Care of the Sick or Hospitalized Child

GENERAL PRINCIPLES FAMILY-CEN ERE! CARE Family-centered care provides a framework for health care providers to ensure all aspects of care and the care environment are designed and focused toward family needs and concerns. The patient and family members are active members of the care team. The family is recognized and cares for the hospitalized child with full information, support, and respect. The goal of family-centered care is to maintain or strengthen the roles and ties of the family with the hospitalized child to promote normality of the family unit. "e#efits for Pare#ts a#d Child Care and teaching are in keeping with specific family needs and strengths. Family roles and close family interactions during time of stress are enhanced. Minimizes separation an iety. !ecreases reactions of protest, denial, and despair. "ncreases sense of security for the child. Family needs to care for their child physically and emotionally are fulfilled. #arents feel useful and important, rather than dependent and peripheral. !ecreases parental guilt feelings. "ncreases parents$ competence and confidence in caring for the sick child. Families of children with special needs share comfort and support from one another. %reater absorption of staff teaching by the family. !iminishes posthospitalization reactions. I$ple$e#tatio# Strate%ies "mplementation of family-centered care will depend on regulations of the particular health care setting as well as the capabilities of the individual family unit. &eview the policies and regulations regularly with the input of children or adolescents and family members. ' amples of activities that can facilitate and strengthen family ties include( Taking a family history and listening for specific family)cultural needs and preferences. *llowing rooming-in for parents of young children. +aving parents participate in the child$s physical care. *cknowledging that parents are not ,visitors-. having fle ible visiting regulations for family members, including siblings. +aving pictures of family members available at the hospital. 'ncouraging telephone contact. /sing family tape recordings. 'ncouraging the child and family members to participate in health care provider or team rounds when appropriate. +aving patient and parental input during the development of the daily medical plan can be beneficial.

*cknowledging that there are varying types of family units. 'nsure that the child$s usual caregiver 0who may not always be a parent1 or legal guardian is included in the decision-making process as appropriate.

Role of the N&rse o create a# e#'iro#$e#t co#d&ci'e to $ai#tai#i#% fa$il( stre#%th) i#te%rit() a#d &#it(* he #&rse sho&ld+ o +elp to maintain a positive nurse-parent-child relationship. *void actions that may cause parents to feel threatened by the nurse. o Facilitate a supportive marital relationship, allowing for differences in style and needs. o "nclude siblings in planning and intervention as appropriate to their age and the situation. o 2upplement the family$s abilities and role in achieving the common goal of the child$s welfare. o assist pare#ts ,ith decisio# $aki#% a-o&t ,he# to sta( ,ith their child a#d ,he# to -e a,a(* o The parents$ presence is especially important if the child is age 3 or younger, especially an ious, upset, or in medical crisis. o The parents$ decision is influenced by needs of other family members, as well as by 4ob, home responsibilities, and personal needs. o The nurse should try to alleviate guilty feelings of parents who are unable to stay with their child. o de'elop tr&sti#%) %oal-directed relatio#ships ,ith fa$ilies* o 5btain a thorough nursing history that provides information to assess broad consideration of strengths, relationships, and concerns. include family and individual stage of development, cultural, spiritual, social, material, and financial areas. o #lan with the family toward mutual, realistic goals. o &ecognize and acknowledge the care and consideration the child receives from the parents. o o-ser'e the pare#t-child relatio#ship a#d -e a-le to+ o 'valuate the degree of participation and effectiveness of the parents in physical and emotional care. o 5bserve the parents$ attitudes, skills, and techni6ues and the child$s behavior and response to them. o *ssess what teaching needs to be done. o !etect and respond to actual and potential problems in the parent-child relationship. o teach pare#ts k#o,led%e) &#dersta#di#%) a#d skills #ecessar( to f&#ctio# effecti'el( ,ith the hospitalized child* he #&rse sho&ld+ o Carefully assess the learning needs, learning styles, and potential barriers to understanding and skill development. assist families that need language interpretation. o #erform nursing techni6ues safely and efficiently.

Mutually with parents, assess and interpret the behavior of the hospitalized child, so appropriate understanding and intervention are reached. o *ssess the child$s and parents$ understanding of essential medical care and wellness-focused information. o "nterpret and reinforce what health care providers have told parents. *nswer 6uestions thoroughly and honestly as knowledge and nurse role permit. &efer core 6uestions about diagnosis and prognosis to the health care provider most involved with the area of concern. o ' plain medical procedures and diagnostic tests and the preprocedure preparations re6uired. o #rovide health teaching and anticipatory guidance concerning medically related information and wellness behaviors, parenting and child-rearing matters, and crisis intervention and community resources. o help pare#ts adapt to the sit&atio# a#d to de'elop their o,# feeli#% of 'al&e -( copi#% ,ith the child.s ill#ess a#d deri'i#% $ea#i#% thro&%h the diffic&lt e/perie#ces the( are faci#%* o 7e aware of common parental reactions to the stress e perienced by families of children who have severe or chronic illness. respond or refer to other discipline as indicated 0ie, child psychiatry or child life personnel1. o 7e aware that defense mechanisms, if used in moderation, are constructive and may facilitate optimal coping. o +elp parents recognize and value their own feelings and the feelings of significant others. o "dentify parental support systems as well as adaptive and maladaptive coping. o 7e perceptive of parents$ physical and emotional needs and limitations. *s possible, help prevent parents becoming fatigued. 'ncourage parents to leave and take a break. o assist fa$ilies) as appropriate) i# deali#% ,ith #or$ati'e fa$il( de'elop$e#tal tasks* o 7e aware that the child$s hospitalization is commonly only one of many stresses a family e periences at a given time. 5thers may include( "nterpersonal problems. /nemployment, 4ob change. &ecent changes in dwelling place and conse6uent disruption. #roblems associated with childcare and discipline. Concurrent illness of other family members. Financial constraints, lack of insurance. Transportation issues 0no car, limited public transportation1. 8anguage barriers. o 9eep in mind that the family unit and family members individually have strengths and resources to be discovered and contributed. o Consciously identify and separate your feelings and 4udgments about the situation from those of the child and family. the goal is to draw on individual and family strengths to meet needs and solve problems as a family unit.
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SE INGS 0F PE!IA RIC ILLNESS CARE !ELI1ERY The ill child benefits from being at home or in a homelike environment, and this setting is preferred when possible. Many additional factors influence the increasing use of nonhospital care for sick children, even those who are seriously ill and those dependent on medical technology( family preference, family$s ability to comprehend and provide medical therapies, increasing availability of community health services, availability of programmable ".:. pumps and other devices, shortened length of hospital stays, and limitations of insurance benefits for inpatient care. Ho$e Care *nticipatory guidance, planning, and teaching are strategies used to prepare the child and family for care at home during acute or chronic illness. he 2&alit( of care a#d fa$il( life is e#ha#ced -( a %e#eral k#o,led%e of the child.s+ o Condition. o Treatment regimens. o Medical e6uipment. o 2igns of complications. o &esources( who and when to call for assistance. 2pecific issues and skill development depend on the age and condition of the child, the home situation, and family resources and abilities as well as the community environment and resources. 0ffice a#d Cli#ic Ser'ices Conditions that were previously diagnosed and treated in the hospital are now managed on an outpatient basis. "ncreased early discharge of hospitalized children with outpatient follow-up re6uires more care by family. his leads to a# i#creased role of the office #&rse to+ o *ssess a child$s and family$s coping with home care. o #rovide education and support. o *dminister treatments in an outpatient setting. o *ct as a liaison between the child and family, the home health nurse, and the health care provider. School or !a(care Children and youth with chronic and)or ongoing health concerns are able to remain in school and participate in activities with their peers. *daptive education and medical technology are bringing new opportunities that foster development and socialization for children with special needs. *ssessment of changing health, wellness counseling, health teaching, referral, and skilled care are among the roles of a school nurse. "nterventions may include medication administration, glucose monitoring, urinary catheterization, tube feedings, and initial crisis intervention. Ca$p

2ummer camp is an e citing e perience for children. They learn about nature and themselves. they e perience independence and group living. they get a change of pace from their usual routines. Many camps are set up for children with chronic or handicapping conditions where their special needs are met and they have an opportunity to learn, play, and socialize with other people who are much like themselves. "n these settings, the nurse serves the role of camp counselor, confidant, and provider of care.

Hospital or E/te#ded-Care Facilit( "npatient facilities have special programs to facilitate the age and development related needs of infants, children, and youth. ;ursing care is directed toward the child and family members. <here the facility is not wholly dedicated to children, attention is given to ensure pediatric standards of care are met throughout the continuum of care( laboratory, diagnostic imaging, surgery, physical therapy, and emergency department. IMPAC 0F PR0L0NGE! ILLNESS 0R H0SPI ALI3A I0N 0N HE CHIL!.S S AGE 0F !E1EL0PMEN The child has the same basic emotional and social needs during a prolonged illness or hospitalization as a child not challenged by these circumstances. #rolonged illness and hospitalization can retard growth and development and cause adverse reactions in the child based on stage of development. Neo#ate 4"irth to 5 Mo#th6 Pri$ar( Co#cer#s 7onding=prolonged illness and hospitalization interrupt the early stages of the development of a healthy mother-child relationship and family integration, thus early stages of the development of trust are missing. 2ensory-motor deprivation=tactile, visual, auditory, and kinesthetic. 2ensory overload. Reactio#s "mpairment of parent-infant attachment and bonding. "mpairment of the infant$s ability to respond to parents and family members. "mpairment of the parent$s ability to love and care for the baby. &isk of compromise in the infant$s emotional and physical well-being. &isk of stress within the family constellation. N&rsi#% I#ter'e#tio#s #rovide care within a family-centered conte t. #rovide for continual contact between baby and the parents 0eye contact, touch, talk1. Minimize isolation and strangeness by e plaining and re-e plaining e6uipment, procedures, and the treatment plan to parents. *ctively involve parents in caring for their baby=provide for rooming-in.

