Balance and Imbalance of Body Fluids

Mechanisms of Fluid Movement,

Maintaining Water Balance,

Changes in Fluid Volume Related to Growth,

Water Balance in Infants,

Types of Dehydration,

Degree of Dehydration,

Mechanisms of Edema Formation,

Hydrogen Ion Concentration,

Compensatory Mechanisms,

Laboratory Measurements,

Associated Disturbances in Acid-Base Balance,

History,

Clinical Observations,

Intake and Output Measurement,

The Child Who Is NPO,

Intravenous Infusion,

Intraosseous Infusion,

Preparing the Child and Parents,

The Procedure,

Securing a Peripheral Intravenous Line,

Removal of a Peripheral Intravenous Line,

Complications,

Peripheral Intermittent Infusion Device,

Peripherally Inserted Central Catheters,

Long-Term Central Venous Access Devices,

Complications,

Parent and Child Teaching,

Complications,

Home Parenteral Nutrition,

Mechanisms of Fluid Movement

Water is retained in the body in a relatively constant amount and, with few exceptions, is freely exchangeable among all body fluid compartments. The proximity of the extravascular compartment to the cells allows for continuous change in volume and distribution of fluids, largely determined by solutes (especially sodium) and physical forces (Fig. 28-1). Transport mechanisms are the basis for all activity within the cells, and because the cells have limited ability to store materials, movement in and out of cells must be rapid. Internal control mechanisms are responsible for distribution and maintenance of fluid balance (Box 28-1).

Maintaining Water Balance

Maintenance water requirement is the volume of water needed to replace obligatory fluid loss such as that from insensible water loss (through the skin and respiratory tract), evaporative water loss, and losses through urine and stool formation. The amount and type of these losses may be altered by disease states such as fever (with increased sweating), diarrhea, gastric suction, and pooling of body fluids in a body space (often referred to as third spacing).

Nurses should be alert for altered fluid requirements in various conditions:

Basal maintenance calculations for required body water are based on the body’s requirements for water in a normometabolic state, at rest; estimated fluid requirements are then increased or decreased from these parameters based on increased or decreased water losses, such as with elevated body temperature or congestive heart failure. Daily maintenance fluid requirements are listed in Table 28-1.

Maintenance fluids contain both water and electrolytes and can be estimated from the child’s age, body weight, degree of activity, and body temperature. Basal metabolic rate (BMR) is derived from standard tables and adjusted for the child’s activity, temperature, and disease state. For example, for afebrile patients at rest, the maintenance water requirement is approximately 100 ml for each 100 kcal expended. Children with fluid losses or other alterations require adjustment of these basic needs to accommodate abnormal losses of both water and electrolytes as a result of a disease state. For example, insensible losses increase when basal expenditure increases by fever or hypermetabolic states. Hypometabolic states, such as hypothyroidism and hypothermia, decrease the BMR.

Changes in Fluid Volume Related to Growth

The percentage of TBW varies among individuals and in adults and older children is related primarily to the amount of body fat. Consequently, females, who have more body fat than males, and obese persons tend to have less water content in relation to weight.

The fetus is composed primarily of water, with little tissue substance. As the organism grows and develops, a progressive decrease occurs in TBW, with the fastest rate of decline taking place during fetal life. The changes in water content and distribution that occur with age reflect the changes that take place in the relative amounts of bone, muscle, and fat making up the body. At maturity the percentage of TBW is somewhat higher in the male than in the female and is probably a result of the differences in body composition, particularly fat and muscle content (Fig. 28-2).

Another important aspect of growth change as it corresponds to water distribution is related to the ICF and ECF compartments. In the fetus and prematurely born infant, the largest proportion of body water is contained in the ECF compartment. As growth and development proceed, the proportion within this fluid compartment decreases as the ICF and cell solids increase. The ECF diminishes rapidly from approximately 40% of body weight at birth to less than 30% at 1 year of age. The different effects on males and females become apparent at puberty.

Water Balance in Infants

Because of several characteristics, infants and young children have a greater need for water and are more vulnerable to alterations in fluid and electrolyte balance. Compared with older children and adults, they have a greater fluid intake and output relative to size. Water and electrolyte disturbances occur more frequently and more rapidly, and children adjust less promptly to these alterations.

The fluid compartments in the infant vary significantly from those in the adult, primarily because of an expanded extracellular compartment. The ECF compartment constitutes more than half of the TBW at birth and has a greater relative content of extracellular sodium and chloride. The infant loses a large amount of fluid in the first few days after birth and still maintains a larger amount of ECF than the adult until about 2 to 3 years of age. This contributes to greater and more rapid water loss during this age period.

Fluid losses create compartment deficits that reflect the duration of dehydration. In general, approximately 60% of fluid is lost from the ECF, and the remaining 40% comes from the ICF. The amount of fluid lost from the ECF increases with acute illness and decreases with chronic loss.

Fluid losses may be divided into insensible, urinary, and fecal losses and vary with the patient’s age. Approximately two thirds of insensible losses occur through the skin, and the remaining one third is lost through the respiratory tract. Environmental heat and humidity, skin integrity, body temperature, and respiratory rate all influence insensible fluid loss. Infants and children have a much greater tendency to become highly febrile than do adults. Fever increases insensible water loss by approximately 7 ml/kg/24 hr for each 1° F rise in temperature above 37.2° C (99° F). Fever and increased surface area relative to volume both contribute to greater insensible fluid losses in young patients.

Types of Dehydration

Because sodium is the primary osmotic force that controls fluid movement between the major fluid compartments, dehydration is often described according to plasma sodium concentrations (i.e., isonatremic, hyponatremic, or hypernatremic). Other osmotic forces, however, such as glucose in diabetic ketoacidosis and protein in nephrotic syndrome, may also play a dominant role. Consequently, dehydration is conventionally classified as isotonic, hypotonic, or hypertonic.

Isotonic (isosmotic or isonatremic) dehydration occurs in conditions in which electrolyte and water deficits are present in approximately balanced proportions. This is the primary form of dehydration occurring in children. The observable fluid losses are not necessarily isotonic, but losses from other avenues make adjustments so that the sum of all losses, or the net loss, is isotonic. Because no osmotic force is present to cause a redistribution of water between the ICF and ECF, the major loss is sustained from the ECF compartment. This significantly reduces the plasma volume and thus the circulating blood volume, with its effect on the skin, muscles, and kidneys. Shock is the greatest threat to life in isotonic dehydration, and the child with isotonic dehydration displays symptoms characteristic of hypovolemic shock. Plasma sodium remains within normal limits, between 130 and 150 mEq/L (Huether, 2010).

Hypotonic (hyposmotic or hyponatremic) dehydration occurs when the electrolyte deficit exceeds the water deficit. Because ICF is more concentrated than ECF in hypotonic dehydration, water transfers from the ECF to the ICF to establish osmotic equilibrium. This movement further increases the ECF volume loss, and shock is a frequent result. Because there is a greater proportional loss of ECF in hypotonic dehydration, the physical signs tend to be more severe with smaller fluid losses than in isotonic or hypertonic dehydration. Plasma sodium concentrations are typically less than 130 mEq/L (Huether, 2010).

Hypertonic (hyperosmotic or hypernatremic) dehydration results from water loss in excess of electrolyte loss and is usually caused by a proportionately larger loss of water or a larger intake of electrolytes. This type of dehydration is the most dangerous and requires much more specific fluid therapy. This sometimes occurs in infants with diarrhea who are given fluids by mouth that contain large amounts of solute or in children receiving high-protein nasogastric tube feedings that place an excessive solute load on the kidneys. In hypertonic dehydration, fluid shifts from the lesser concentration of the ICF to the ECF. Plasma sodium concentration is greater than 150 mEq/L (Huether, 2010).

Because the ECF volume is proportionately larger, hypertonic dehydration consists of a greater degree of water loss for the same intensity of physical signs. Shock is less apparent in hypotonic dehydration. However, neurologic disturbances, such as seizures, are more likely to occur. Cerebral changes are serious and may result in permanent damage. These include disturbance of consciousness, poor ability to focus attention, lethargy, increased muscle tone with hyperreflexia, and hyperirritability to stimuli (tactile, auditory, bright lights).

Degree of Dehydration

Diagnosis of the type and degree of dehydration is necessary to develop an effective plan of therapy. The degree of dehydration has been described as a percentage of body weight dehydrated: mild—less than 3% in older children or less than 5% in infants; moderate—5% to 10% in infants and 3% to 6% in older children; and severe—more than 10% in infants and more than 6% in older children (Greenbaum, 2007). Water constitutes only 60% to 70% of the infant’s weight. However, adipose tissue contains little water and is highly variable in individual infants and children. A more accurate means of describing dehydration is to reflect acute loss (time frame of ≤48 hours) in milliliters per kilogram of body weight. For example, a loss of 50 ml/kg is considered to be a mild fluid loss, whereas a loss of 100 ml/kg produces severe dehydration.

