used. Meticulous hand washing is practiced during the procedure to prevent bacterial contamination of the feeding, especially during continuous-drip feedings.

Gastrostomy Feeding

Feeding by way of gastrostomy, or G tube, is often used for children in whom passage of a tube through the mouth, pharynx, esophagus, and cardiac sphincter of the stomach is contraindicated or impossible. It is also used to avoid the constant irritation of a nasogastric tube in children who require tube feeding over an extended period. A gastrostomy tube may be placed with the child under general anesthesia or percutaneously using an endoscope with the patient sedated and under local anesthesia (percutaneous endoscopic gastrostomy [PEG]). The tube is inserted through the abdominal wall into the stomach about midway along the greater curvature and secured by a purse-string suture. The stomach is anchored to the peritoneum at the operative site. The tube used can be a Foley, wing-tip, or mushroom catheter. Immediately after surgery the catheter may be left open and attached to gravity drainage for 24 hours or more.

Direct postoperative care of the wound site toward prevention of infection and irritation. Cleanse the area at least daily or as often as needed to keep the area free of drainage. After healing, meticulous care is needed to keep the area surrounding the tube clean and dry to prevent excoriation and infection. Daily applications of antibiotic ointment or other preparations may be prescribed to aid in healing and prevent irritation (see p. 1049). Exercise care to prevent excessive pull on the catheter that might cause widening of the opening and subsequent leakage of highly irritating gastric juices. Secure the tube to the abdomen, leaving a small loop of tubing at the exit site to prevent tension on the site (see Evidence-Based Practice box).

Granulation tissue may grow around a gastrostomy site (Fig. 27-22). This moist, beefy red tissue is not a sign of infection. However, if it continues to grow, the excess moisture can irritate the surrounding skin.

For children receiving long-term gastrostomy feeding, a skin-level device (e.g., MIC-KEY, Bard Button) offers several advantages. The small, flexible silicone device protrudes slightly from the abdomen, is cosmetically pleasing, affords increased comfort and mobility to the child, is easy to care for, and is fully immersible in water. The one-way valve at the proximal end minimizes reflux and eliminates the need for clamping. However, the skin-level device requires a well-established gastrostomy site and is more expensive than the conventional tube. In addition, the valve may become clogged. When functioning, the valve prevents air from escaping; therefore the child may require frequent bubbling. With some devices, during feedings the child must remain fairly still because the tubing easily disconnects from the opening if the child moves. With other devices, extension tubing can be securely attached to the opening (Fig. 27-23). The feeding is instilled at the other end of the tubing in a manner similar to that for a regular gastrostomy. The extension tubing may also have a separate medication port. Both the feeding and the medication ports have plugs attached. Some skin-level devices require a special tube to be able to decompress the stomach (to check residual or decompress air).

Feeding of water, formula, or pureed foods is carried out in the same manner and rate as for gavage feeding. A mechanical pump may be used to regulate the volume and rate of feeding. After feedings the infant or child is positioned on the right side or in the Fowler position, and the tube may be clamped or left open and suspended between feedings, depending on the child’s condition. A clamped tube allows more mobility but is only appropriate if the child can tolerate intermittent feedings without vomiting or prolonged backup of feeding into the tube. Sometimes a Y tube is used to allow for simultaneous decompression during feeding. If a Foley catheter is used as the gastrostomy tube, apply very slight tension. The tube is securely taped to maintain the balloon at the gastrostomy opening and prevent leakage of gastric contents and the tube’s progression toward the pyloric sphincter, where it may occlude the stomach outlet. As a precaution, the length of the tube is measured postoperatively and then remeasured each shift to be certain it has not slipped. The nurse can make a mark above the skin level to further ensure its placement. When the gastrostomy tube is no longer needed, it is removed; the skin opening usually closes spontaneously by contracture.

Nasoduodenal and Nasojejunal Tubes

Children at high risk for regurgitation or aspiration such as those with gastroparesis, mechanical ventilation, or brain injuries may require placement of a postpyloric feeding tube. A trained practitioner inserts the nasoduodenal or nasojejunal tube because of the risk of misplacement and potential for perforation in tubes requiring a stylet. Accurate placement is verified by radiography. Small-bore tubes may easily clog. Flush tube when feeding is interrupted, before and after medication administration, and routinely every 4 hours or as directed by institutional policy. Tube replacement should be considered monthly to ensure optimal tube patency. Continuous feedings are delivered by mechanical pump to regulate volume and rate. Bolus feeds are contraindicated. Tube displacement is suspected in the child showing signs of feeding intolerance such as vomiting. Stop feedings and notify the practitioner.

Total Parenteral Nutrition

Total parenteral nutrition (TPN) provides for the total nutritional needs of infants or children whose lives are threatened because feeding by way of the gastrointestinal tract is impossible, inadequate, or hazardous.