Foster neonate-sibling relationships as appropriate. "dentify areas of infant deprivation or overstimulation. #lan a schedule of appropriate stimulation 0ie, hold and rock every > to ? hours, eye contact1. #rovide sensory-motor stimulation as appropriate. *llow individuality to begin to emerge. #rovide consistent caretakers when possible.

Yo&#% I#fa#t 45 to 7 Mo#ths6 Pri$ar( Co#cer#s 2eparation=mother and father are learning to identify and meet the needs of their infant. The infant is learning to make his needs known and to trust the mother to meet them. 2ensory-motor deprivation. ;eeds=security, motor activity, comforting measures. Reactio#s 2eparation an iety is different from that of an older child because the young infant sees the primary caregiver as an e tension of himself. !evelopment of trust is disturbed when the infant is separated from his mother and when illness or hospitalization interferes with meeting the infant$s needs. "nterference with development of a basic sense of trust has lifelong implications. N&rsi#% I#ter'e#tio#s 'ncourage the parents to balance their responsibilities and minimize separation, staying with the infant and providing care for their baby. <hen the parents are absent, meet the baby$s basic needs promptly and give him attention and appropriate handling from a limited number of personnel. #rovide opportunity for sensory stimulation, motor development, and social responsiveness appropriate to the infant$s age and condition. +elp the parents to see the infant as a uni6ue individual with needs and personal style, to ac6uire infant care skills, and to work through their an ieties about parenting and the infant$s condition. &emember, parental touch communicates comfort and calm or discomfort and stress to the infant. Mid-A%e I#fa#t 47 to 8 Mo#ths6 Pri$ar( Co#cer#s 2eparation from the parents and family members, as the infant now recognizes the parents as separate people from self. The infant re4ects strangers. !evelopment of self-6uieting behaviors. Reactio#s 2eparation an iety=crying, terror, somatic upset, blank facial e pression, e treme preoccupation. 'motional withdrawal and depression. "nterference with development of basic trust. "nterference with growth and achievement of developmental milestones.

N&rsi#% I#ter'e#tio#s 'ncourage the parents$ presence and nurturing of their baby. Foster the parents$ confidence and competence in this new role. 'ncourage the parents and family to ad4ust their schedules and home routines. %et to know the infant through the parents, avoid overshadowing the parents. The infant is beginning to develop purposeful activities and to strive toward independence. #rovide opportunities and encouragement for this development to continue, and provide ways for infant to use newly ac6uired skills. 0lder I#fa#t 48 to 59 Mo#ths6 Pri$ar( Co#cer#s 7eginning definition of self=infant is aware of a growing ability to influence his environment. 2eparation=infant becomes more possessive of the parents and clings to them at the time of separation. Reactio#s #assivity toward environment. 2eparation an iety=tolerance is limited. fear of strangers, e cessive crying, clinging, and overdependence on the parents. N&rsi#% I#ter'e#tio#s +ave the mother stay and care for her child. &elieve some of tensions and loneliness with ,transference- ob4ect 0ie, blanket, toy1. #repare the child for procedures. !etailed e planations are usually unnecessary due to limited understanding. The procedures should be performed in another room or a treatment room. let the parents soothe the child afterward. #rovide for sensory stimulation and motor development appropriate for age. #rovide opportunities for the child to continue using ac6uired skills, such as feeding self and drinking from a cup. The child needs opportunity to foster increased independence, curiosity and e ploration, locomotion, and language skills. /se infant seats, swing. give room to move around in crib, playpen, or floor. use color, te ture, and sound. physical stroking, rocking, and talking. oddler 4A%es 5 to :6 Pri$ar( Co#cer#s 2eparation an iety=relationship with mother is intense. 2eparation represents the loss of family and familiar surroundings, resulting in feelings of insecurity, grief, an iety, and abandonment. The toddler$s emotional needs are intensified by the parents$ absence. Changes in rituals and routines, all of which are important to sense of security, become a source of concern.

"nability to communicate=beginning use and understanding of language affords child limited communication between self and the world. The child has limited capacity to understand reality, passage of time. 8oss of autonomy and independence=egocentric view of life helps the child develop a sense of autonomy. The child sees self as a separate being with some potential control of own body and environment. 7ody integrity=incomplete and inaccurate understanding of the body results in fear, an iety, frustration, and anger. !ecrease in mobility=restricting mobility causes frustration. The child wants to keep moving for the pleasure it gives as well as for the feeling of independence, the opportunity to learn about the world, and the route it provides for coping with frustrations that cannot be verbally e pressed. #hysical interference with this freedom results in a sense of helplessness.

Reactio#s Protest+ o +as urgent desire to find mother. o ' pects that they will answer cries, ," want mommy-. ," want daddy.o Fre6uently cries and shakes crib. o &e4ects attention of nurses. o <hen with parents, the child shows signs of distrust with anger or tears. !espair+ o Feels increasingly hopeless about seeing his parents. o 7ecomes apathetic, anorectic, listless. looks sad. o May cry continuously or intermittently. o /ses comfort measures=thumbsucking, fingering lip, tightly clutching a toy or blanket. !e#ial+ o &epresses all feelings and images of parents. o !oes not cry when parents leave. o May seem more attached to nurses=will go to anyone. o Finds little satisfaction in relationships with people. o *ccepts care without protest. &egression( temporarily ceases use of newly ac6uired skills in an attempt to retain or regain control of a stressful situation. N&rsi#% I#ter'e#tio#s Pro'ide roo$i#%-i#) &#li$ited 'isiti#%* Pare#tal 'isits pro'ide+ o 5pportunity for the child to e press some of his feelings about the situation. o *ssurance that parents are not abandoning or punishing child. o #eriods of comfort and reassurance that allow for the reestablishment of family bonds. *ttempt to continue routines used at home, especially with regard to sleeping, eating, and bathing. &eestablish trust through body contact and comfort. 2et limits.

5btain from the parents key words in communicating with the child. Find out about nonverbal behavior as well. Familiar toys, blankets, pillowcases, and family pictures can reinforce the child$s sense of security. *llow the child to make choices when possible. *rrange physical setting to encourage independence. *llow the child to e plore his environment. 'nsure an age-appropriate and safe environment. ;o balloons at the bedside. *n adhesive bandage may give the child a security of wholeness after an in4ection. &eplace lost mobility with another form of motion, such as moving about in a wheelchair, cart, or bed. ' ercise restrained e tremity. #rovide opportunities for the child to release energy suppressed by decreased mobility 0ie, by pounding, throwing1. #rovide opportunities to continue learning about world through sensory modalities, such as water play and diversional play. !ischar%e;if roo$i#%-i# has #ot occ&rred d&ri#% hospitalizatio#) pare#ts $&st -e prepared for the possi-le post-hospital -eha'ior of their toddler* he( ,ill #eed s&pport i# &#dersta#di#% a#d ha#dli#% these -eha'iors* he child $a( do a#( of the follo,i#%+ o 2how lack of affection or resist close physical contact. #arents may interpret this as re4ection. o &egress to an earlier stage of development. o Cling to parents, unable to tolerate any separation from them. show e cessive need for love and affection. Appropriate pare#tal respo#se to the child.s -eha'ior is 'ital if relatio#ships are to -e reesta-lished* o ' tra love and understanding will help restore the child$s trust. o +ostility and withdrawal of love will cause the child$s further loss of trust, self-esteem, and independence. o Continue with previously established routines at home. Continue to set limits.

Preschool Child 4A%es : to <6 Pri$ar( Co#cer#s 2eparation=although cognitive and coping capabilities have increased and the child responds less violently to separation from parents, separation and hospitalization represent stress beyond the coping mechanisms and adaptive capabilities of the preschool child. 8oneliness and insecurities are e perienced. 8anguage is important. although children may not verbally e press what they are feeling, there is an attempt at this in ?- to 3-year-old children. /nfamiliar environment=this re6uires coping with a change in daily routine and represents a loss of control and security. *bandonment and punishment=fantasies and thoughts may contain vengeful wishes for other persons, for which the child e pects retribution. "llness may be interpreted as punishment for thoughts. 'nforced parental separation may be interpreted as loss of parental love and represents abandonment by them.

7ody image and integrity=hospitalization and intrusive procedures provide a multitude of threats of both bodily mutilation and loss of identity, which are 4ust beginning to develop along with the ac6uisition of autonomy. "mmobility=mobility is the child$s dominant form of self-e pression and adaptation to the environment. The child has great urge for locomotion and e ercise of large muscles. "t represents the main e pression of emotion and release of tension. 8oss of control=this influences the preschooler$s perception of and reaction to separation, pain, and illness.