Clinical signs provide clues to the extent of dehydration (Table 28-3). The earliest detectable sign is usually tachycardia, followed by dry skin and mucous membranes, sunken fontanels, signs of circulatory failure (coolness and mottling of extremities), loss of skin elasticity, and prolonged capillary filling time (see Table 28-4 for clinical manifestations of dehydration and Fig. 28-3 for signs of dehydration).

Compensatory mechanisms attempt to maintain fluid volume by adjusting to these losses. Interstitial fluid moves into the vascular compartment to maintain the blood volume in response to hemoconcentration and hypovolemia, and vasoconstriction of peripheral arterioles helps maintain pumping pressure. When fluid losses exceed the body’s ability to sustain blood volume and blood pressure, circulation is seriously compromised and the blood pressure falls. This results in tissue hypoxia with accumulation of lactic acid, pyruvate, and other acid metabolites, which contribute to the development of metabolic acidosis.

Renal compensation is impaired by reduced blood flow through the kidneys, and little urine is formed. Increased serum osmolality stimulates the secretion of antidiuretic hormone (ADH) to conserve fluid and initiates the renin-angiotensin mechanisms in the kidney, causing further vasoconstriction. Aldosterone is released to promote sodium retention and conserve water in the kidneys. If dehydration increases in severity, urine formation is greatly diminished and metabolites and hydrogen ions that are normally excreted by this route are retained.

Shock, a common manifestation of severe depletion of ECF volume, is preceded by tachycardia and signs of poor perfusion and tissue oxygenation (by pulse oximeter readings). Peripheral circulation is poor as a result of reduced blood volume; therefore the skin is cool and mottled, with decreased capillary filling after blanching. Impaired kidney circulation often leads to oliguria and azotemia. Although low blood pressure may accompany other symptoms of shock, in infants and young children it is usually a late sign and may herald the onset of cardiovascular collapse.

Diagnostic Evaluation

To initiate a therapeutic plan, several factors must be determined:

Initial and regular, ongoing evaluations assess the patient’s progress toward equilibrium and the effectiveness of therapy.

In the examination of an infant or younger child, one of the most important determinants of the extent of dehydration is the weight, since this can assist in determining the percentage of total body fluid lost; however, since the preillness weight is often unknown, clinical manifestations must be evaluated (see Research Focus box). Important clinical manifestations include changing sensorium (irritability to lethargy); decreased response to stimuli; integumentary changes (decreased elasticity and turgor); prolonged capillary refill; increased heart rate; sunken eyes; and, in infants, sunken fontanels. Using multiple predictors increases the sensitivity of assessing the fluid deficit, and early studies have shown a reasonably high degree of agreement between experienced observers in assessment of the level of dehydration. Objective signs of dehydration are present at a fluid deficit of less than 5%.

Laboratory data are said to be useful only when results are significantly abnormal (Emond, 2009). Urine specific gravity, urine ketones, and urinary output during rehydration are reportedly unreliable assessments for determining dehydration in children (Steiner, Nager, and Wang, 2007).

Therapeutic Management

Medical management is directed at correcting the fluid imbalance and treating the underlying cause. When the child is alert, awake, and not in danger, correction of dehydration may be attempted with oral fluid administration. Most cases of dehydration are mild and can be managed at home by this method. Several commercial rehydration fluids are available for use (see Table 29-2). Oral rehydration management consists of replacement of fluid loss over 4 to 6 hours, replacement of continuing losses, and provision for maintenance fluid requirements. In general, the mildly dehydrated child may be given 50 ml/kg of oral rehydration solution (ORS), whereas the child with moderate dehydration may be given 100 ml/kg of ORS. The child with fluid losses from diarrhea may be given 10 ml/kg for each stool (Greenbaum, 2007). Amounts and rates are determined from body weight and severity of dehydration and are increased if rehydration is incomplete or if excess losses continue, until the child is well hydrated and the basic problem is under control.

The child may not be thirsty even though dehydrated and may refuse oral fluids initially for fear of continued emesis (if occurring) or because of decreased strength, oral stomatitis, or thrush. In such children rehydration may proceed by administering 2 to 5 ml of ORS by a syringe or small medication cup every 2 to 3 minutes until the child is able to tolerate larger amounts; if the child has emesis, administering small amounts (5 to 10 ml) of ORS every 5 minutes or so may help overcome fluid deficit, and the emesis will often lessen over time (Greenbaum, 2007). Oral administration of ondansetron (Zofran) to children with acute gastroenteritis and vomiting may reduce emesis and increase time to oral rehydration, thus preventing intravenous (IV) therapy (DeCamp, Byerly, Doshi, et al, 2008; Freedman, Adler, Seshadri, et al, 2006; Roslund, Hepps, and McQuillen, 2008). Oral rehydration therapy (ORT) is effective for treating mild or moderate dehydration in children, is less expensive, and involves fewer complications than therapy (American Academy of Pediatrics, 2009; Spandorfer, Alessandrini, Joffe, et al, 2005). (See Diarrhea, Chapter 29, for a complete discussion of fluid replacement therapy for dehydration.)

Mechanisms of Edema Formation

A defect of any of the homeostatic mechanisms maintaining fluid balance can cause accumulation of interstitial fluid. Disequilibrium results from anything that (1) alters the retention of sodium, such as renal disease or hormonal influences; (2) affects the formation or destruction of plasma proteins, such as starvation or liver disease; or (3) alters membrane permeability, such as minimal change nephrotic syndrome or trauma.

Edema may be localized to a small or large area, such as that occurring in urticaria, infection, and pulmonary congestion, or it can be generalized, as in the hypoproteinemia of the nephrotic syndrome and starvation. A severe, generalized accumulation of great amounts of fluid in all body tissues is termed anasarca.

Assessment

Generalized edema resulting from any of the above types is manifested by swelling in the extremities, face, perineum, and torso. Loss of normal skin creases may be assessed. Daily weights are more sensitive indicators of water gain or loss and should be obtained. Abdominal girth measurement changes may also be an indicator of edema in children. Pitting edema may occur and can be assessed by pressing the fingertip against a bony prominence for 5 seconds. If the tissue rebounds immediately on removing the finger, the patient does not have pitting edema. A quick way to determine the severity is to measure the degree of pitting edema (Fig. 28-4).

Therapeutic Management

The primary goal in the management of edema is treatment of the underlying disease process, which is discussed elsewhere in relation to the specific disorder. However, an essential aspect in the management of any fluid overload is early recognition, in which nurses play a vital role. The management of edema is discussed throughout the text with specific conditions.

Hydrogen Ion Concentration

The pH represents the concentration of hydrogen (H⁺) in solution and indicates only whether the imbalance is more acidic or more alkaline. It does not reflect the nature of the imbalance (i.e., whether it is of metabolic or respiratory origin). Body metabolism affects primarily the base bicarbonate (HCO₃⁻); therefore alterations in the concentration of bicarbonate are termed metabolic disturbances of acid-base balance. Also, because the amount of carbon dioxide (CO₂) exhaled through the lungs affects the carbonic acid (H₂CO₃), changes in carbonic acid concentration are referred to as respiratory disturbances. Consequently, the simple disturbances (those with a single primary cause) are categorized as metabolic acidosis or alkalosis and respiratory acidosis or alkalosis (Greenbaum, 2007).

It is also significant that the major signs and symptoms of hydrogen ion imbalances (acidosis and alkalosis) reflect CNS involvement. Depression of the CNS, manifested by lethargy, diminished mental capacity, delirium, stupor, and coma, is observed in acidosis of either metabolic or respiratory origin. On the other hand, alkalosis produces clinical manifestations of nervous system stimulation and excitement, including overexcitability, nervousness, tingling sensations, and tetany that may progress to seizures. Persons with epilepsy are particularly susceptible to seizures, which can be precipitated by hyperventilation.

It is also important to note that eventually all body systems become dysfunctional if the “normal” limits of pH are violated for long. The extent and severity of signs and symptoms depend on the length of time the imbalance has existed and the magnitude or degree of the deviation from normal. A rapid, severe imbalance will seriously compromise the compensatory mechanisms to the point where it is incompatible with life, whereas the body will be able to compensate adequately for a mild, gradual distortion and produce few if any observable signs or symptoms.