TPN therapy involves IV infusion of highly concentrated solutions of protein, glucose, and other nutrients. The solution is infused through conventional tubing with a special filter attached to remove particulate matter or microorganisms that may have contaminated the solution. The highly concentrated solutions require infusion into a vessel with sufficient volume and turbulence to allow for rapid dilution. The wide-diameter vessels selected are the superior vena cava and innominate or intrathoracic subclavian veins approached by way of the external or internal jugular veins. The highly irritating nature of concentrated glucose precludes the use of the small peripheral veins in most instances. However, dilute glucose-protein hydrolysates that are appropriate for infusing into peripheral veins are being used with increasing frequency. When peripheral veins are used, intralipid becomes the major calorie source. For long-term alimentation, central venous catheters are usually used.

Evidence-Based Practice—Central Venous Catheter Site Care

The major nursing responsibilities are the same as for any IV therapy: control of sepsis, monitoring of the infusion rate, and assessment of the patient. The TPN solution must be prepared under rigid aseptic conditions, which is best accomplished by specially trained technicians. Specially trained nurses should change the solution and tubing and redress the infusion using meticulous aseptic precautions. In some institutions this may be a nursing responsibility. If so, the procedure is carried out according to hospital protocol.

The infusion is maintained at a constant rate by means of an infusion pump to ensure the proper concentrations of glucose and amino acids. Accurate calculation of the rate is required to deliver a measured amount in a given length of time. Because alterations in flow rate are relatively common, the drip should be checked frequently to ensure an even, continuous infusion. The TPN infusion rate should not be increased or decreased without the practitioner being informed, since alterations can cause hyperglycemia or hypoglycemia.

General assessments, such as vital signs, input and output measurements, and checking results of laboratory tests, facilitate early detection of infection or fluid and electrolyte imbalance. Additional amounts of potassium and sodium chloride are often required in hyperalimentation; therefore observation for signs of potassium or sodium deficit or excess is part of nursing care. This is rarely a problem except in children with reduced renal function or metabolic defects. Hyperglycemia may occur during the first day or two as the child adapts to the high-glucose load of the hyperalimentation solution. Although hyperglycemia occurs infrequently, insulin may be required to help the body adjust. When this occurs, nursing responsibilities include blood glucose testing. To prevent hypoglycemia when the hyperalimentation is disconnected, the rate of the infusion and the amount of insulin are decreased gradually.

Family Teaching and Home Care

When alternative feedings are needed for an extended period, the family needs to learn how to feed the child with a nasogastric, gastrostomy, or TPN feeding regimen. The same principles apply as discussed earlier in this chapter for compliance, especially in terms of education, and in Chapter 26 for discharge planning and home care. Plan ample time for the family to learn and perform the procedures under supervision before they assume full responsibility for the child’s care. Refer the family to community agencies that provide support and practical assistance. The Oley Foundation* is a nonprofit research and education organization that assists persons receiving enteral nutrition and home TPN.

Enema

The procedure for giving an enema to an infant or child does not differ essentially from that for an adult, except for the type and amount of fluid administered and the distance for inserting the tube into the rectum (Table 27-8). Depending on the volume, use a syringe with rubber tubing, an enema bottle, or an enema bag.

An isotonic solution is used in children. Plain water is not used because, being hypotonic, it can cause rapid fluid shift and fluid overload. The Fleet enema (pediatric or adult sized) is not advised for children because of the harsh action of its ingredients (sodium biphosphate and sodium phosphate). Commercial enemas can be dangerous to patients with megacolon and to dehydrated or azotemic children. The osmotic effect of the Fleet enema may produce diarrhea, which can lead to metabolic acidosis. Other potential complications are extreme hyperphosphatemia, hypernatremia, and hypocalcemia, which may lead to neuromuscular irritability and coma (Walton, Thomas, Aly, et al, 2000).

Because infants and young children are unable to retain the solution after it is administered, the buttocks must be held together for a short time to retain the fluid. The enema is administered and expelled while the child is lying with the buttocks over the bedpan and with the head and back supported by pillows. Older children are ordinarily able to hold the solution if they understand what to do and if they are not expected to hold it for too long. The nurse should have the bedpan handy or, for the ambulatory child, ensure that the bathroom is available before beginning the procedure. An enema is an intrusive procedure and thus threatening to the preschool child; therefore a careful explanation is especially important to ease possible fear.

A preoperative bowel preparation solution given orally or through a nasogastric tube is increasingly being used instead of an enema. The polyethylene glycol–electrolyte lavage solution (GoLYTELY) mechanically flushes the bowel without significant absorption, thereby avoiding potential fluid and electrolyte imbalances. NuLYTELY, a modification of GoLYTELY, has the same therapeutic advantages as GoLYTELY and was developed to improve on the taste. Another effective oral cathartic is magnesium citrate solution.