Reactio#s &egression=child temporarily stops using newly ac6uired skills in an attempt to retain or regain control of a stressful situation. #reschooler may return to behavior of infant or toddler. &epression=child may attempt to e clude the undesirable and unpleasant stresses from consciousness. #ro4ection=preschooler may transfer own emotional state, motives, and desires to others in environment. !isplacement or sublimation=emotions are permitted to be directed and e pressed in other situations, such as art or play. "dentification=the child assumes characteristics of the aggressor in an attempt to reduce fear and an iety and to feel in control of the situation. *ggression=hostility is direct and intentional. physical e pression takes precedence over verbal e pression. !enial and withdrawal=the child is able to ignore interruptions and disavow any thought or feeling that would result in a painful e perience. Fantasy=a mental activity to help the child bridge the gap between reality and fantasy because of lack of e perience. The preschooler may simply show similar behaviors 0protest, despair, denial1 to those of the toddler although the stage of protest is usually less aggressive and direct. N&rsi#% I#ter'e#tio#s Minimize stress of separation by providing for parental presence and participation in care. 2trive to shorten the hospital stay. +elp parents understand what hospitalization means to the child. "dentify defense mechanisms apparent in the child and help him through the stressful situation by accepting, showing love and concern, and being alert to readiness to relin6uish them. 2et limits for the child. 8et him know that someone is there. +elp the child become master of something in the situation. #rovide opportunity and encouragement for the child to verbalize. Careful preparation for all procedures should be done on the child$s level of development and comprehension. #rovide privacy during these procedures. 7e sure the child has opportunities for play. #lay is one important medium through which the child can overcome fear and an iety. "ncorporate child life

therapy into care as appropriate. * body outline, doll, and simple visual aids are appropriate teaching tools. #rovide self-e pression, role reversal through puppets, dolls, and drawings. 'ncourage activities with other children, especially those in similar circumstances. #rovide consistency in nursing personnel and approach to care. 'ncourage the child to participate in his own care and hygiene as appropriate. #rovide a safe, age-appropriate environment. !eal specifically with castration and mutilation fears. "f the child is having surgery, describe e actly which body part will be repaired. #rovide pictures and other visual aids to reinforce teaching. <henever appropriate, reassure the child that no one is to blame for the illness or hospitalization. !iscourage parents from reinforcing negative feelings to the child=,"f you are not good, " will leave you here- or ," will have the nurse give you a shot.-

School-A%e Childre# 4A%es < to 596 Pri$ar( Co#cer#s Many fear loss of recently mastered skills. Many worry about separation from school and peers. They may fear loss of former roles. Mutilation fantasies are common. 2ome may believe that they or their parents magically caused the illness merely by thinking that the event would occur. Typically, they have increased concerns related to modesty and privacy. The imposed passivity may be interpreted as punishment for being bad. Children may feel their body no longer is their own but rather is controlled by doctors and nurses. Reactio#s &egression. 2eparation an iety=especially early school-age period. ;egativism. !epression. e#de#c( to -e pho-ic 4#or$al6+ o Fears include that of the dark, doctors, hospitals, surgery, medication, and death. o /nrealistic fears are commonly attached to needles, @-ray procedures, and blood. Conscious attempts at mature behavior. 2uppression or denial of symptoms. N&rsi#% I#ter'e#tio#s +elp parents to prepare the child for elective hospitalizations.

5btain a thorough nursing history, including information regarding health and physical developments, hospitalizations, social and cultural background, and normal daily activities. /se this information to plan care. #rovide order and consistency in the environment whenever possible. 'stablish and enforce reasonable policies to protect the child and to increase his sense of security in the environment. *rrange the environment to allow for as much mobility as possible 0ie, make sure articles are appropriately placed. move the bed if the child is immobilized1. &espect the child$s need for privacy, and respect modesty during e aminations, bathing, and other activities. /se treatment rooms whenever possible when performing painful or intrusive procedures. 9eep the room as ,safe- territory. +elp young children identify problems and 6uestions 0often through play1. Then help them find the answers. #rovide information about the illness and hospitalization based on assessment of what facts the child needs and wants and how this information can be made readily understandable. :iew all nursing care activities as teaching situations. ' plain the function of e6uipment, and allow the child to handle it. Teach scientific terminology for body parts, procedures, and e6uipment. #rovide visual aids whenever possible. <hen e plaining a procedure, make sure that the child knows its purpose, what will be done, and what will be e pected. &eassure the child during the procedure by continuing the e planations and support. &eassure the child having surgery. e plain where the organ to be removed or repaired is located and that no other body part will be removed. Carefully assess pain, and provide appropriate relief. /se play whenever appropriate to provide information about the hospital e perience and to identify and decrease the child$s fantasies and fears. "ncorporate child life therapy. %ive tours of the operating room and recovery room or special procedure room preoperatively to the child and his family. &eassure the child that neither he nor his parents are to blame for the illness. Facilitate discharge of energy and aggression through appropriate play activities or through sharing aspects of ward management. 'ncourage the child$s participation in care and self-hygiene. 2upport intellectual potential through the use of games, puzzles, schoolwork, and drawings. Contact school tutors if necessary. *ssist the family to understand the child$s reactions to illness and hospitalization so family members can facilitate positive coping patterns. 8et the child know that his normal status as a family member remains intact during hospitalization. 'ncourage a consistent visiting pattern and allow sibling visits. +elp parents to deal with their own an ieties about hospitalization, and assist them to help their child cope with the situation. 'ncourage parental participation in the child$s care. 'ncourage written communication with peers, and allow peer visiting when appropriate.

7egin discharge planning early, including plans for physical and emotional needs. *lert families to possible behavioral changes, including phobias, nightmares, regression, negativism, and disturbances in eating and learning.

Adolesce#t Pri$ar( Co#cer#s #hysical illness, e posure, and lack of privacy may cause increased concern about body image and se uality. 2eparation from security of peers, family, and school may cause an iety. "nterference with struggle for independence and emancipation from parents is a concern. The adolescent may be threatened by helplessness and may see illness as a punishment for feelings not mastered or for breaking rules imposed by parents or physicians. "llness and hospitalizations may interfere with peer associations, self-concept, se uality, and independence. Reactio#s *n iety or embarrassment related to loss of control. "nsecurity in strange environment. "ntellectualization about disease details to avoid addressing actual concerns. They may know others with the same chronic type of illness who have died. may fear the future or feel guilty they have survived. &e4ection of treatment measures, even if previously accepted. *nger 0may be directed toward parents or staff1 because goals are being thwarted. !epression. "ncreased dependency on parents and staff. !enial or withdrawal. !emanding or uncooperative behavior 0usually an attempt to assert control1. Capitalization on gains from illness or pain. N&rsi#% I#ter'e#tio#s +elp parents to prepare the adolescent for elective hospitalization. *ssess the impact of illness on the adolescent by considering factors such as timing, nature of illness, new e periences imposed, changes in body image, and e pectations for the future. 7e aware of misconceptions. "ntroduce the adolescent to the hospital staff and to regular routines soon after admission. 5btain a thorough nursing history that includes information about hobbies, school, family, illness, hospitalization, food habits, se uality, recreational activities, and drug and alcohol e posure or addictions. 'ncourage adolescents to wear their own clothes, and allow them to decorate their beds or rooms to e press themselves. +ave drawers and closets available to store personal items. *llow the adolescent access to a telephone.

*llow adolescents control over appropriate matters 0ie, timing of bath, selection of food1. &espect their need for periodic isolation and privacy. +ave a supervised recreational and activities program available that is planned by a professional childcare worker. *ccept the adolescent$s level of performance. *llow regression with e pectation of growth. "nvolve adolescent patients in planning care so they will be more accepting of restrictions and receptive to health teaching. Focus on capabilities rather than limitations. *dolescent should be accepted as a vital member of the health care team. The adolescent$s consent should be obtained for procedures and surgery. ' plain clearly all procedures, routines, e pectations, and restrictions imposed by illness. "f necessary, clarify the adolescent$s interpretation of illness and hospitalization. #lan separate teaching sessions for parents. %ive tours of the operating room and recovery room or special procedure room preoperatively to the child and his family. Facilitate verbal re4ection of treatment measures to protect the adolescent from harming himself physically by stopping treatment. *ssess the adolescent$s intellectual skills, and provide necessary information to allow for problem solving to deal with illness and hospitalization. &ecognize positive and negative coping behaviors as attempts to ad4ust to a threatening situation. *ttempt to deal with feeling that caused the behavior as well as with the behavior itself. 7e a good listener. Maintain a sense of humor. 7e honest and respectful with the adolescent and his family. #rovide opportunities such as writing, artwork, and recreational activities to allow nonverbal adolescents to e press themselves. Foster interaction with other hospitalized adolescents and continuation of peer relationships with outside friends. 'stablish regular group meetings to allow patients to meet with staff members and with each other to comment and ask 6uestions about their hospital e periences. 2et necessary limits to encourage self-control and ensure the rights of others. +elp adolescents work through se ual feelings. *void behavior that could be interpreted as provocative or flirtatious. !escribe and interpret the needs and reactions of the hospitalized adolescent to his parents. 'mphasize the adolescent$s need to be respected as a uni6ue individual, separate from his parents. *ssist the parents to cope with the illness and hospitalization as well as to deal effectively with the adolescent$s response to related stress. 'ncourage continuation of education. Contact school tutors if necessary. 2tress the confidential nature of conversations between nurse and patient, physician and patient. #rovide employers with ,absence from work- paperwork if necessary. *ssess for signs and symptoms of drug or alcohol withdrawal.