Compensatory Mechanisms

Respiratory regulation in acid-base balance involves carbon dioxide regulation; that is, the rate and depth of alveolar ventilation determine the concentration of carbon dioxide that is eliminated or retained. Renal processes, however, involve the regulation of bicarbonate via reabsorption, regeneration, and secretion of hydrogen ions. When the fundamental acid-base ratio is altered for any reason, the body attempts to correct the deviation. In a simple disturbance, a single primary factor affects one component of the acid-base pair and is usually accompanied by a compensatory or secondary change in the component that is not primarily affected. For example, increased formation of metabolic acid rapidly reduces the bicarbonate in the formation of carbonic acid. The respiratory mechanism immediately attempts to compensate for the imbalance by eliminating the carbonic acid through exhaled carbon dioxide and water. The imbalance is corrected when the kidneys excrete hydrogen and ammonium ions in exchange for reabsorbed sodium bicarbonate.

When the secondary changes (the hyperventilation and renal excretion of hydrogen ions in the preceding example) succeed in preventing a distortion of the acid-base ratio and the pH is restored to normal, the disturbance is described as compensated. The uncompensated state exists when there is no compensatory effect and the pH remains uncorrected. The imbalance is said to be corrected when physiologic mechanisms fully correct the primary abnormality. Mixed acid-base imbalances may also occur in diseases states, and the patient will manifest two simultaneous acid-base imbalances rather than a single imbalance. It is not within the scope of this text to discuss the many variations of mixed acid-base imbalances; the reader is referred to other published sources for such material (Huether, 2010; Curley and Moloney-Harmon, 2001) (see also Table 28-5).

Laboratory Measurements

Several laboratory tests are employed to assess the nature and extent of acid-base disturbances. The importance of these data is readily apparent when a clinical observation such as hyperventilation can represent either the primary factor in respiratory alkalosis or a secondary or compensatory factor in metabolic acidosis. The laboratory tests of value in the assessment of acid-base status are outlined in Table 28-6. To determine the acid-base status, three variables—the respiratory component (Pco₂), the metabolic component (arterial bicarbonate or serum carbon dioxide [HCO₃⁻]), and the serum pH—must be determined. In addition, the anion gap (AG) may be useful in determining the cause and extent of metabolic acidosis; therefore serum chemistry is obtained as well. Measurement of any two variables (Pco₂, pH, HCO₃⁻) will allow computation of the third using the Henderson-Hasselbach equation. A summary of relationships between these and other variables is outlined in Table 28-7.

Associated Disturbances in Acid-Base Balance

Physiologic functions of the body take place optimally when the pH is maintained within a normal range. The disequilibrium created by moderately altered pH can produce disordered function of physiologic and enzyme systems, but great divergences are incompatible with life. In addition, electrolyte shifts that take place in response to changes in pH alter the electrolyte concentration in the fluid compartments to disturb the normal concentrations. For example, cell membrane permeability is affected by changes in pH. A lowered pH allows potassium (K⁺) to move from the ICF to the ECF. Serum potassium levels increase with acidosis and decrease with alkalosis.

History

The nurse can obtain much of the information regarding the child’s behavior from the parent or primary caregiver. In addition to initial observations, a good history is extremely valuable to the assessment. The amount and type of fluid I&O (especially abnormal output) are important. An accurate estimate of fluid losses is beyond the capacity of history givers, but rough estimates of excessive fluid losses or diminished output can usually be obtained from information such as the number and consistency of stools the child has passed in the past 24 hours, the number of times the child voided, and the type and amount of food and fluid ingested or vomited. For an infant, ask about the number of wet diapers in the past 24 hours. Parents frequently omit this information from their discussion with the health professional. They tell how much has been taken but not how much was excreted unless asked specifically. Having the parents estimate the amount of urine in the diaper at each void is of little value because of the absorbent diaper material, which pulls fluids away from the child’s skin.

Both the type and the amount of intake provide valuable information. The quality and quantity can be determined—is intake sustained, excessive, or curtailed? Loss early in diarrheal illness progresses rapidly, and the water losses can exceed sodium losses, leading to hypernatremia. Hypernatremic dehydration indicates a significant interference with water intake. Also important is a history of normal or increased intake of an unusual fluid, such as one containing sucrose, tea, juice, athletic hydration fluid (e.g., Gatorade), an alternative home remedy fluid, or other solute-containing fluids, which can contribute to hyponatremic dehydration in the face of abnormal losses.

A history of gradual weight gain and observations of any puffiness, especially in areas with less dense tissues (periorbital, scrotal), or “clothes fitting tighter” offer early clues to edema. A history of excessive water intake, especially when associated with diminished output, is important in assessing edema and water intoxication.

Clinical Observations

Fever and infection can also produce tachycardia, the earliest manifestation of dehydration. Therefore these are considered in the assessment of dehydration. Dry skin and mucous membranes (oral) usually appear early. A sunken fontanel is a useful observation if the status of the fontanel is known when the infant is healthy. Signs of circulatory failure usually indicate severe dehydration, since compensatory mechanisms are able to sustain blood pressure in the low normal range for some time. Loss of skin elasticity, generally manifested in children less than 2 years of age, is measured by the time it takes for pinched abdominal skin to recoil. This sign is also observed in undernourished children. Also, in hypertonic dehydration the skin has a smooth, velvety feel before it develops disturbed elasticity.

Assess capillary filling time by pinching a toe or a thumb or lightly pressing the abdominal skin and estimating the time it takes for the blood to return. Capillary filling time in mild dehydration is less than 2 seconds, increasing to more than 4 seconds in severe dehydration. The technique is effective in children of all ages. However, it can be altered in the presence of heart failure, which affects circulation time, and hypertonic dehydration, in which fluid loss is primarily intracellular. Additional clinical signs observed in children with dehydration include cool mottled extremities, sunken eyes, tachypnea, and changes in sensorium.

When caring for the ill child, assess vital signs as often as every 15 to 30 minutes, and record weight frequently during the initial phase of therapy. It is important to use the same scale each time the child is weighed and to predetermine the weight of any equipment or devices that must remain attached during the weighing process, including arm boards, and any clothing the child might be wearing. Take routine weights at the same time each day.

Intake and Output Measurement

One of the nurse’s most important roles in fluid and electrolyte disturbance is related to I&O. Accurate measurements are essential to the assessment of fluid balance. Measurements from all sources—including gastrointestinal and parenteral I&O from urine, stools, vomitus, fistulas, nasogastric suction, sweat, and drainage from wounds—must be taken into consideration. Although the practitioner usually indicates when I&O are to be recorded, it is a nursing responsibility to keep an accurate I&O record on certain children, including those:

Infants or small children who are unable to use a bedpan or those who have bowel movements with every voiding will require the application of a collecting device. (See Urine Specimens, Chapter 27.) Collecting bags may not be suitable for all infants (e.g., preterm and other infants whose fragile skin does not tolerate some types of self-adhesive appliances). If collecting bags are not used, wet diapers or pads are carefully weighed to ascertain the amount of fluid lost. This includes liquid stool, urine, vomitus, and other losses. The volume of fluid in milliliters is approximately equivalent to the weight of the fluid measured in grams. The specific gravity as a measure of osmolality is determined with a refractometer or urine dipsticks and assists in assessing the degree of hydration.

Disadvantages of the weighed diaper method of fluid measurement include (1) inability to differentiate one type of loss from another because of admixture (liquid stool versus urine); (2) loss of urine or liquid stool from leakage or evaporation, especially if the infant is under a radiant warmer; and (3) additional fluid in the diaper (superabsorbent disposable type) from absorption of atmospheric moisture (high-humidity incubators). Evaporative losses render measurements inaccurate unless the diaper is weighed and measured for specific gravity at least every 30 minutes when critical values are needed. Evaporative losses are greater in very low–birth-weight and extremely low–birth-weight infants, those under radiant warmers, and those being treated with phototherapy. However, research indicates that accurate specific gravity measurements can be made for up to 2 hours on urine obtained from a diaper that has been removed from an infant, folded, and stored in a utility room (Kee and Paulanka, 2000; Metheny, 2000).

It is important to measure and record all intake, oral and parenteral, as well as output from all sources, including urine, stool, emesis, drainage tubes, fistulas, and wounds from which appreciable amounts of fluid are lost. At home, advise parents to observe the number of times and how much the child voids. The newborn may be expected to void at least once in the first 24 hours, two or three times in the second 24 hours of life, three or four times in the third and fourth days of life, and a minimum of five or six times by the fifth and sixth days; if intake is adequate, the infant 5 to 6 days old and older may be expected to have a minimum of six to eight voidings per day (American Academy of Pediatrics, 2009). Infants younger than 1 year of age may void every 1 to 2 hours; toddlers urinate approximately every 3 hours. As children get older, they void less frequently. Instruct the parents to notify the nurse or clinician if the child appears to be voiding an insufficient amount or persistently losing fluid through vomiting or diarrhea.