Ostomies

Children may require stomas for various health problems. The most frequent causes in the infant are necrotizing enterocolitis and imperforate anus and, less often, Hirschsprung disease. In the older child the most frequent causes are inflammatory bowel disease, especially Crohn disease (regional enteritis), and ureterostomies for distal ureter or bladder defects.

Care and management of ostomies in the older child differ little from the care of ostomies in the adult patient. The major emphasis in pediatric care is preparing the child for the procedure and teaching care of the ostomy to the child and family. The basic principles of preparation are the same as for any procedure (see p. 1000). Simple, straightforward language is most effective, together with the use of illustrations and a replica model (e.g., drawing a picture of a child with a stoma on the abdomen and explaining it as “another opening where bowel movements [or any other term the child uses] will come out”). At another time the nurse can draw a pouch over the opening to demonstrate how the contents are collected. Using a doll to demonstrate the process is an excellent teaching strategy, and special books are available.

Children with ileostomies are fitted immediately after surgery with an appliance to protect the skin from the proteolytic enzymes in the liquid stool. Infants may not be fitted with a pouch in the immediate postoperative period. When stomal drainage is minimal, as is often the case in small or preterm infants, a gauze dressing will suffice. Give your parents a choice of caring for the colostomy with or without an appliance. Pediatric appliances are available in a variety of sizes to ensure an adequate fit.*

Ostomy equipment consists of a one- or two-piece system with a hypoallergenic skin barrier to maintain peristomal skin integrity (Fig. 27-24). The pouch should be large enough to contain a moderate amount of stool and flatus but not so large as to overwhelm the infant or child. A backing helps minimize the risk of skin breakdown from moisture trapped between the skin and pouch. Avoid small clips or rubber bands to prevent choking in the young child.

Protection of the peristomal skin is a major aspect of stoma care. Well-fitting appliances are important to prevent leakage of contents. Before applying the appliance, prepare the skin with a skin sealant that is allowed to dry. Then apply stoma paste around the base of the stoma or to the back of the wafer. The sealant and paste work together to prevent peristomal skin breakdown.

In infants with a colostomy left unpouched, skin care is similar to that of any diapered child. However, protect the peristomal skin with a barrier substance (e.g., zinc oxide ointment [Sensi-Care] or a mixture of zinc oxide ointment and stoma powder [Stomahesive]). A diaper larger than the one usually worn may be needed to extend upward over the stoma and absorb drainage. If the skin becomes inflamed, denuded, or infected, the care is similar to the interventions used for diaper dermatitis. (See Chapter 13.) A zinc-based product helps protect healthy skin, heal excoriated skin, and minimize pain associated with skin breakdown. The skin protectant adheres to denuded, weeping skin. The nurse can apply zinc-based products over topical antifungal and antibacterial agents if infection is present. No-sting barrier film is a skin sealant that has no alcohol base and can be used on open skin without stinging.

With young children, preventing them from pulling off the pouch is also an important consideration. One-piece outfits keep exploring hands from reaching the pouch, and the loose waist avoids any pressure on the appliance. Keeping the child occupied with toys during the pouch change is also helpful. As children mature, encourage their participation in ostomy care. Even preschoolers can assist by holding supplies, pulling paper backings from the appliance, and helping clean the stoma area. Toilet training for bladder control needs to begin at the appropriate time, as for any other child.

Older children and adolescents should eventually have total responsibility for ostomy care just as they would for usual bowel function. During adolescence, concerns for body image and the ostomy’s impact on intimacy and sexuality emerge. The nurse should stress to teenagers that the presence of a stoma need not interfere with their activities. These youngsters can choose which ostomy equipment is best suited to their needs. Attractively designed and decorated pouch covers are well liked by teenagers.

Children with familial adenomatous polyposis may require a colectomy with ileoanal reservoir to prevent or treat carcinoma of the colon. Peristomal skin care for these children is particularly challenging because of increased liquid stools, increased digestive enzymes that may cause skin breakdown, and the stoma being at skin level rather than raised. Additional care with this condition includes close monitoring of fluid and electrolyte status and increased incidence of bowel obstruction.

An enterostomal therapy nurse specialist is an important member of the health care team and will have additional suggestions and assistance with skin care information and ostomy pouching options. The nurse can obtain further information by contacting the Wound, Ostomy and Continence Nurses Society.*

Family Teaching and Home Care

Because these children are almost always discharged with a functioning colostomy, preparation of the family should begin as early as possible in the hospital. The nurse instructs the family in the application of the device (if used), care of the skin, and appropriate action in case skin problems develop. Early evidence of skin breakdown or stomal complications, such as ribbonlike stools, excessive diarrhea, bleeding, prolapse, or failure to pass flatus or stool, is brought to the attention of the physician, nurse, or stoma specialist. The same principles are applied as discussed earlier in this chapter for compliance, especially in terms of education, and in Chapter 26 for discharge planning and home care.

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