7ecause many adolescents use the "nternet, review information that the patient might have found on the "nternet regarding diagnosis and treatment to ensure they have found credible and accurate information.

PE!IA RIC AC= E CARE N=RSING &efer to the previous section on the impact of hospitalization on the developmental stage of the child. "n addition to the stress of hospitalization and the illness itself, the child must deal with multiple providers and the no ious environment( high noise level, loss of sleep, bright lights, random and unpredictable procedures, and the drastic change from normal routine. The parental role changes when their child is admitted to the intensive care unit 0"C/1, from that of parents of a well child to one of parents of a critically ill child. To ease this transition, parents need to be informed about their child$s current condition, care plan, and the future. They also need to feel needed and vital in their child$s recovery. E$otio#al S&pport to Child "f possible, familiarize the child with the setting or unit before admission. #rovide immediate physical care that communicates competence, caring, and strength and facilitates trust. 7e alert to behavioral changes that may indicate physical distress. Facilitate parent-child interaction. facilitate fre6uent family visits. *sk the parents about the child$s own way of responding to emotional stress. /se particular comforts that are most soothing to the child. 2upport parents so they will be best able to support their child. *sk a social worker to visit the family to ensure the parents have a plan regarding transportation, daycare for siblings, and sleeping arrangements if they have come to the facility from out of town. Foster rest and prolonged periods of sleep. Time activities to reduce interruptions. dim lights to allow for ade6uate sleep. whenever possible, cluster caregiving activities. !o everything possible to reduce the amount of pain the child must endure. anticipate and prevent an iety and pain. provide comfort measures and therapeutic distractions as appropriate. *dminister an iety-reducing or painreducing medications as ordered, and determine effectiveness. &e6uest topical anesthetics 0eg, lidocaine A.3B and prilocaine A.3B1 prior to venipuncture and in4ections when appropriate. Consider conscious sedation, and assist according to standards and procedures. #rovide age-appropriate stimulation when indicated by the child$s condition 0T:, games, books, and toys1. 'ncourage child life therapy whenever appropriate. #rovide opportunities for the child to e press his fears and concerns. "f possible, avoid e posing an alert child to the death or resuscitation of another child. "f the child is e posed, provide ade6uate and developmentally appropriate e planation. +elp the child e press his own feelings and work through the e perience. #repare the child and his family for transfer from the "C/ by implementing a nursing care plan similar to one that the child will e perience on a regular unit

0eg, decrease fre6uency of monitoring of vital signs, encourage independence1. %ive a thorough report to the receiving nurse during transfer. E$otio#al S&pport to the Fa$il( 0rie#t pare#ts to the &#it a#d its ,aiti#% areas* Clarif( 'isiti#% policies a#d hospital e/pectatio#s* o "f the admission to the "C/ is e pected, familiarize the parents with the "C/ before the admission. o "f the admission is une pected and sudden, the e perience can be traumatic for the family. Care to reduce fears, stress, and an iety is of prime importance for the family. 'ncourage liberal visiting hours and unlimited phone calls from the parents to the "C/. *ssure the parents that everything possible is being done for their child. <henever possible, allow them to see the child receiving treatment. Make certain that the parents are informed of important changes in the child$s clinical status. "f the parents are leaving the unit, e change telephone numbers to ensure contact if needed. &einforce medical interpretations. ' plain special e6uipment and changes in nursing management. #rovide opportunities for the parents to ask 6uestions and have them answered. 'ncourage the parents to keep a 4ournal of their hospital e perience. "t is a very real way for parents to confront their feelings, especially if they are not e pressing them to the hospital team. /rge them to include information such as medical updates they receive from staff members. This allows them to have a written summary of the medical plan. 'ncourage the parents to interact verbally and physically with their child. 2upport them in this endeavor. Facilitate e pression of parental grief. #rovide opportunities for the parents to talk to a person with whom they can share their concerns and fears 0ie, chaplain, social worker, psychiatrist1. 7e sure this person can see them as often as they re6uire. #rovide opportunities for parents to meet together to share e periences and offer mutual support. 'ncourage parents not to compare progress of other patients to their child. "t can set them up to be 6uickly disappointed. Focus on each child and situation as uni6ue. 7e sensitive to the parents$ additional commitments to family as well as to their need to remain with their child. <henever possible, allow visiting at mutually convenient time. +elp the parents provide anticipatory guidance for siblings and e tended family members. &efer the parents to appropriate community resources for help for financial, environmental, or psychological problems. 5ffer follow-up contact to the parents if appropriate. %uide families in the use of the "nternet, and help connect them with support groups for information and peer support. Candlelighters Childhood Cancer Foundation can be reached at CDD->EE-AAA> or http())www.candlelighters.org

*sk the parents to discuss any medical information they find on the "nternet to ensure accuracy.

HERAPE= IC PLAY AN! CHIL! LIFE PR0GRAMS #lay is a central mechanism in which children cope. Through play, children communicate, learn, and master a traumatic e perience such as hospitalization. Many hospitals have established programs with a specially trained staff whose 4ob it is to concern themselves solely with the social and emotional welfare of every pediatric patient. 2uch programs are called by a variety of names, including ,Child 8ife,,Children$s *ctivities,- ,&ecreational Therapy,- ,#lay Therapy,- and others. Collaboration between nurses and child life specialists e tends the benefits of these approaches across time and settings of care. Goals of Child Life Pro%ra$s o pre'e#t so$e of the e$otio#al pai# a#d fear associated ,ith ill#ess a#d hospitalizatio#* o Child life workers may assume primary responsibility or a supportive role in the preparation of patients for hospitalization, surgery, or particular procedures. o "n many hospitals, child life workers arrange preadmission tours, puppet shows, and similar activities to which all children who are planned pediatric admissions are invited. o pro'ide a co$forta-le) accepti#%) a#d #o#threate#i#% e#'iro#$e#t ,here the child $a( pla( a#d i#teract ,ith other childre# a#d ,ith a# ad&lt ,ho is #ot i#'ol'ed ,ith health care* o "deally, there is a separate child life playroom in every unit. +owever, there may be only an open area at the end of the corridor or in the middle of the unit. o %enerally, there is a specific regulation that no medical procedures 0even a relatively benign one such as taking a child$s temperature1 are to be carried out in the play area. o "n many settings, children are encouraged to have their meals in the playroom. %enerally, they not only en4oy the opportunity to eat with others, but also seem to eat better. o pro'ide the child ,ith a# opport&#it( for choice* o The child may choose whether he wishes to come to the playroom. 5nce there, the child may choose what to do. o * variety of craft and play materials, including real and miniature medical e6uipment, are available. o 2hould the child choose to sit and watch or be held and rocked, these activities are seen as acceptable choices. o Certain items 0puzzles, games1 may be brought back to the child$s room for use when the playroom is closed. o #ortable T:s and video games may be available. o pro'ide a co#ti#&i#% ed&catio#al pro%ra$*

"n some settings, teachers are paid by the hospital and are an integral part of the child life program. "n others, teachers are provided by the local public schools, and they work in close cooperation with the child life department. "n most hospitals, the educational program includes special activities for preschoolers and toddlers as well as a program of infant stimulation that may be in collaboration with physical and occupational therapists.

PAIN MANAGEMEN Ge#eral Co#sideratio#s #ain e perienced by infants and children is not effectively identified or managed in many cases. There are still misunderstandings about the ways pain is e perienced and e pressed by infants and children. 7ehavioral and physiologic cues are used to assess pain in infants. 2pecial rating tools are available to involve children in assessing the intensity of their pain, including the #ain ' perience "nventory, C&"'2 ;eonatal #ostoperative #ain Measurement 2cale, 5ucher #ain &ating 2cale, ;umerical or :isual *nalog 2cale, and the F*C'2 #ain &ating 2cale.

FACES Pai# Rati#% Scale* 4>hale() L*) ? >o#%) !* @5AABC* Esse#tials of pediatric #&rsi#% @<th ed*C* Mos-(DYear "ook*6 #ain caused by a condition is not always proportional to the seriousness of the illness or in4ury. For e ample, a relatively minor illness, such as an earache, is a very painful e perience, whereas an enlarging tumor may not cause pain in early stages. "t is important to consider pain when a child is noncommunicative, has decreased consciousness, or is intubated. "t is e6ually important to consider pain when a child re6uires an in4ection, blood test, or noninvasive or invasive diagnostic test. Co#sider pare#ts ,he# assessi#% a#d $a#a%i#% the pai# of their child* It is ,ell doc&$e#ted that pare#ts are i$porta#t i#fl&e#ces o# their childre#* o Consider the way in which the parents view the situation e perienced by the child, and work with them to intervene effectively. o #resence of the parents during a procedure can be very positive, especially when the family has been prepared. o *t other times, it is recommended that the parents mutually agree to wait in a nearby area.