The Child Who Is NPO

Infants or children who are unable or not permitted to take fluids by mouth (NPO) have special needs. To ensure that they do not receive fluids, place a sign in some obvious place, such as over their beds or pinned to their shirts, to alert others to the NPO status. Remove fluids from the bedside to reduce the temptation.

Oral hygiene, a part of routine hygienic care, is especially important when fluids are restricted or withheld. (See Chapter 27.) For young children who cannot brush their teeth or rinse their mouth without swallowing fluid, clean the mouth and teeth and keep it moist by swabbing with saline-moistened gauze. Judicious administration of ice chips provides moist, cool relief (if permitted by the practitioner). To meet the need to suck, provide infants a safe commercial pacifier.

The child on restricted fluids provides an equal challenge. Having fluids limited is often more difficult for the child than being NPO, especially when IV fluids are also eliminated. To make certain the child does not drink the entire amount allowed early in the day, the daily allotment is calculated to provide fluids at periodic intervals throughout the child’s waking hours. Serving the fluids in small containers gives the illusion of larger servings. No extra liquid is left at the bedside.

Intravenous Infusion

Before beginning an IV infusion, the nurse performs several preparatory activities. All needed equipment is gathered so that the operator can proceed without interruption. More important, the child and the family must be prepared for this stressful procedure.

Intraosseous Infusion

Situations may occur in which rapid establishment of systemic access is vital and venous access is complicated by peripheral circulatory collapse, hypovolemic shock (secondary to vomiting or diarrhea, burns, or trauma), cardiopulmonary arrest, or other conditions (de Caen, Reis, and Bhutta, 2008). It is recommended that intraosseous access be obtained if venous access cannot be readily achieved in a pediatric resuscitation (de Caen, Reis, and Bhutta, 2008; Hazinski, Zaritsky, Nadkarni, et al, 2002). Intraosseous infusion provides a rapid, safe, and lifesaving alternate route for administration of fluids and medications until intravascular access is possible, especially in children 6 years old or younger. Health care providers, including physicians, nurses, and paramedics, can secure intraosseous cannulation within 30 to 60 seconds. Some hospitals recommend pediatric advanced life support training before performing this procedure. This procedure is usually reserved for children who are unconscious or for those receiving analgesia, since the procedure is painful. Local anesthesia should be used for a semiconscious patient.

A large-bore rigid needle such as a bone marrow aspiration needle (e.g., Jamshidi) or an intraosseous needle (e.g., Cook) is inserted into the medullary cavity of a long bone. The anteromedial aspect of the tibia—1 to 3 cm (0.4 to 1.2 inch) below the tibial tuberosity—is the preferred site for children of all ages because it is flat and has a large marrow cavity. In newborns the distal third of the femur may be used. The distal tibia is an alternative site.

Observe the extremity closely for swelling or oozing of fluid at the insertion site. Give particular attention to the dependent tissue of the leg. Extravasation of fluid from the bone marrow may be hidden under the leg. Check for swelling of the entire lower leg when the intraosseous bone marrow needle is in the tibia or ankle, and check the entire upper leg when the intraosseous needle is in the femur. Compartment syndrome has resulted from an infiltrated intraosseous line. Other complications, although rare, include fractures, skin necrosis, osteomyelitis, and cellulitis (de Caen, Reis, and Bhutta, 2008; Fiorito, Mirza, Doran, et al, 2005).

Once the bone marrow needle is in place, the needle should stand alone and feel secure. Tape and gauze are used to secure the needle to the leg. Gauze should be built up around the needle to provide support and prevent trauma or dislodgment. Drugs may be pushed and fluids delivered via an infusion pump. The intraosseous line may be discontinued after IV access has been achieved.

Preparing the Child and Parents

Children of any age are anxious and fearful of injections, and unless the IV infusion is implemented as an emergency procedure, there will be time to prepare them. (See Preparation for Diagnostic and Therapeutic Procedures, Chapter 27.) Many children have never undergone the procedure, and those who have will remember the experience. Using an age-appropriate developmental approach, the nurse can ask them what they think about the procedure and why it is needed for them specifically. Children’s perceptions of the anticipated experience reveal any misconceptions that need to be clarified and help the nurse prepare them for what to expect. In addition, children’s observations provide some insight into how to cope with their reactions during the insertion procedure and throughout the course of the IV therapy. For children who have repeated venipunctures, it is helpful to ask them or their parents which vein has been successfully accessed in the past.

Play, always an excellent stress reduction technique, can be employed during the preparation process. Allowing children to handle the equipment and to “start” an IV infusion on a toy animal or doll helps familiarize them with the frightening aspects of the procedure. In some instances it may be helpful to introduce a child to another child who is coping well in the same situation.

It is best to arrange for a quiet, private setting for the child during the insertion. Avoid “safe places,” such as the playroom or the child’s hospital room when possible. The assurance of privacy relieves the child of some anxieties concerning loss of control in front of others. It also avoids subjecting other children to the potentially stress-provoking scene. Provide the child with some distracting activity, such as those described for injections, and perhaps allow them to “help” by holding supplies such as a gauze square, helping to clean the site with an antiseptic, and assisting in taping the site after the procedure.

Children usually cooperate better and feel more in command if they are allowed to sit up during the process, although this may not be possible even in some older, normally cooperative children. Toddlers and young children can be held on a parent’s lap, with the child’s legs tucked between the parent’s legs, and the child’s arm (not being used for the venipuncture) behind the parent. A hug should both restrain the child and provide comfort. The torso of the patient is held against the parent with the same hug. It is a mistake to assume that children will not lose control even after they promise to cooperate. It is wise to have ample assistance available in the event that a child cannot control anxiety. The child need not be restrained until necessary, but the assistant should be prepared to grasp a child gently but firmly during the insertion. Explaining to children what is being done during each step of the procedure and how they can participate helps obtain their cooperation and reduce their stress. Make every effort to reduce the pain of the needle insertion (see Atraumatic Care box).

Inform parents about the procedure, including the reasons for the procedure, how long the catheter must remain in place, and what they can expect during and after the insertion. Offer them the option of remaining with their child or leaving. Encourage parents who remain to kiss, hug, and distract the child during the procedure.

The Procedure

The site selected for PIV infusion depends on accessibility and convenience. Although it is possible to use any accessible vein in older children, consider the child’s developmental, cognitive, and mobility needs when selecting a site. Whenever possible, it is best to avoid the child’s favored hand to reduce the disability related to the procedure. Choose a site that restricts the child’s movements as little as possible; a site over a joint in an extremity is avoided as much as possible. An older child can help select the site and thereby maintain some measure of control.

For veins in the extremities, it is best to start with the most distal sites. If the vein is damaged, using distal sites initially preserves access to the vein in proximal sites. A scalp vein or a superficial vein of the wrist may also be used if larger veins are not accessible (Fig. 28-6). Avoid arteries for PIV therapy.

Most infants have one or two possible IV sites on each hand, arm, and foot and four to eight sites on the scalp. Because insertion is easy, scalp veins are sometimes used for IV therapy in infants less than 9 months of age but should be used only when attempts at other sites have failed. The temporal and forehead areas are suitable and do not interfere with side-to-side head movements. The use of a scalp vein site may require removing hair around the site to better visualize the vein and provide a smoother surface on which to tape the tubing. Clipping off a portion of the infant’s hair is upsetting to parents; therefore always tell them what to expect and reassure them that the hair will grow in again rapidly (save the hair, since parents often wish to keep it). Remove as little hair as possible directly over the insertion site and taping surface. To avoid microabrasions, do not shave the site, which increases the potential for introduction of microorganisms into the vascular system (Infusion Nurses Society, 2006). A rubber band slipped onto the head from brow to occiput will usually suffice as a tourniquet, although if the vessel is visible, a tourniquet may not be necessary in some infants.

An assistant should carefully restrain the extremity or head to facilitate venipuncture and minimize trauma from the child’s inadvertent movement. (See Chapter 27 for additional restraining methods.) For a scalp site it is helpful to visualize the way in which the needle will be secured after insertion.

Locating an extremity vein may be difficult because the veins are smaller and children have a significant amount of subcutaneous fat. When veins are not readily visible, applying a warm compress to the site, running warm water over the extremity, or holding the limb in a dependent position below body level will help fill the veins for better visualization. Gentle tapping sometimes causes the veins to stand out. A flashlight held against the skin below the intended site sometimes assists in locating vessels. A commercial vein transilluminator is often helpful in locating veins and assessing the depth and patency of the vessels but it requires an extra set of hands in infants and smaller children. If these measures do not help, a tourniquet applied with light pressure medial to the site may be needed. Although the tourniquet makes the veins more visible and provides a more rapid blood return, the added venous pressure may cause fragile veins to “blow” when punctured, producing a hematoma.

