STOOL SPECIMENS

Stool specimens are frequently collected in 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, then defecate in the toilet, 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, the containers are marked with the date and time and kept in a specimen refrigerator. Care is exercised in handling the specimen because of the risk of contamination.

BLOOD SPECIMENS

Whether the specimen is collected by the nurse or others, the nurse is responsible for making certain that specimens, such as serial examinations and fasting specimens, are collected on time and 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 (see Evidence-Based Practice box). Withdrawing blood specimens through peripheral lock devices in small peripheral veins has met with 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. When using an IV infusion site for specimen collection, consider the type of fluid being infused. For example, a specimen collected for glucose level would be inaccurate if removed from a catheter through which glucose-containing solution was being administered.

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; by deep heel puncture; or from indwelling arterial catheters. Adequate circulation should be assessed 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. Because unclotted blood is required, only heparinized collection tubes are used. In addition, no air bubbles should enter the tube, since they can alter blood gas concentration. Crying, fear, and agitation also affect blood gas values; therefore every effort is made to comfort the child. The nurse should pack the sample in ice to reduce blood cell metabolism and take it to the laboratory for immediate analysis.

Capillary blood samples are taken from children by a 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, the heel is warmed for 3 minutes. The area is cleansed with alcohol, the infant’s foot firmly restrained with the free hand, and the heel punctured with an automatic lancet device (Clinical and Laboratory Standards Institute, 2006). An automatic device delivers a more precise puncture depth and is less painful than using a lance (Vertanen, Fellman, Brommels, and others, 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, and others, 2001). Shepherd, Glenesk, Niven, and others (2006) 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, or abscess (Meehan, 1998). 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 to the lateral aspect of the heel and another line extending posteriorly from the middle of the great toe and running parallel to the medial aspect of the heel (Fig. 22-11). Repeated trauma to the walking surface of the heel can cause fibrosis and scarring that may interfere with locomotion.

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

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 bodies is a threat to their lives. Explaining to them that their body is continuously producing blood provides them with 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 reassurance that the vital fluids will not leak out.

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 arterial punctures as being one of the most painful of all procedures experienced (Van Cleve, Johnson, and Pothier, 1996). The ones most distressed by venipunctures are toddlers, followed by school-age children and then adolescents. Consequently nurses need to institute pain reduction techniques to lessen the discomfort of these procedures (see Atraumatic Care box).

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 and supply sputum specimens when given proper directions. It must be made clear to them that a coughed specimen, not mucus that is 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 is 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 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 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 (Kennedy, 1996). 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 preterm 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, since the dosage of analgesics may need to be increased or the interval between doses decreased.

Various formulas involving age, weight, and body surface area as the basis for calculations have been devised to determine children’s drug dosage. Because the administration of medication is a nursing responsibility, nurses need knowledge of not only drug action and patient responses, but also some resources for estimating safe dosages for children. The method most often used to determine children’s dosage is based on a specific dose per kilogram of body weight, such as 0.1 mg/kg.

The most reliable method for determining children’s dosage is to calculate the proportional amount of body surface area (BSA) to body weight. 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 surface area than would be expected from the weight. The usual determination of BSA requires the use of the West nomogram or an electronic calculator (widely available on the internet). The BSA is estimated from the height and weight of the child.

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 ease of administration. Some have a slightly unpleasant aftertaste, but most children will swallow these liquids with little if any resistance. The nurse can taste a minute amount of an oral preparation to ascertain 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 (see Evidence-Based Practice box).

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 (up to 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 have poor absorption as a result of diarrhea, dehydration, or peripheral vascular collapse; who need a high serum concentration of a drug; who have resistant infections that require parenteral medication over an extended time; who need continuous pain relief; and who require emergency treatment.

Insertion sites and observation of the IV infusion are discussed on p. 733. Several factors need to be considered 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 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, the site of insertion is checked for patency. Medications are never administered with blood products. Only one antibiotic should be administered at a time.

IV infusion is suitable for children who can tolerate the necessary infusion rate and the extra fluid needed to administer the medication. For the very small infant or fluid-restricted child who is not able to tolerate the increased rate of fluids, special delivery systems, such as syringe pumps, are used. Regardless of the technique, the nurse must know the minimum dilutions for safe administration of IV medications to infants and children.