*rbitrary rules against parental presence are often designed to meet the needs of staff, not the needs of the child and his parents.

N&rsi#% I#ter'e#tio#s *nticipate pain and intervene early. /se a rating scale that the child can understand, and use it consistently with that child for initial pain assessment and to determine the effectiveness of interventions. *ttempt to introduce the pain rating scale to the child prior to the surgery or procedure. /se self as therapeutic presence to help ease pain. Teach self-regulation and self-control techni6ues. /tilize distraction by sounds, music, audio images, and movies. *llow self-soothing maneuvers 0thumb sucking, clinging to blanket, rocking1. Consider referral for self-hypnosis and conscious rela ation techni6ues. /tilize medication delivered by way of noninvasive routes where possible. *dminister premedication=anesthetizing, antian iety, and antiemetic medications as indicated. *ssist with conscious sedation when indicated, following standards of practice related to assessment, staffing, care, and documentation. HE CHIL! =N!ERG0ING S=RGERY Ps(cholo%ical Preparatio# a#d S&pport S&ch preparatio# a#d s&pport ,ill $i#i$ize stress a#d ,ill help the child a#d his fa$il( cope ,ith fears* Pote#tial threats for the hospitalized child a#ticipati#% s&r%er( are+ o #hysical harm=bodily in4ury, pain, mutilation, death. o 2eparation from parents. peers for the older child or adolescent. o The strange and unknown=possibility of surprise. o Confusion and uncertainty about limits and e pected behavior. o &elative loss of control of their world, loss of autonomy. o Fear of anesthesia. o Fear of the surgical procedure itself. o Misinterpretation of medical 4argon 0eg, dye-die1. he attit&des of the pare#ts to,ard hospitalizatio# a#d s&r%er( lar%el( deter$i#e the attit&des of their child* o The e perience may be emotionally distressing. o #arents may have feelings of fear or guilt. o The preparation and support should be integrated for parent, child, and family unit. o %ive individual attention to parents. e plore and clarify their feelings and thoughts. provide accurate information and appropriate reassurance. o 2tress parents$ importance to the child. +elp parents understand how they can care for their child.

Preoperati'e eachi#% *ll preparation and support must be based on the child$s age, developmental stage, and level. personality. past history and e perience with health professionals and hospitals. background including religion, socioeconomic circumstances, culture, and family attitudes and dynamics. "n6uire as to what information the child has already received. !etermine what the child knows or e pects. identify family myths and possible misunderstandings. Additio#al %&ideli#es i# preparatio# i#cl&de+ o /se illustration or model of a child$s body, concrete e amples, and simple terms 0not medical 4argon1. o "dentify changes that may occur as a result of the procedure, both in body and daily routine. o %ive e planations slowly and clearly, saving an iety-producing aspects until the end. &epeat as needed. o Make use of the child$s creative ability and logical thinking powers to aid in preparation for procedures. o "nvolve parents, as indicated, depending on the situation. o *llow and encourage the child to participate as able. o 2uggest ways for the child to cope=crying is okay. o 5ffer constant reassurance. speak in a calm manner. o +ave the child tell you what they understand from your teaching. &epeat and correct information as necessary. 5rient the patient and his family to the unit, room, location of playroom, operating room, and recovery room, and introduce them to other children, parents, and some personnel. Make arrangements for the child to meet the anesthesiologist as well as the operating room nurse and recovery room nurse. Allo, a#d e#co&ra%e 2&estio#s* Gi'e ho#est a#s,ers* o 2uch 6uestions will give the nurse a better understanding of the child$s fears and perceptions of what is happening. o "nfants and young children need to form a trusting relationship with those who care for them. o The older the child the more reassuring information can be. #rovide opportunity for the child and his parents to work out concerns and feelings 0play, talk1. 2uch supportive care should result in less upset behavior and more cooperation. #repare the child for what to e pect postoperatively 0ie, e6uipment to be used or attached to child, where the child will wake up, how the child will feel, what the child will be e pected to do, diet, any physical restrictions1. Ph(sical Preparatio# *ssist with necessary laboratory studies. ' plain to the child what is going to happen before the procedure and how he may respond. %ive continual support during the procedure. 2ee that the patient has nothing by mouth 0;#51. ' plain to the child and his parents what ;#5 means and the importance of it. #lace signs on the patient$s

hospital door indicating the ;#5 status to ensure that nonfamily members and nonstaff members do not give the patient food. Assist ,ith fe'er red&ctio#* o Fever will result from some surgical problems 0eg, intestinal obstruction1. o Fever increases risk of anesthesia and need for fluids and calories. *dminister appropriate medications as prescribed. 2edatives and drugs to dry the secretions are often given on the unit preoperatively. 'stablish good hydration. #arental therapy may be necessary to hydrate the child, especially if the child is ;#5, vomiting, or febrile.

I$$ediate Postoperati'e Care Mai#tai# a pate#t air,a( a#d pre'e#t aspiratio#* o #osition the child on side or abdomen to allow secretions to drain and to prevent the tongue from obstructing the pharyn . o 2uction any secretions present. *void causing a gag refle or spasm during suctioning. Make fre2&e#t o-ser'atio#s of %e#eral co#ditio# a#d 'ital si%#s* Postoperati'e protocols $a( 'ar( per proced&re a#d facilit(* o Take vital signs every F3 minutes until the child is awake and his condition is stable. o ;ote temperature, respiratory rate and 6uality, pulse rate and 6uality, blood pressure, skin color. o <atch for signs of shock. Children in shock may have signs of pallor, coldness, increased pulse, and irregular respiration. 5lder children have decreased blood pressure and respiration. o Change in vital signs may indicate airway obstruction or compromise, hemorrhage, atelectasis, altered hemodynamics. o &estlessness may indicate pain or hypo ia. Medication for pain is not usually given until anesthesia has worn off. %ive analgesics and sedatives per the pain management team orders. o Check dressings for drainage, constriction, and pressure. #erform dressing changes per protocol. 2ee that all drainage tubes are connected and functioning properly. %astric decompression relieves abdominal distention and decreases the possibility of respiratory embarrassment. Chest tubes evacuate pleural air and fluid. 'nsure all tubes are secure to prevent accidental removal. Monitor parenteral fluids as prescribed. 7e physically near as the child awakens to offer soothing words and a gentle touch. &eunite the parents and child as soon as possible after the child recovers from anesthesia. "f a language barrier e ists, the parents should be with the child during recovery from anesthesia and an interpreter should be present when medical e planations are being given to the parents or child. After Reco'er( fro$ A#esthesia

*fter undergoing simple surgery and receiving a small amount of anesthesia, the child may be ready to play and eat in a few hours. More complicated and e tensive surgery debilitates the child for a longer period of time. Co#ti#&e to $ake fre2&e#t a#d ast&te o-ser'atio#s i# re%ard to -eha'ior) co$fort le'el a#d pai# co#trol) 'ital si%#s) dressi#%s or operati'e site) a#d special apparat&s 4I*1* li#es) chest t&-es) o/(%e#6* o ;ote signs of dehydration=dry skin and membranes. sunken eyes. poor skin turgor. sunken fontanelle, poor urine output in an infant. o &ecord any passage of flatus or stool and bowel sounds. 5bserve for intestinal ileus because crying children swallow air, which may cause gastric distention. o &ecord vomiting time, amount, and characteristics. *ssess behavior for signs of pain, and medicate appropriately. Record i#take a#d o&tp&t acc&ratel(* o #arenteral fluids and oral intake. o !rainage from gastric tubes or chest tubes, colostomy, wound, and urinary output. o #arenteral fluid is evaluated and prescribed by considering output and intake. "t is usually maintained until the child is taking ade6uate oral fluids. Ad'a#ce diet as tolerated) accordi#% to the child.s a%e a#d the health care pro'ider.s directio#s* o First feedings are usually clear fluids. if tolerated, advance slowly to full diet for age. ;ote any vomiting or abdominal distention. o 7ecause anore ia may occur, offer what the child likes, in small amounts and in an attractive manner. Pre'e#t i#fectio#* o 9eep the child away from other children or personnel with respiratory or other infections. o Change the child$s position every A to ? hours. prop infants with a blanket roll. o 'ncourage the child to cough and breathe deeply. let the infant cry for short periods of time, unless contraindicated. 5ffer older children incentive spirometry every F hour while awake. o 9eep operative site clean=change dressing as needed. keep the diaper away from the wound. o 'nforce diligent handwashing by family members and staff before any contact with the patient. o !o not cohort surgical patients with patients with a proven or presumptive infection. o *dminister prophylactic antibiotics as ordered. #rovide good general hygiene, and opportunities for e ercise and diversional activity. encourage sleep and rest. #rovide emotional support and psychological security. &eassure the child that things are going well. if there are complications, offer honest information based

on the patient$s health and developmental level and the parents$ willingness to share this information with their child. Talk about going home if appropriate. 7egin early to prepare for discharge( teach special procedures, provide written instructions, and arrange for community nurse referral.