Before beginning the procedure, the nurse should prepare the materials needed to secure the IV. Tape should be precut and easily reached. All other necessary equipment should be set up in an orderly fashion, allowing the venipuncture to be performed in a timely manner.

The needle or catheter must be placed in the direction of the blood flow, which creates no problem when an extremity is used. Scalp veins are easy to visualize but difficult to assess and may actually be an artery. Therefore palpation for a pulse on scalp sites is recommended but again may be difficult because the veins may be hidden within the suture lines. In general, the venous blood flows from the top of the head toward the neck, so point the catheter downward toward the heart. To test the direction before insertion, place a forefinger on the vein at the site chosen for venipuncture. While gently pressing the vein, use a second finger to “strip” the vein in the direction of the top of the head. Release the pressure from the second finger. If the vein fills distal to the compressing finger, the direction of flow is toward the stationary finger.

Securing a Peripheral Intravenous Line

To maintain the integrity of the IV line, adequate protection of the site is required (Box 28-7). Firmly secure the catheter hub at the puncture site with a transparent dressing or clear, nonallergenic tape. Transparent dressings are ideal because the insertion site is easy to observe. Use minimum tape at the puncture site and on about 2.5 to 5 cm (1 to 2 inches) of skin beyond the site to avoid obscuring the insertion site for early detection of infiltration.

Apply a sterile dressing such as a transparent semipermeable membrane directly over the catheter insertion site to protect the infusion site (Infusion Nurses Society, 2006). Consider easy access to the IV site for frequent (hourly) assessments (Infusion Nurses Society, 2006). Improvised plastic cups that are cut in half with the ridged edges covered with tape should not be used, since they have injured patients. A commercial site protector, I.V. House, is available in different sizes (Fig. 28-7). Its ventilation holes prevent moisture from accumulating under the dome. This device is designed to protect the IV site and allows for visibility of the site. The device also minimizes use of padded boards, splints, or other restraints and tape and maintains skin integrity. The connector tubing or extension tubing can be looped to make it small enough to fit under the protective cover to prevent accidental snagging of the catheter. It is important to safely secure the IV tubing to prevent infants and children from becoming entangled in the tubing or from accidentally pulling the catheter or needle out. This securement also eliminates movement of the catheter hub at the insertion site (mechanical manipulation). Apply a colorful and interesting sticker to the protective device to add a positive note to the procedure.

Finger or toe areas are left unoccluded by dressings or tape to allow for assessment of circulation. The thumb should not be immobilized because of the danger of contractures with limited movement later on. An extremity should never be encircled with tape, since this may impede necessary blood flow to and from the extremity. The use of roll gauze, self-adhering stretch bandages, and Ace bandages can cause the same constriction and hide signs of infiltration.

Traditionally, padded boards or splints were used to partially immobilize the IV site. When metal needles were inserted into the vein, padded boards or splints and restraints were appropriate to prevent the sharp end from puncturing the vessel, especially at a joint. With the more recent use of soft, pliable catheters, arm or leg boards may not be necessary and have several disadvantages. They obscure the IV site, can constrict the extremity, may excoriate the underlying tissue and promote infection, can cause joint contracture, restrict useful movement of the extremity, and are uncomfortable. Unfortunately, no research has been conducted to demonstrate their proposed benefit of increasing dwell time (patency of the IV line). Adequate taping and protection with a commercial device should eliminate the need for padded boards in most circumstances. A number of elbow restraint or protective arm restraint devices are available that prevent the child from bending the arm or pulling at the IV site on the arm; these are made of cloth and a semi-rigid mold with Velcro straps or ties so the device may be adjusted to the child’s limb size and does not impair circulation. (See Chapter 27.) Older children who are alert and cooperative can usually be trusted to protect the IV site.

Immobilization is intolerable to the naturally active child, and the nurse should make every effort to reduce the use of restraints. To relieve the stress of immobilization, frequent removal of the restraints (if used at all) allows the child to move the extremities. Whenever possible, the infant or child is held and cuddled to help meet emotional needs during this trying time (Fig. 28-8). Range-of-motion exercises are employed for infants and children who are too ill or unable to move their extremities, but others should be encouraged to move their arms and legs. Most infants or small children instinctively move their extremities when released. If not, a toy or other stimulus can provide incentive.

Appropriate documentation of the procedure, type of cannula used, patient tolerance, and status of the skin site is an important nursing intervention (Box 28-8).

Removal of a Peripheral Intravenous Line

When it comes time to discontinue an IV infusion, many children are distressed by the thought of catheter removal. Therefore they need a careful explanation of the process and suggestions for helping. Encouraging children to remove or help remove the tape from the site provides them with a measure of control and often fosters their cooperation. The procedure consists of turning off any pump apparatus, occluding the IV tubing, removing the tape, pulling the catheter out of the vessel in the opposite direction of insertion, and exerting firm pressure at the site after the catheter is removed until bleeding stops. (It is painful to apply pressure on the catheter while pulling it out.) Place a small dry dressing (adhesive bandage strip) over the puncture site. The use of adhesive removal pads can decrease the pain of tape removal, but the skin should be washed off after use to avoid irritation. An adhesive removal agent should be used with caution in some preterm infants and children with compromised skin because absorption is variable and toxicity may occur. To remove transparent dressings (e.g., OpSite or Tegaderm), pull the opposing edges parallel to the skin to loosen the bond. If a catheter was used for the IV infusion, inspect the tip to make certain the catheter is intact and no portion remains in the vein.

Removal of the IV line, especially the tape, is another painful and frightening experience for the child. Consider the child’s age, developmental and neurologic status, and predictability (how the child responds to painful treatments) when determining the need for assistance to maintain safety with this procedure. Manual removal of tape is the preferred method. Only if absolutely necessary should a small cut be made in the tape, using bandage scissors, to facilitate its removal. Before cutting the tape:

Complications

The same precautions regarding maintenance of asepsis, prevention of infection, and observation for infiltration are carried out with patients of any age. However, infiltration is often more difficult to detect in infants and small children than in adults. The increased amount of subcutaneous fat and the amount of tape used to secure the catheter hub obscure the signs of early infiltration. When the fluid appears to be infusing too slowly or ceases, the usual assessment for obstruction within the apparatus (i.e., kinks; screw clamps; shutoff valve; and positioning interference, such as a bent elbow or wrist) often locates the difficulty. When these actions fail to detect the problem, it may be necessary to carefully remove some of the tape and other material that obscure a clear view of the venipuncture site. Examine dependent areas, such as the palm and undersides of the extremity or the occiput and behind the ears.

Whenever possible, place the IV infusion in an extremity to which the identification band (or bracelet) is not attached. Serious circulatory impairment can result from infiltrated solution distal to the band, which acts as a tourniquet preventing adequate venous return. To check for return blood flow through the catheter, lower the solution bag below the level of the infusion site. A good blood return, or lack thereof, is not always an indicator of infiltration in small infants. Flushing the catheter and observing the site for discoloration (i.e., blanching or redness), pain, tenderness, and edema or noting any exudate or drainage and increase in skin or basal temperatures is an appropriate assessment of the IV site. If the tubing is connected to an infusion pump, it must be removed from the pump before lowering.

IV therapy in pediatrics tends to be difficult to maintain because of mechanical and physical factors that tend to shorten dwell times. Such factors include vascular trauma resulting from PIV device selection (gauge and length of the catheter), the insertion site, the catheter dwell time, the size of the vessel, vessel fragility, and pressure of the infusion pump (determined in PSI, or pounds per square inch). Different infusion pumps have preset pressures for infusion, delivery, and occlusion; therefore the pump’s occlusion alarm is not entirely reliable for detecting infiltration. The patient’s activity level, operator skill and insertion technique, forceful administration of boluses of fluid, type of infusion solution, antibiotics and other medications being infused, and infusion of irritants or vesicants through a small vessel are also factors. These factors cause infiltration and extravasation injuries, which are reported with relative frequency (Fig. 28-9).

Infiltration is defined as inadvertent administration of a nonvesicant parenteral solution or medication into surrounding tissue as a result of catheter dislodgment (Infusion Nurses Society, 2006). Extravasation is defined as inadvertent administration of vesicant solution or medication into surrounding tissue as a result of catheter dislodgment (Infusion Nurses Society, 2006). A vesicant or sclerosing agent causes varying degrees of cellular damage when even minute amounts escape into surrounding tissue. A scale that provides a uniform standard for measuring the degree of infiltration is available from the Infusion Nurses Society*; the characteristics of infiltration include the degree of skin discoloration, blanching, edema, the amount of pain, and warmth or coolness of the area (Infusion Nurses Society, 2006).