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 is 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, 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.

The wrapping on the suppository is removed and the suppository lubricated 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. The buttocks are then held together firmly to relieve pressure on the anal sphincter until the urge to expel the suppository has passed—5 to 10 minutes. Sometimes the amount of drug ordered is less than the dosage available. The irregular shape of most suppositories makes the process of dividing them into a desired dose difficult if not dangerous. If the suppository 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 between 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 that can be eliminated with various techniques.

To instill eye medication, the child is placed supine or sitting with the head extended, and the child is asked to look up. One hand is used 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 of dropping medication on the face (Fig. 22-15). As the lower lid is pulled down, a small conjunctival sac is formed; the solution or ointment is applied to this area, never 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. The lids are gently closed to prevent expression of the medication, and the child is asked to look in all directions to enhance even distribution of the preparation. Excess medication is wiped from the inner canthus outward to prevent contamination to the contralateral eye.

Instilling eye drops in infants can be difficult, since 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 infant 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 until the count of 3 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. To place the drops deep in 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, the pledgets should be loose enough to allow any discharge to exit from the ear. Premoistening thecotton 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 a pillow (Fig. 22-16). Depending on size, the infant can be positioned in the football hold (see Fig. 22-5, 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 as shown in Fig. 22-16. 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.

Nasal spray dispensers are inserted into the naris vertically and then angled nasally to avoid trauma to the septum and to direct medication toward the inferior turbinate.

FAMILY TEACHING AND HOME CARE

The nurse usually assumes the 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, following the same guidelines for teaching as outlined in the Nursing Care Guidelines box (p. 699).

The caregiver is carefully instructed regarding the correct dosage. Some persons have difficulty understanding medical terminology from the pharmacy; just because they nod or otherwise indicate an understanding, it cannot be assumed 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 be asked to 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 for one person to hold the child and safely give the drug.

The time that the drug is to be administered is clarified with the parent. 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 child 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 the drug must be given at equal intervals throughout a 24-hour period. For example, telling parents that the child needs 1 teaspoon of medicine four times a day is subject to misinterpretation, since 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 therapeutic dosage listed. Modification should also be made to accommodate sleep schedules. Written instruction should accompany all drug prescriptions.

MEASUREMENT OF INTAKE AND OUTPUT

Accurate measurements of fluid intake and output (I&O) 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 and considered. Although the practitioner usually indicates when I&O measurements 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 require the application of a collecting device (p. 711). If collecting bags are not used, wet diapers or pads are carefully weighed to ascertain the amount of fluid lost. This includes liquid stool, vomitus, and other losses. The volume of fluid in milliliters is 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 (see FYI, p. 712).

Disadvantages of the weighed-diaper method of fluid measurement include (1) inability to differentiate one type of loss from another because of admixture, (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 (in high-humidity incubators).

PARENTERAL FLUID THERAPY

INHALATION THERAPY

BRONCHIAL (POSTURAL) DRAINAGE

Bronchial drainage is indicated whenever excessive fluid or mucus in the bronchi is not being removed by normal ciliary activity and cough. Positioning the child to take maximum advantage of gravity facilitates removal of secretions. Postural drainage can be effective in children with chronic lung disease characterized by thick mucus, such as cystic fibrosis.

Postural drainage is carried out three or four times daily and is more effective when it follows other respiratory therapy, such as bronchodilator or nebulization medication. Bronchial drainage is generally performed before meals (or 1 to 1½ hours after meals) to minimize the chance of vomiting and is repeated at bedtime. The duration of treatment depends on the child’s condition and tolerance; it usually lasts 20 to 30 minutes. Several positions facilitate drainage from all major lung segments (Fig. 22-25); all positions are not employed at each session. Children will usually cooperate for four to six positions. Older children can tolerate longer periods.

In the hospital an older child can be positioned over an elevated knee rest. Small children and infants can be positioned with pillows or on the therapist’s lap and legs. Infants should not be placed in the Trendelenburg position because they do not have an autonomic regulation of blood flow to the head. Special modifications of the techniques are required in children whose conditions contraindicate the standard positioning, such as head injuries, some types of surgical incisions or burns, and casts.