HE !YING CHIL! The nursing role is to assist the child and family to cope with the e perience in such a way that it will promote growth rather than destroy family integrity and emotional wellbeing. Reco%#ize the Sta%es of !(i#% Sta%es of !(i#% as Ide#tified -( !r* Eliza-eth EF-ler-Ross S AGE N=RSING C0NSI!ERA 0NS I* !e#ial) shock) dis-elief *ccept denial, but function within a reality sphere. !o not tear down the child$s 0or family$s1 defenses. 7e aware that denial usually breaks down in the early morning when it may be dark and lonely.

II* A#%er) ra%e) hostilit(

7e certain that it is the child or family who is using denial, not the staff. *ccept anger and help the child e press it through positive channels. 7e aware that anger may be e pressed toward other family members, nursing staff, physicians, and other persons involved. +elp families recognize that it is normal for children to e press anger for what they are losing. &ecognize this period as a time for the child and family to regain strength. 'ncourage the family to finish any unfinished business with the child. This is the time to do things such as take the promised trip or buy the promised toy. &ecognize this as a normal reaction and e pression of strength. +elp families to accept the child who does not want to talk and e cludes help. This is the usual pattern of behavior. &eassure the child that you can understand

III*"ar%ai#i#% 4fro$ GNo) #ot $e)H to GYes) $e) -&tIH6

I1*!epressio# 4 he child a#dJor fa$il( e/perie#ces sile#t %rief a#d $o&r#s past a#d f&t&re losses*6

his or her feelings. 1* Accepta#ce *ssist families to provide significant loving human contact with their child and one another. 7e aware that dying children, their families, and the staff will all progress through these stages, not necessarily at the same time. Children e perience the stages with much variation. They tend to pass more 6uickly through the stages and may merge some of these stages. The nursing goal is to accept the child and his family at whatever stage they are e periencing, not to push them through the stages. /nderstand the meaning of illness and death at various stages of growth and development. Sta%es i# the !e'elop$e#t of a Child.s Co#cept of !eath AGE 0F CHIL! S AGE 0F !E1EL0PMEN Child &p to o *t this stage, the child cannot comprehend the a%e : relationship of life to death because the child has not developed the concept of infinite time. o The child fears separation from protecting and comforting adults. o The child perceives death as a reversible act. Preschool o *t this age, the child has no real understanding of the child* meaning of death. the child feels safe and secure with parents. o The child may view death as something that happens to others. o The child may interpret the separation that occurs with hospitalization as punishment. the painful tests and procedures that the child is sub4ected to support this idea. o The child may become depressed because of not being able to correct these wrongdoings and regain the grace of adults. o The concept may be connected with magical thoughts of mystery. School-a%e o The child at this age sees death as the cessation of child life. child understands that he or she is alive and can become ,not alive-. child fears dying. o The child differentiates death from sleep. /nlike sleep, the horror of death is in pain, progressive mutilation, and mystery. o The child is vulnerable to guilt feelings related to death because of difficulty in differentiating death wishes and the actual event. o The child believes death may be caused by angry feelings or bad thoughts. o The child learns the meaning of death from own

personal e periences, such as the death of pets, family members, and public figures. o Television and movies have contributed to the concept of death and understanding of the meaning of illness. There may be more knowledge in the meaning of the diagnosis and an awareness that death may occur violently. Adolesce#t o The adolescent comprehends the permanence of death as the adult does, although the adolescent may not comprehend death as an event occurring to persons close to self. o The adolescent wants to live=sees death as thwarting pursuit of goals( independence, success, achievement, physical improvement, and self-image. o The adolescent fears death before fulfillment. o The adolescent may become depressed and resentful because of bodily changes that may occur, dependency, and the loss of social environment. o The adolescent may feel isolated and re4ected because adolescent friends may withdraw when faced with impending death of a friend. o The adolescent may e press rage, bitterness, and resentment. especially resents the fact that fate is to die. "e a,are of other factors that i#fl&e#ce a child.s perso#al co#cept of death* 0f partic&lar i$porta#ce are+ o The amount and type of direct e posure a child has had to death. o Cultural values, beliefs, and patterns of bereavement. o &eligious beliefs about death and an afterlife. Meet with the parents separately from the child and discuss their wishes regarding dissemination of information to their child.

Co$$&#icate ,ith the Child a-o&t !eath &esearch indicates that children generally can cope with more than adults will allow and that children appreciate the opportunity to know and understand what is happening to them. "t is important that the child$s 6uestions be answered simply, but truthfully, and that they be based on the child$s particular level of understanding. The following responses have been suggested by 'asom in The !ying Child and may be useful as a guide( Preschool-A%e Child <hen the child at this age is comfortable enough to ask 6uestions about illness, 6uestions should be answered. <hen death is anticipated at some future time and the child asks, ,*m " going to dieG- a response might be, ,<e will all die someday, but you are not going to die today or tomorrow. <hen death is imminent and the child asks, ,*m " going to dieG- the response might be, ,Hes, you are going to die, but we will take care of you and stay with you. <hen the child asks, ,<ill it hurtG- the response should be truthful and factual.

!eath may be described as a form of sleep=a sleep where the child will be secure in the love of those around him or her. +owever, some children may fear sleep as the result of this type of e planation. *nesthesia is sometimes called a ,special sleep- so it is not currently recommended to refer to death as ,sleep.#arents can e press to the child the fact that they do not want the child to go and that they will miss the child very much. they feel sad, too, that they are going to be separated.

School-A%e Child &esponses to the school-age child$s 6uestions about death should be answered truthfully. The child looks for support from those he trusts. The school-age child should be given a simple e planation of his diagnosis and its meaning. the child should also receive an e planation of all treatments and procedures. The child should be given no specific time in terms of days or months because each individual and each illness is different. <hen the school-age child asks, ,*m " going to dieG- and death is inevitable, the child should be told the truth. The school-age child has the emotional ability to look to his parents and those he trusts for comfort and support. The school-age child believes in his parents. The child should be allowed to die in the comfort and security of his family. The school-age child knows death means final separation and knows what will be missed. The child must be allowed to mourn this loss. The dying child may be sad and bitter and demonstrate aggressive behavior. The child must be allowed the opportunity to verbalize this if able to do so. Adolesce#t The adolescent should be given an e planation of his illness and all necessary treatment and procedures. The adolescent feels deprived and reasonably resentful regarding his illness because he wants to live and reach fulfillment. *s death approaches, the adolescent becomes emotionally closer to his family. The adolescent should be allowed to maintain emotional defenses=including absolute denial. The adolescent will indicate by 6uestions what kind of answers are desired. "f the adolescent states, ," am not going to die,- he is pleading for support. 7e truthful and state, ,;o, you are not going to die right now. The adolescent may ask, ,+ow long do " have to liveG- *dolescents are able to face reality more directly and can tolerate more direct answers. ;o absolute time should be given because that blocks all hope. "f an adolescent has what is felt to be a prognosis of appro imately > months, the response might be, ,#eople with an illness like yours may die in > to E months, but some may live much longer.S&pport Pare#ts. Adaptatio# to Child.s !eath !e'elop a care pla# that i#cl&des this approach+

The primary responsibility for communicating with the parents should be designated to one nurse. o "nformation regarding the parents$ concerns should be communicated to all staff members and should be included in the patient$s care plan. Accept pare#tal feeli#%s a-o&t the child.s a#ticipated death) a#d help pare#ts deal ,ith these feeli#%s* o "t is not unusual for parents to reach the point of wishing the child dead and to e perience guilt and self-blame because of this thought. o The parents may withdraw emotional attachments to the child if the process of dying is lengthy. This occurs because the parents complete most of the mourning process before the child reaches biologic death. They may relate to the child as if he were already dead. Pro'ide a#ticipator( %&ida#ce re%ardi#% the child.s act&al death a#d i$$ediate decisio#s a#d respo#si-ilities after,ard* o !escribe what the death will probably be like and how to know when it is imminent. This is necessary to dispel the horrifying fantasies that many parents have. &eassure the parents that all measures will be taken to keep the child comfortable at the time of death. 0;ote( certain diseases, despite appropriate medical interventions, may cause an uncomfortable or painful death. #arents should be promised complete comfort for their child only if this e pectation is realistic1 o Clarify the parents$ wishes about being present at the child$s death, and respect their desires. 2ee if they want to hold the child=before, during, or after the death. o "f appropriate, allow the parents to discuss their feelings about issues such as autopsy and organ donation in order that they may make appropriate decisions. !o not make them feel guilty if they do not consent. o "f necessary, assist the parents to think about funeral arrangements. 7e aware of factors that affect the family$s capacity to cope with fatal illness, especially social and cultural features of the family system, previous e periences with death, present stage of family development, and resources available to them. Contact the appropriate clergy if the family desires. Contact other e tended family members for support if they wish. !uring final hours, do not leave the family alone, unless they re6uest it. 'ncourage parents and siblings to share their thoughts with the dying child. #rovide information on bereavement support groups, usually available through hospital or church.
o

PE!IA RIC PR0CE!=RES RES RAIN S #rotective measures to limit movement are mechanisms for restraining children. They can be a short-term restraint to facilitate e amination and minimize the child$s discomfort during special tests, procedures, and specimen collections. &estraints can also be used for a longer period of time to maintain the child$s safety and protection from in4ury.