Phlebitis, or inflammation of the vessel wall, may also develop in children who require IV therapy. Lamagna and MacPhee (2004) describe three types of phlebitis: mechanical (caused by rapid infusion rate, manipulation of the IV), chemical (caused by medications such as nafcillin, amphotericin B), and bacterial (caused by staphylococcal organisms). The initial sign of phlebitis is erythema (redness) at the insertion site. Pain may or may not be present (Lamagna and MacPhee, 2004).

Standardized IV site assessment tools, such as the one used at Children’s Hospital of Boston, assist in detection of infiltration, extravasation, and phlebitis in children so early intervention can prevent vessel and skin damage (Lamagna and MacPhee, 2004). Treatment of an infiltration or extravasation varies according to the type of infusate (see Nursing Care Guidelines box).

The following guidelines should be considered when starting a pediatric PIV:

PIV catheters are the most commonly used intravascular devices. Heavy cutaneous colonization of the insertion site is the single most important predictor of catheter-related infection with all types of short-term, percutaneously inserted catheters. Phlebitis, largely a mechanical rather than infectious process, remains the most important complication associated with the use of peripheral venous catheters (see Community Focus box).

Proper education of the patient and family regarding signs and symptoms of an infected site can help prevent infections from going unnoticed. When an IV infusion continues for several days, the tubing and solution administration set is changed at regular intervals according to hospital policy or at least every 72 hours for a continuous infusion and at least every 24 hours for an intermittent infusion (Infusion Nurses Society, 2006). Gillies, O’Riordan, Wallen, and colleagues (2004) recommend changing IV administration solution sets and tubing every 72 hours to decrease the probability of infection. Lipid-containing parenteral nutrition (PN) fluids such as three-in-one solutions should be changed after 24 hours (Gillies, O’Riordan, Wallen, et al, 2005; Infusion Nurses Society, 2006), whereas a 12-hour limit is recommended for pure intralipid infusions (O’Grady, Alexander, Dellinger, et al, 2002). The dressing can be left in place for the duration of the IV infusion unless the integrity has been compromised. To ensure that the solution and IV equipment is changed regularly, it is labeled with the date and time that the new bag and tubing are attached. Any signs of inflammation, such as redness or pain, are reported immediately. This usually requires removing the infusion and restarting it at another site or administering the medication by another route.

Prevention of insertion site infection can be decreased by strict adherence to the following guidelines:

1. Short-term or nontunneled catheters (subclavian, femoral, and jugular)

2. PICCs (Box 28-9)

3. Long-term, tunneled catheters and implanted ports (Table 28-8)

Peripheral Intermittent Infusion Device

The peripheral lock, also known as an intermittent infusion device or saline or heparin lock, is an alternative for a keep-open infusion when extended access to a vein is required without the need for continuous fluid. It is most frequently employed for intermittent infusion of medication into a peripheral venous route. A short, flexible catheter is used as the lock device, and a site is selected where there will be minimum movement, such as the forearm. The catheter is inserted and secured in the same manner as any IV infusion device, but the hub on the proximal end is occluded with a stopper or injection cap.

The type of device used may vary, and the care and use of the peripheral lock are carried out according to the specific protocol of the institution or unit. However, the general concept is the same. The catheter remains in place and is flushed with saline or heparin (1 : 10 units/ml) after infusion of the medication. The flush solution prevents blood from clotting in the device between infusions. Because heparin is incompatible with many drugs, the peripheral lock must also be flushed with saline before and after administering medication. There are conflicting data regarding the use of saline flush versus a heparinized saline flush and the dwell time of peripheral locks in children (see Evidence-Based Practice box). Some children are discharged with a peripheral lock in place in order to continue receiving medications without hospitalization; this is usually reserved for children who require medications on a short-term basis and are referred to a home-based infusion company. Those with chronic illnesses who require repeated blood sampling or medications, long-term chemotherapy, or frequent hyperalimentation or antibiotic therapy are best managed with a long-term central VAD.

There is controversy concerning the need to flush with heparin in any VAD, peripheral or central. A more important issue is the technique of flushing. The use of the turbulent-flow flush has proven successful in preventing clot formation in the device. It is described as the forward flushing motion on the syringe with a flush-stop-flush-stop technique. This causes a swirling and vigorous fluid movement that clears the catheter better than the continuous flush motion most commonly used. This procedure is combined with the positive pressure technique. As the flush is completed, hold the syringe stopper down, clamp the catheter, then remove the syringe. This prevents blood from backing into the tip of the catheter.

Peripherally Inserted Central Catheters

PICCs can be used for short-term to moderate-length therapy (see Box 28-9). These catheters consist of silicone or polymer material and are placed by specially trained nurses (Gamulka, Mendoza, and Connolly, 2005). The most common insertion site is the antecubital area using the median, cephalic, or basilic vein. The catheter is threaded either with or without a guide wire into the superior vena cava. The modified Seldinger technique is often used with ultrasonography to access very small veins in infants and children (Mickler, 2008). PICCs are sometimes inserted a shorter length; this is often referred to as a “midline” catheter. The insertion length of the midline catheter is usually somewhere between the insertion site and the axilla; in some cases the midline catheter may be placed in a scalp vein and threaded into the external jugular vein (Petit, 2006). The midline has an average dwell time of 6 to 10 days in neonates (Petit, 2006). Centrally placed catheter tips are associated with fewer complications (phlebitis, occlusion, leaking) than noncentrally placed catheters (Racadio, Doellman, Johnson, et al, 2001).

If the catheter is threaded midline, total parenteral nutrition (TPN) should not be administered, because the high concentration of glucose irritates the vessel; it should be infused through a central catheter.

The decision to insert a PICC needs to be made before several attempts at IV insertions are done. In one center PICC lines were inserted in children undergoing operative procedures. The PICCs were inserted in the operating room in pediatric patients under general anesthesia whose hospital stay was expected to be at least 4 days; when compared with similar patients undergoing surgery and with only a PIV, children in the PICC group experienced fewer needlesticks for blood draws and failed PIV complications postoperatively. The cost of PICC insertion was higher than PIV, but satisfaction was greater and complications were lower (Schwengel, McGready, Berenholtz, et al, 2004). Once the antecubital veins have been punctured repeatedly, they are not considered candidates for this type of catheter. Because this catheter is the least costly VAD and has a lower risk of complications than other central VADs, it is an excellent choice for many pediatric patients. This catheter is also usually inserted in the unit’s treatment room.

PICC lines may be used for blood draws, although there is often a greater number of occlusions with blood draws (Knue, Doellman, Rabin, et al, 2005).

PICCs can create problems with removal. Causes for resistance in removal include infectious processes, fibrin formation, and endothelial thrombosis. Methods to free the catheter include gentle traction to the catheter, taping the catheter to create tension on the line, and warm soaks to the site. Aggressive pulling of the catheter is contraindicated.

Long-Term Central Venous Access Devices

Long-term central VADs include tunneled catheters (Broviac, Hickman, or Groshong) and implanted infusion ports (see Table 28-8). They may have single, double, or triple lumens. Several lumens (multilumen catheters) allow more than one therapy to be administered at the same time. Reasons to use multilumen catheters include repeated blood sampling, TPN infusion, administration of blood products or infusion of large quantities or concentrations of fluids, administration of incompatible drugs or fluids at the same time (through different lumens), and central venous pressure monitoring.

Critical Thinking Exercises—Central Venous Access Device

With the patient under local or general anesthesia, the long-term catheter of choice is placed with aseptic technique. A vein, such as the jugular or subclavian, is entered through a small cutdown site, and the catheter is threaded to the junction of the superior vena cava and right atrium, confirmed by radiography with fluoroscopic dye injection, and then sutured in place. To stabilize the catheter and reduce the risk of infection, the remainder is tunneled beneath the skin to exit through a small incision at a convenient location on the anterior aspect of the chest or upper abdomen (Fig. 28-10, A and B). One or two Dacron cuffs or VitaCuffs on the catheter remain in the subcutaneous tunnel; as tissue adheres to the cuff, the cuff provides a barrier to infection. The cutdown site is surgically closed, the catheter is sutured to the skin at the exit site, and a sterile dressing is applied. A radiograph is taken to ascertain the location of the catheter before instillation of fluids. With any of the central venous catheters, medications are easily instilled through the injection cap. Maintenance of the catheter includes dressing changes, flushing to maintain patency, and prevention of occlusion or dislodgment.