CHEST PHYSICAL THERAPY

Chest physical therapy (CPT) usually refers to the use of postural drainage in combination with adjunctive techniques that are thought to enhance the clearance of mucus from the airway. These techniques include manual percussion, vibration, and squeezing of the chest; cough; forceful expiration; and breathing exercises. Special mechanical devices are also currently used to perform CPT (e.g., ThAIRapy Vest). Postural drainage in combination with forced expiration has been shown to be beneficial. Noninvasive inspiratory nasal pressure—support ventilation (PSV) during CPT has demonstrated a significant improvement in respiratory muscle performance and a reduction in oxygen desaturation (Fauroux, Boule, Lofaso, and others, 1999).

The most common technique used in association with postural drainage is manual percussion of the chest wall. The patient is dressed in a lightweight shirt and placed in a postural drainage position. The nurse then gently but firmly strikes the chest wall with a cupped hand (Fig. 22-26, A). For infants, special devices are available for percussing small areas (Fig. 22-26, B). A “popping,” hollow sound should be the result, not a slapping sound. The procedure should be done over the rib cage only and should be painless. Percussion can be performed with a soft circular mask (adapted to maintain air trapping) or a percussion cup marketed especially for the purpose of aiding in loosening secretions.

CPT is contraindicated when patients have pulmonary hemorrhage, pulmonary embolism, end-stage renal disease, increased intracranial pressure, osteogenesis imperfecta, or minimal cardiac reserves.

ARTIFICIAL VENTILATION

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 (see Atraumatic Care box).

Not all feeding tubes are the same. Polyethylene and polyvinylchloride types lose their flexibility and need to be replaced frequently, usually every 3 or 4 days. The polyurethane and silicone tubes are indwelling and remain flexible; so that they can remain in place longer and afford more patient comfort. Use of these small-bore tubes for continuous feeding has reduced the incidence of complications such as pharyngitis, otitis media, and incompetence of the lower esophageal sphincter. Although the increased softness and flexibility of the tubes are advantages, they also have disadvantages such as difficult insertion (may require a stylet or metal guidewire), collapse of the tube during aspiration of gastric contents to test for correct placement, dislodgment during forceful coughing, and unsuitability for thick feedings. Traditional methods for verifying placement are less reliable with the small-bore tubes.

Infants will be easier to control if they are first wrapped in a mummy restraint (see Fig. 22-7). Even tiny infants with random movements can grasp and dislodge the tube. Preterm infants do not ordinarily require restraint, but if they do, a small blanket folded across the chest and secured beneath the shoulders is usually sufficient. Care must be taken so that breathing is not compromised.

Whenever possible, the infant should be held and provided a means of nonnutritive sucking during the procedure to associate the comfort of physical contact with the feeding. When this is not possible, gavage feeding is carried out with the infant or child on the back or toward the right side and the head and chest elevated. Feeding the child in a sitting position helps maintain the placement of the tube in the lowest position, thus increasing the likelihood of correct placement in the stomach (see Nursing Care Guidelines box).

Two standard methods of measuring tube length for insertion are (1) measuring from the nose to the bottom of the earlobe and then to the end of the xiphoid process or (2) measuring from the nose to the earlobe and then to a point midway between the xiphoid process and the umbilicus (Fig. 22-30, A). For very low—birth-weight infants, weight can be used to predict insertion length (Table 22-7). See Evidence-Based Practice box for placement verification techniques.

GASTROSTOMY FEEDING

Feeding by way of a gastrostomy tube is a variation of tube feeding that 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 gastric tube in children who require tube feeding over an extended period. Placement of a gastrostomy tube may be performed with the patient 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, when surgically placed, is 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 is left open and attached to gravity drainage for 24 hours or more.

Postoperative care of the wound site is directed toward prevention of infection and irritation. The area is cleansed at least daily or as often as needed to keep the area free of drainage. After healing takes place, 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 prevention of irritation. Care is exercised to prevent excessive pull on the catheter that might cause widening of the opening and subsequent leakage of highly irritating gastric juices. The tube is securely taped to the abdomen, leaving a small loop of tubing at the exit site to prevent tension on the site.

Granulation tissue may grow around a gastrostomy site (Fig. 22-31). 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 in appearance, 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 button 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. 22-32). 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 decompress the stomach (to check residual or release air).