(pes of restrai#ts* Ge#eral Co#sideratio#s #rotective devices should be used only when necessary and after all other considerations are e hausted, never as a substitute for careful observation of the child. #rotective devices cannot be used on a continuous basis without an order. Continuous use re6uires 4ustification and full documentation of the type of restraint used, reason for use, and the effectiveness of the restraint used. 5ngoing monitoring, documentation, and renewal of the order are re6uired. The reason for using the protective device should be e plained to the child and his parents to prevent misinterpretation and to ensure their cooperation with the procedure. Children often interpret restraints as punishment.

Teach the child and his family about specific devices they may be using in the hospital 0ie, side rails1 and after discharge 0ie, mitts, elbow restraints1. *ny protective device should be checked fre6uently to make sure it is effective and is not causing any ill side effects. "t should be removed periodically to prevent skin irritation or circulation impairment. #rovide range of motion and skin care routinely. #rotective devices should always be applied in a manner that maintains proper body alignment and ensures the child$s comfort. *ny protective device that re6uires attachment to the child$s bed should be secured to the bed springs or frame, never the mattress or side rails. This allows the side rails to be ad4usted without removing the restraint or in4uring the child$s e tremity. *ny re6uired knots should be tied in a manner that permits their 6uick release. This is a safety precaution. <hen a child must be immobilized, an attempt should be made to replace the lost activity with another form of motion. For e ample, although restrained, a child can be moved in a stroller, wheelchair, or in bed. <hen arms are restrained, the child may be allowed to play kicking games. <ater play, mirrors, body games, and blowing bubbles are helpful replacements.

N=RSING ALER * health care provider$s order is needed to initiate continuous restraints. #roper documentation is re6uired when restraints are in use. !o not secure restraints to bed rails or mattresses. +ourly assessment of the restrained e tremity is needed to ensure there has been no impairment of circulation and constriction or respiratory compromise with chest restraints. M&$$( !e'ice The mummy device involves securing a sheet or blanket around the child$s body in such a way that the arms are held to the sides and leg movements are restricted. This short-term type of restraint is used on infants and small children during treatments and e aminations involving the head and neck. E2&ip$e#t 2mall sheet or blanket. N&rsi#% Actio# #lace the blanket or sheet flat on the bed. Fold over one corner of the blanket. #lace the child on the blanket with neck at the edge of the fold. #ull the right side of the blanket firmly over the child$s right shoulder. Tuck the remainder of the right side of the blanket under the left side of the child$s body. &epeat the procedure with the left side of the blanket.

2eparate the corners of the bottom portion of the sheet, and fold it up toward the child$s neck. Tuck both sides of the sheet under the child$s body. 2ecure by crossing one side over the other in the back and tucking in the e cess, or by pinning the blanket in place.

Special Preca&tio#s Make certain the child$s e tremities are in a comfortable position during this procedure. Kacket !e'ice The 4acket device is a piece of material that fits the child like a 4acket or halter. 8ong tapes are attached to the sides of the 4acket 0see Figure ?>-A, page F>IJ1. Kacket device restraints are used to keep the child in a wheelchair, high chair, or crib. N&rsi#% Actio# #ut the 4acket on the child so the opening is in the back. Tie the strings securely. #osition the child in wheelchair, high chair, or crib. Sec&re the lo#% tapes appropriatel(+ o /nder the arm supports of a chair. o *round the back of the wheelchair or high chair. o To the springs or frame of a crib. Special Preca&tio#s Children in cribs must be observed fre6uently to make certain they do not become entangled in the long tapes of the 4acket device. "elt !e'ice The belt device is e actly like the 4acket method of restraining, e cept that the material fits the child like a wide belt and buckles in the back 0see Figure ?>-A, page F>IJ1. El-o, !e'ice The elbow device is a plastic device that fits around the arm at the elbow bend and is secured with a :elcro strap. This type of restraint prevents fle ion of the elbow. "t is especially useful for pediatric patients receiving a scalp vein infusion, those with eczema or other skin rashes, and those following a cleft lip repair, eye surgery, or any other type of procedure or surgery in which touching the upper e tremities, head, or neck should be prevented. E2&ip$e#t 'lbow device. 2kin protective material for under the device 0long-sleeved shirt or gauze1. N&rsi#% Actio# Cover the elbow with a long-sleeved shirt or gauze if irritation or sweating is e pected.

#lace the child$s arm in the center of the elbow restraint. <rap the restraint around the child$s arm. 2ecure with :elcro.

Special Preca&tio#s The child$s fingers should be observed fre6uently for coldness or discoloration, and the skin under the device should be checked for signs of irritation. The device should be removed periodically according to facility policy or standards of care to provide skin care and range of motion. !e'ices to Li$it Mo'e$e#t of the E/tre$ities Many different kinds of devices are available to limit motion of one or more e tremities. 5ne commercial variety consists of a piece of material with tapes on both ends to be secured to the frame of the bed. The material also has two small flaps sewn to it for securing the child$s ankles or wrists. 2imilar devices are available that use sheepskin flaps. These should be used when the device will be necessary over a prolonged period or for children with sensitive skin. This restraining device may be used to restrain infants and young children for procedures, such as ".:. therapies and urine collection. E2&ip$e#t ' tremity restraint of appropriate size for the child 0small, medium, or large1. N&rsi#% Actio# 2ecure the device to the crib frame. :elcro the small flaps securely around the child$s ankles or wrists. Special Preca&tio#s The child$s fingers or toes should be observed fre6uently for coldness or discoloration, and the skin under the device should be checked for signs of irritation. The device should be removed periodically according to policy or standards of care to provide skin care and range-of-motion e ercises. A-do$i#al !e'ice The abdominal device is used for restraining a small child in a crib. "t operates e actly like the method described for limiting the movements of e tremities. +owever, the strip of material is wider and has only one wide flap sewn in the center for fastening around the child$s abdomen. Mitts Mitts are used to prevent a child from in4uring self with his hands and from removing tubes or ".:. lines. They are especially useful for children with dermatologic conditions such as eczema or burns, and for those with nasogastric or naso4e4unal feeding tubes. Mitts can be purchased commercially or made by wrapping the child$s hands in 9ling gauze or by covering the child$s hands with a pair of clean socks and securing them to the wrist with tape.

N=RSING ALER Mitts should be removed at least every ? hours to permit skin care and to allow the child to e ercise fingers. Cri- op !e'ice * crib top device is used to prevent an infant or small child from climbing over the crib sides. 2everal types of commercial devices are available, including nets, plastic tops, and domes. * crib top device should be applied to the crib of a child capable of climbing over the crib sides 0usually between ages F and ?1. N=RSING ALER "n all instances, it is essential to be certain that the crib sides are kept all of the way up and latched securely. There should be no space between the top of the crib sides and the bottom of the crib top device. Papoose "oard * papoose board is the most cumbersome restraint device that may be used for procedures of the head, chest, and abdomen. 2traps restrain the child or infant at the forehead, lower arms, and thighs 0see Figure ?>-A, page F>IJ1. SPECIMEN C0LLEC I0N 'valuation of specimens such as blood, urine, and stool is important in determining the status of the child. The nurse should be adept in the techni6ues for obtaining specimens, as well as meticulous in labeling and recording them. PR0CE!=RE G=I!ELINES Assisti#% ,ith "lood Collectio# EL=IPMEN A>- to FI-gauge short needle or scalp vein needle 2maller volume or micro blood-collecting tubes 2maller tourni6uet 0rubber band may be used with infant1 %loves per standard precautions N&rsi#% Actio# Preparator( phase F "mmobilize the child by placing in a mummy restraint if . necessary 0see page F>IE1. A #osition the patient. . a. Femoral venipuncture: #lace child on back with legs in froglike position. #lace your hands on the child$s knees. Ratio#ale

F "nfants and young children s6uirm. "mmobili . them allows easier access to the venipunctur also helps keep the child warm. A These positions allow for optimal visualizati . stabilization of the patient. a.Cover perineum to protect site in case child

b External jugular venipuncture: #lace the child in mummy b.Crying will make e ternal 4ugular vein visi . restraint and lower head over the side of the bed or table. causes blood to flow more readily. Turn head to side and stabilize. 02ee accompanying figure.1 c. Antecubital fossa venipuncture: #lace the child in a supine c.The nurse$s hands are used to straighten an position. The nurse stands on the side opposite the site to the child$s arm still. arms are used to maint be used 0across from the person drawing the specimen1. stability of child$s upper body. The nurse positions her right arm across the upper part of the child$s chest and grasps the shoulder at the a illa position. The nurse$s left arm is placed across the lower part of the child$s chest and is used to e tend the child$s arm at the wrist 0see accompanying figure1. d Infantheel, toe, or digital puncture: <arm area with d.This dilates vessels allowing blood to flow . warm compress for 3-FD minutes. freely.

Assisting with jugular venipuncture.