Children may benefit from an implanted port, which consist of a small, circular “port of entry” that is placed under the skin (while the patient is under local or general anesthesia) over a bony prominence to provide a stable surface, usually under the distal third of the clavicle (Fig. 28-10, C and D). A tunnel is created from the port to the point where the catheter enters a central vein leading to the entrance to the right atrium. Medication or other solution is injected with a special Huber needle (a 90-degree angled needle) through the skin into the port. The device can remain situated indefinitely and may be placed in small infants as well as older children and adolescents.

With the implanted device, palpate the port for placement and stabilize it with the thumb and index finger. Cleanse the overlying skin, and use only special noncoring Huber needles to pierce the port’s diaphragm on the top or side, depending on the style. A special infusion set with a Huber needle and extension tubing with Luer connection can be used to access the port when blood work or infusion therapy (chemotherapy or blood product administration) is required. A small gauze pad is placed under the horizontal portion of the protruding needle and a transparent dressing is placed over the protruding needle and gauze for stabilization and infection control. In small, curious children the tubing may be tunneled under a cotton shirt or one-piece suit and out the leg or back to prevent the child from pulling on the port tubing.

With the port accessed, the injection procedure is the same as for the venous catheters. To prevent infection, use meticulous aseptic technique anytime the devices are accessed, including instillation of heparin or saline to prevent clotting. Protocols are established in most centers for periodic flushing with normal saline and heparin solution (amount and frequency). Maintenance includes intermittent flushing to prevent clotting and a dressing change if the Huber needle is left in place for long periods (>1 week). There should be a protocol stating that the Huber needle needs to be changed at established intervals, usually 5 to 7 days. Advantages to the port include cosmetic appearance, which may be important for older school-aged children and adolescents, and relatively easy access for blood work and fluid and medication administration. When the port must be accessed with a Huber needle, apply a topical anesthetic such as EMLA or LMX4 before the procedure to reduce the pain of penetrating the skin with the Huber needle (see Atraumatic Care box, p. 1073).

Chapter 10 discusses umbilical artery and venous catheters used in neonates.

Complications

Central venous line bacteremia can be of major concern in a child. The mean incidence of catheter-related bloodstream infection in children varies in the literature, but it averages around 3% to 7% with an estimated cost of $9000 to $46,000 per episode (Kline, 2005). Centrally placed catheters are associated with fewer complications than are peripherally placed catheters (Racadio, Doellman, Johnson, et al, 2001).

Catheter-related bloodstream infections have a significant impact on the duration of the catheter and cost of care. Studies have shown that the following practices result in a decrease in catheter-related bloodstream infections (Krein, Hofer, Kowalski, et al, 2007; Morgan and Thomas, 2007; Smith, 2008):

Guidelines for prevention, diagnosis, and management of intravascular catheter–related infections are available from the Infectious Diseases Society of America (Mermel, Allon, Bouza, et al, 2009).

Line connections should have a Luer-Lok connection device or be wrapped with tape to prevent accidental disconnection. The nurse should minimize the number of line accesses for blood withdrawal or medication administration. Central line dressing protocols should be developed, and nurses experienced in dressing change techniques should be responsible for line care. Family teaching must include how to care for the line, what to do if the line becomes disconnected or broken, and how to flush the line using aseptic technique.

Catheter-related central venous thrombosis and catheter occlusion can also be serious problems in children (McCloskey, 2002). Approximately 60% of all catheter-related occlusions occur as a result of thrombus formation (Fisher, Deffenbaugh, Poole, et al, 2004). Small thrombi at the tip of the catheter can usually be prevented with regular heparin flushes (Table 28-9) and, if present, lysed with a thrombolytic solution. The most common drug used to treat catheter-related thrombi is alteplase, a tissue plasminogen activator, which initiates fibrinolysis and clot dissolution. Alteplase has been demonstrated to be safe and effective for treating catheter-related occlusions in children (Blaney, Shen, Kerner, et al, 2006; Fisher, Deffenbaugh, Poole, et al, 2004; Kerner, Garcia-Careaga, Fisher, et al, 2006; Shen, Li, Murdock, et al, 2003). Written protocols should be available for the administration of alteplase for catheter occlusion in children in health care institutions and home care.

Catheter occlusion may be partial, in which case fluid can be flushed into the device, or complete, in which case fluid or blood can be neither withdrawn nor flushed through the catheter (McCloskey, 2002). A fibrin sheath may form over the inner tip of the catheter within the vessel; the catheter may flush easily, but when attempts to withdraw fluid or blood are made, the sheath falls over the tip of the catheter, thus precluding withdrawal of blood or fluid (McCloskey, 2002). Larger thrombi outside of the catheter may require removal and anticoagulant therapy. A central venous thrombosis may also develop as the catheter brushes against the vessel wall, prompting thrombus formation, which may lead to superior vena cava syndrome (McCloskey, 2002). Symptoms of large thrombi include signs of superior vena cava occlusion, such as facial swelling and cyanosis, distended neck veins, blurred vision, vertigo, and swelling of the upper arm.

Complications associated with indwelling ports include port migration and difficulty accessing the port; the latter problem may occur if the Huber needle is not long enough to penetrate the subcutaneous skin.

Parent and Child Teaching

Regardless of which catheter is used, teach the child and family the care and management of the device with practice under supervision. It can be frightening to both child and parents to know that the catheter tip is situated near the heart. They need reassurance that with reasonable care they will do no harm to the apparatus. It is often useful to introduce the family to other children and families who are using central venous catheters successfully and with whom they can share concerns and helpful tips regarding care and management. This sharing is especially valuable for teenage patients. Because teenagers usually have a positive attitude toward use of the catheter, it is beneficial for them to share their experiences with adolescents who face the prospects of catheter placement.

Parents of children who engage in outside activities, go to school, or are otherwise under the supervision of another adult should inform the teacher, school nurse, coach, and baby-sitter about the presence of the central venous catheter. Vigorous contact sports, such as football, soccer, and hockey, are generally not allowed. Provide a written information sheet concerning the VAD, including its purpose, pertinent facts about any restrictions for the child, and directions related to management of the device, for their reference. The nurse or the parents should teach grandparents and other family members who care for the child the care and management of the catheter.

Procedures and published standards for catheter care vary widely among organizations, and there is no evidence that one method is superior. For example, some advocate covering the healed catheter site with a dressing; others do not. All companies that manufacture central catheters have patient and professional teaching kits. The user should become thoroughly familiar with the specific device selected for use.

The catheter is not a deterrent to most routine daily activities, including showers or tub bathing. However, the practitioner is consulted before activities such as swimming or physical contact sports are attempted. Swimming is usually prohibited but may be allowed in certain situations. If the exit site is healed and the cuff adheres to the tissue, place a transparent dressing over the catheter and exit site. Swimming may be permitted for a limited time, such as 1 hour or less, in a chlorinated pool. Most contact sports are prohibited because of the possibility of the catheter being hit or pulled. A protective vest can prevent active children from accidentally dislodging the catheter.

Family members need to know the signs of infection and an occluded catheter. Signs of a localized infection are redness, swelling, and pain at the vein entry site. Bacteremia is a serious complication that produces fever, chills, general malaise, and an ill appearance. Prevent uncapping by taping the cap securely to the catheter and the clamped line to the dressing. Prevent leaks by using a smooth-edged or padded clamp. Caution parents to keep scissors away from the child to prevent accidental cutting of the catheter. If the catheter leaks, they are instructed to tape it above the leak (between the leak and the entry site on the skin) and then clamp the catheter at the taped site. The child should be taken to the practitioner as soon as possible to prevent infection, blood loss, or clotting following a catheter leak.

Complications

Complications from TPN and TNA are numerous, and a major nursing responsibility is to prevent these when possible and to be alert to signs of their development. Complications are either (1) related to the infusate (metabolic complications); or (2) mechanical complications related to the indwelling catheter, the administration set, or the infusion pump.

Metabolic complications are associated with the infant’s or child’s capacity for the various components of the TNA or TPN solution. Excessive intake of any of the components will create an imbalance, such as hyperglycemia, azotemia, acid-base disorders, anemia, bone demineralization, vitamin and mineral deficiencies, hyperosmotic dehydration and coma, fluid overload, and a variety of electrolyte imbalances.