Feeding of water, formula, or pureed foods is carried out in the same manner and rate as in 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 appropriate only 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, very slight tension is applied. The tube is securely taped to maintain the balloon at the gastrostomy opening to prevent leakage of gastric contents and to prevent the tube’s progression toward the pyloric sphincter, where it may occlude the stomach outlet. As a precaution, the length of the tube should be measured postoperatively and then remeasured each shift to be certain it has not slipped. A mark can be made 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. Insertion of a nasoduodenal or nasojejunal tube is done by a trained practitioner 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

TPN provides for the total nutritional needs of infants or children when feeding by the gastrointestinal tract is impossible, inadequate, or hazardous. Some common conditions include chronic intestinal obstruction, inadequate intestinal length, and prophylactically after surgery or during critical illness.

TPN therapy involves IV infusion of highly concentrated solutions of carbohydrates, lipids, amino acids, vitamins, minerals, water, trace elements and other additives in a single container (Teitelbaum, Guenter, Howell, and others, 2005). 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, VADs are commonly used (see p. 725).

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’s tolerance of the solution. The TPN solution must be prepared under sterile conditions. The infusion is maintained at a constant rate by an infusion pump. 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, I&O measurements, and 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 assist the body’s adjustment. To prevent hypoglycemia at the time the hyperalimentation is disconnected, the rate of the infusion and the amount of insulin are decreased gradually.

In addition to children’s physical needs, their developmental needs must also be considered during the often long-term use of TPN. Development should be regularly assessed to monitor the child’s progress, and appropriate interventions should be instituted to encourage expected milestones. Delays in the areas of gross motor and language skills are found most often; therefore special attention should be directed to these areas.

FAMILY TEACHING AND HOME CARE

When alternative feedings are needed for an extended period, the family may need to learn how to feed the child with a nasogastric, gastrostomy, or TPN feeding regimen. The same principles discussed earlier in this chapter for compliance, especially in terms of education (p. 698), and in Chapter 21 for discharge planning and home care are applied. Because of the numerous skills the family must learn for home TPN, ample time must be allowed for the family to learn and perform the procedures under supervision before assuming full responsibility for the child’s care.

The family may be referred 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. Depending on the volume, a syringe with rubber tubing, an enema bottle, or an enema bag should be used (see Nursing Care Guidelines box).

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, and others, 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 usually 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 imbalance. 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 (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. 689). 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.^*

Ostomy equipment consists of a one- or two-piece system with a hypoallergenic skin barrier to maintain peristomal skin integrity. 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. Small clips or rubber bands should be avoided to prevent choking in the young child. Granulation tissue may grow around an ostomy site (see Fig. 22-31). This moist, beefy red tissue is not a sign of infection. However, if it continues to grow, the excess moisture can cause irritation of the surrounding skin.

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

In infants with a colostomy left unpouched, skin care is similar to that of any diapered infant. However, the peristomal skin is protected with a wafer barrier, such as a hydrocolloid dressing (e.g., DuoDERM) or a barrier substance (e.g., zinc oxide ointment [Desitin], or a mixture of the zinc oxide ointment and stoma [Stomahesive] powder). A gauze dressing may be applied over the stoma and wafer to absorb stomal drainage. If the skin becomes inflamed, denuded, or infected, the care is similar to the interventions used for diaper dermatitis (see Chapter 30). A product that helps protect healthy skin, heal excoriated skin, and minimize pain associated with skin breakdown is Proshield Plus. The skin protectant adheres to denuded weeping skin. Proshield Plus can be applied 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, protection of the pouch from being pulled off is also an important consideration. One-piece outfits keep exploring hands from reaching the pouch, and the loose waist prevents any pressure on the appliance. Keeping the child occupied with toys during the pouch change is also helpful. As children mature, their participation in ostomy care is encouraged. 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.

An enterostomal therapy nurse specialist is an important member of the health care team and will have additional suggestions and skin care information and ostomy pouching options. Further information may be obtained 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 family is instructed 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, the nurse, or the stoma specialist. The same principles are applied as discussed earlier in this chapter for compliance, especially in terms of education (p. 699), and in Chapter 21 for discharge planning and home care.

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