Liver disease is the most important gastrointestinal complication in pediatric populations. The cause is obscure, but liver disease appears to be more prevalent in preterm infants who were begun on TPN at an early age. In general, the lower the birth weight and gestational age, the higher the incidence of TPN-associated cholestasis; approximately 50% of infants weighing less than 1000 g develop TPN-associated cholestasis (Xanthakos and Balistreri, 2007). Affected infants develop cholestasis, hepatocellular necrosis, and, in advanced disease, cirrhosis or hepatic failure. Manifestations are often insidious and include hepatomegaly; jaundice; and elevated serum aminotransferase, bilirubin, and alkaline phosphatase levels, which become evident approximately 2 weeks after initiation of TPN (Xanthakos and Balistreri, 2007). In the low-birth-weight infant on TPN, onset of jaundice may overlap the phase of neonatal jaundice; therefore fractionated serum bilirubin measurements are recommended (Xanthakos and Balistreri, 2007). TPN-associated cholestasis is less common in older children. Cholelithiasis is an uncommon but possible occurrence in pediatric patients. Therefore children receiving TNA should be assessed periodically for signs and symptoms of cholelithiasis or cholecystitis.

Mechanical complications include catheter-related complications such as those involving catheter placement: pneumothorax, hemothorax, perforation, catheter dislodgment, and thrombus formation. However, the major complication associated with the catheter is infection: infection at the catheter entrance site, catheter “seeding” sepsis, venous thrombosis with infection and embolization, and endocarditis.

Pediatric TPN solution generally has a higher concentration of calcium and phosphorus, which makes some solutions more susceptible to precipitation. In the event of observed precipitation, stop the infusion and disconnect the container and tubing from the child; notify the practitioner so that a replacement infusion of dextrose can be started to prevent hypoglycemia. Other additives, including electrolytes, may need to be added depending on the child’s status and the contents of the original solution. The nurse should take the original solution to the originating pharmacy for analysis.

Home Parenteral Nutrition

Some children require TPN over an extended period, often weeks, months, or even years. For many children, HPN is an alternative to long-term hospitalization. The child must be one who is unable to maintain adequate enteral alimentation, has no medical problems requiring hospitalization, has a parent who is able to manage the home care (or is an older child who can participate in his or her own care), and has the potential to benefit from the treatment.

Before a home care program can be implemented, a thorough assessment is made of the family and the home situation. The parents must be capable of performing the technical aspects of the procedure and be able to adapt to the changes inherent in the home program. Psychosocial readiness of the family; family support systems; and practical considerations are investigated, including availability of a pharmacy to prepare the parenteral alimentation solution, a practitioner to handle day-to-day emergency needs, and a cooperating insurance company or agency (because of the exorbitant cost of maintaining long-term parenteral feeding). In many areas home health care agencies are able to assume the major management of HPN for families; however, a shortage of skilled nursing staff and decreased third-party reimbursement often require a family member to assume major responsibility for the child’s home care. (See also Family-Centered Home Care, Chapter 25.)

The major nursing responsibilities for the child and family with HPN include assurance that the proper solution is infusing, proper maintenance of the VAD, prevention of sepsis and other mechanical complications, monitoring of infusion rate, and assessment of the patient’s tolerance to the solution. In most cases a family member may assume responsibility for starting (hanging) and monitoring the infusion. The TPN or TNA solution is prepared under sterile conditions, usually in a hospital pharmacy or home health agency pharmacy, and then is distributed to the primary caretaker by a home health aide or family member. Teach family members how to maintain the child’s VAD, including dressing changes and routine flushing as required, and how to evaluate the progress of the infusion. In most cases the infusion is delivered by an infusion pump to prevent too rapid an infusion, which may cause fluid and electrolyte problems. HPN complications include those listed above for long-term TPN: infection (catheter-related sepsis), exit site infection, catheter occlusion, catheter tears, thrombosis, fluid and electrolyte imbalance, and liver dysfunction (Howard and Ashley, 2003).

In a study of adult and pediatric patients on HPN, Howard and Ashley (2003) found that the single most important factor influencing the outcome of home TPN was the patient’s primary diagnosis. Mortality and morbidity for patients with cancer was much greater than for those with bowel disorders such as obstruction and Crohn disease.

Colomb, Dabbas-Tyan, Taupin, and colleagues (2007) also noted that most children on HPN with primary digestive disease survived if early referral occurred; survival probabilities in the study at 2, 5, 10, and 15 years were 97%, 89%, 81%, and 72%, respectively. In this study the primary diagnosis strongly influenced the outcome and survival rate of the child on HPN. Johnson and Sexton (2006) noted that HPN was associated with fewer catheter infections than hospital PN; however, HPN was associated with more physical and psychologic stress for families. Social isolation, depression, and loneliness were identified in children and families with HPN.

An important goal with HPN is the normalization of the child to optimize ability to perform activities of daily living and promote a healthy lifestyle in anticipation of the day when TPN or TNA is no longer required. (See also Chapter 25.) One study found that the quality of life for children and their families on HPN was not significantly different from that of a reference group of healthy children without HPN (Gottrand, Staszewski, Colomb, et al, 2005). The researchers concluded that children on HPN developed appropriate coping skills; parents of children on HPN, especially parents of infants, had lower quality-of-life scores than controls, and adolescents on HPN had quality-of-life scores similar to those of controls, except for those with ileostomy, who scored lower on quality-of-life issues.

Before beginning HPN, the parents are prepared for taking over the child’s total care. Teaching may occur in the hospital or at home, depending on the policies of insurance companies and the home health care agency monitoring the family. The parents assume full responsibility for the child’s care, with help being readily available when needed.

The emotional and economic benefits of this approach are readily apparent. The familiar environment and the atmosphere of normality are enormously therapeutic, and the stress of separation is avoided. With multidisciplinary support from health professionals, a home care program can be the ideal alternative to hospitalization for a capable, motivated family of a child who requires TNA.

Encourage the family to make the home life as normal as possible for the child within the limits imposed by the therapy. For example, having the infant or child at the table during mealtimes and including the child in family activities contribute to a normal family atmosphere. Activity restrictions often depend on the child’s illness, the type of VAD, and period of HPN (continuous versus intermittent), but the provider should promote normalization of all allowed activities (Fig. 28-11). Allow infants and toddlers to crawl and pull up to a standing position to promote optimum development. The length of tubing can be adjusted to accommodate such activities. Running the tubing under a one-piece clothing outfit and out the back often encourages ambulation. At times the nurse must give the parents permission to allow the child to play because they may be frightened by the tubing and VAD setup. Once the parents or caregivers becomes familiar with the usual complications of mobility, they are resourceful at adapting the clothing and home environment to allow the child to play with minimum restrictions. It is also important to make certain the child’s dental care is not neglected.

The family is referred to community agencies that provide support and practical assistance. The Oley Foundation,* a nonprofit research and education organization, maintains a national registry of persons receiving HPN and publishes a bimonthly newsletter for consumers, families, clinicians, and home care services.

• Water distribution and maintenance are determined by solutes, physical forces, internal control mechanisms, and boundary organs through which external exchanges occur.

• Infants are subject to fluid depletion because of their relatively greater surface area, their high rate of metabolism, and their immature kidney function.

• Management of fluid volume disturbances focuses on volume of body fluids, osmolality, hydrogen ion status, electrolyte deficits, and disturbances in mineral skeleton and body fluid equilibrium.

• Fluid disturbances experienced by children are dehydration, water intoxication, and edema.

• Dehydration may be classified as isotonic, hypotonic, or hypertonic.

• Parenteral fluid therapy is initiated to meet ongoing daily physiologic losses, restore previous deficits, and replace ongoing abnormal losses.

• Fluid gains or losses from the interstitial spaces depend on venous hydrostatic pressure, colloidal osmotic pressure, semipermeable capillary wall, tissue tension, and lymphatic flow.

• Edema formation is caused by increased venous pressure, capillary permeability, diminished plasma proteins, lymphatic obstruction, or decreased tissue tension.

• Disturbances in acid-base balance are respiratory acidosis, respiratory alkalosis, metabolic acidosis, and metabolic alkalosis.

• Respiratory acidosis may result from factors that depress the respiratory center, affect the lungs, or interfere with the bellows action of the chest wall.

• Respiratory alkalosis results primarily from CNS stimulation.

• Metabolic acidosis is a lowered plasma pH caused by any process that reduces base bicarbonate concentration or increases metabolic acid formation.

• Metabolic alkalosis is an elevated plasma pH that occurs when there is a reduction of hydrogen ion concentration or an excess of base bicarbonate.

• Nursing assessment of fluid and electrolyte disturbances entails observation of general appearance, vital signs, daily weights, I&O measurement, and review of relevant laboratory results.

• Long-term venous access is accomplished by intermittent IV devices; central venous catheters, including short-term (subclavian, femoral, and jugular), short-term to moderate-term (PICCs), and long-term (tunneled) catheters and ports; or implanted ports.

• PN provides for total nutritional needs when feeding via the gastrointestinal tract is impossible, inadequate, or hazardous.

• Before initiating HPN, the nurse assesses the parents’ ability to perform the procedure, existence of family support systems, availability of nearby pharmacies, and insurance coverage.