Assisting with antecubital fossa venipuncture Perfor$a#ce phase F Capillary: Clean area with antiseptic and dry with sterile A- F 2tandard precautions. 7oth persons holding t . L A- gauze. +old heel firmly, and with free hand 6uickly . infant and drawing the blood should wear glo puncture with microlancet or sterile AF-gauge needle on %owns, masks, and goggles may be used if most medial or lateral part of plantar surface. #uncture splattering is anticipated. deeply enough to get free-flowing blood=never deeper than A mm. !iscard first drop of blood. rapidly collect specimen in proper capillary tube. A *fter the specimen is collected and the needle is removed, A The femoral and 4ugular veins are large vess . apply pressure to the site with dry gauze for >-3 minutes. . 7ecause intravascular pressure is great, bleed oozing, and hematoma formation may result. ' ternal pressure prevents this from happeni a. ugular venipuncture: <hile applying pressure to the site, a./pright position will reduce pressure in 4ug

place the patient in an upright sitting position. !o not vein. apply e cessive pressure that may compromise circulation or respiration. > <hen the bleeding has stopped, apply a pressure dressing or > Crying and thrashing about may initiate blee . adhesive bandage to the site. 2oothe and comfort the child . before leaving. Follo,-&p phase F Check the patient fre6uently for F hour after the procedure F &eapply pressure and report if oozing contin . for oozing, bleeding, or evidence of a hematoma. . A &ecord carefully and accurately( . a. 2ite of venipuncture b. +ow the patient tolerated procedure c. 7leeding stopped or continued and for how long d. Test for which the specimen was collected as well as the place to which it was sent for analysis and the time at which it was sent. PR0CE!=RE G=I!ELINES Collecti#% a =ri#e Speci$e# fro$ the I#fa#t or Yo&#% Child EL=IPMEN Collecting device=plastic, disposable urine bag or collector 0+ollister, /-7ag, double chamber1 Cleansing agent <iping material=?- L ?- gauze pads or cotton balls 2terile water Containers for solutions 2pecimen container %loves N&rsi#% Actio# Ratio#ale Preparator( phase F 5ffer the young child a choice of fluids to drink >D-ED minutes F To increase urine . before the procedure, if no contraindications. . production. A #osition the patient so genitalia are e posed by placing child A #roper positioning will . on back with legs in a froglike position. *ssistance may be . facilitate cleansing and needed to hold the legs of the young child in proper position. allow for proper > <hen small samples of urine are needed for tests to be done placement of . by the nurse, such as p+ and Clinitest, urine can be e tracted collection device. from the diaper using a syringe or dropper. Perfor$a#ce phase F <ear gloves. F 2tandard precautions. . .

A Cleanse genital area. A This method of . . cleansing the female a. Female: /sing cotton balls, dip into cleansing agent, wipe will prevent labia ma4ora from top to bottom 0clitoris to anus1 only once contamination of the with each cotton ball. &epeat this once more. <ipe again genitalia from the anus with sterile water. Then spread labia apart with one hand and will prevent while wiping the labia minora in the same manner with other contamination of the hand. <ipe area dry. urine specimen b !ale: <ipe tip of penis in circular motion down toward the obtained. !uring the . scrotum. 7e certain to retract foreskin if present. <ipe first cleansing, be gentle to with cleansing agent two to three times, then sterile water. avoid any in4ury or !ry the area. possible stimulation of urination. > *pply collecting bag firmly so the opening is e posed to > "f collecting bag is . receive urine. . properly and securely placed, it is less likely that the procedure will have to be repeated. a. Female: 2tretch perineum taut during application. *ttach a. This should ensure bag to perineum first, then proceed up to symphysis. leak-proof contact. b !ale "small boys#: #lace penis inside bag. .

Urine collector for male infants. ? *pply diaper and comfort patient. possibly give additional . clear fluids. 3 'levate head of bed or place the child in an infant seat if . appropriate. E Check the patient every 3-FD minutes to see whether he has

3 To aid flow of urine . by gravity. E The adhesive on the

. voided. <hen the patient has voided, gently remove the bag. . collecting bag may Cleanse area and reapply diaper to the child. "f the child has tend to be sticky. not voided within ?3 minutes, procedure must be repeated. Careful removal of the bag will prevent skin in4ury on and around genitalia. *lso avoid spilling urine out of the bag during removal. &eapplication of the bag will decrease the possibility of unreliable test results. Follo,-&p phase F #our specimen into proper collecting container. 2end F #rompt delivery of . specimen to the laboratory within >D minutes or refrigerate. . specimen to the A *ccurately chart and describe the following in the nurse$s laboratory will prevent . notes( growth of organisms a.Time specimen collection was started and ended in an uncontrolled b *mount of urine voided environment and . distortion of the test c.Color of urine 0cloudy, clear, any sediment1 results. d Type of test to be done . e.Condition of skin in perineal area $ote: "f A?-hour urine collection is needed, use a collection bag that has a long tube attachment to facilitate fre6uent emptying of urine every F-A hours. #lace urine in a labeled receptacle in refrigerator. *dherence of bag to skin can be improved by applying a thin coating of tincture of benzoin to skin and allowing this to dry before attaching the collection bag. PR0CE!=RE G=I!ELINES Assisti#% ,ith a Perc&ta#eo&s S&prap&-ic "ladder Aspiratio# EL=IPMEN *ntiseptic skin cleansing solution *dhesive bandage 2terile ?- L ?- gauze pads %loves ;eedle, AD-AA gauge, FM inches long 2yringe, AD m8 2pecimen container N&rsi#% Actio# Preparator( phase Ratio#ale

F Check diaper for wetness. "f the child has F To perform a successful bladder . 4ust voided, report this or report last . aspiration, enough urine must be present voiding time. *t least F hour should pass to distend the bladder up above the pubic without voiding. symphysis=so bladder is accessible. A #osition child on back on the e amination A This position allows the nurse to stabilize . table. +ead should be toward the nurse, . the child. "t also gives a full view of the feet toward the health care provider child, making it easier to observe, talk to, performing the aspiration. 2pread child$s and soothe the child. legs apart in a froglike position. #lace your hands on the child$s knees. > 'nsure that the skin over the puncture site > To prevent infection from being . is cleansed in an antiseptic manner. . introduced into the bladder by inserting the needle through unclean skin, which would contaminate the specimen. Perfor$a#ce phase F The health care provider and nurse should F 2tandard precautions. . wear gloves and other protective . e6uipment 0gown, mask, and goggles1 if necessary. A <hile the procedure is being performed, A &eport any changes in color, respiration . note the condition of the patient and any . rate, or other signs. 2oothing the child will signs of distress. Comfort the child by promote rela ation and decreased talking and smiling. movement. Crying increases the muscle tone of the lower abdomen, making it more difficult to insert the needle. > To prevent urination during procedure, . compress the infant$s urethra( a. !ale: #ressure on penis. b. Female: !igital pressure upward on urethra from rectum. ? <hen urine has been obtained or the ? This prevents any bleeding from occurring . procedure is discontinued and the needle is . either internally or e ternally. #ressure removed, apply pressure over the puncture should be maintained for about > minutes site with a ? L ? and gloved fingers. or until oozing ceases and coagulation has taken place. 3 *pply an adhesive bandage if necessary. 3 +olding the child will help to restore and . &eapply diaper. +old and comfort the . maintain a good nurse-patient relationship child for a few minutes. and will help the child to rela after a frightening and painful procedure. Follo,-&p phase F Check the child periodically for F hour F This is not likely if pressure was applied . after the procedure to see that bleeding or . properly after the procedure and the oozing has not occurred. patient was left 6uiet. A ;ote time of first voiding after procedure. A "t is important to note any changes in . ;ote color of urine 0it may be pink1. . voiding pattern after the procedure 7loody urine should be reported to the because change might indicate in4ury. The

health care provider. > *ccurately describe and chart the . procedure, including( a. Time of procedure b. <hether a specimen was obtained c. +ow the patient tolerated the procedure d. !escription and amount of urine obtained e. #atient$s condition and activity after the procedure. PR0CE!=RE G=I!ELINES Collecti#% a Stool Speci$e#

first voided urine may be pink because of a small amount of local capillary bleeding at the time of the procedure.

EL=IPMEN !iaper Cellophane or plastic liner 0used when stool is loose or watery1 2pecimen container Tongue blade %loves ;ote( Collecting a stool specimen from an older child who is toilet-trained is the same as collecting a specimen from an adult. N&rsi#% Actio# Ratio#ale Preparator( phase F "f a specimen is needed from a patient whose F The liner and position will allow the . stools are loose or watery enough to be absorbed . loose stool specimen to collect in in the diaper, line the diaper with a piece of the liner and not be absorbed by the cellophane or plastic. #lace this liner between the diaper. diaper and the skin. Then apply diaper to the child and position so head is slightly elevated. "f stools are soft or formed, apply only diaper. Perfor$a#ce phase F <ear gloves. F 2tandard precautions. . . A Check the child fre6uently to see if a bowel A * fresh specimen should be . movement has occurred. . obtained so test results will not be > &emove soiled diaper from the child. Clean distorted by time lapse. This will . perineal area, apply clean diaper, and leave the also decrease the chance of child comfortable. contamination of the stool with ? &emove small amount of stool from diaper with urine and will prevent skin irritation . the tongue blade and place it in the clean from the stool.

specimen container. 3 2end labeled specimen to the laboratory . promptly. Follo,-&p phase F *ccurately describe and record the following( . a. Time specimen was collected. b. Color, amount, and consistency of stool 0note any foul smell or blood-tinged stool1. c. Type of specimen collected. d. ;ature of test for which the specimen was collected. e. Condition of the perineal and anal areas.

3 #rompt delivery to the laboratory . will prevent changes from occurring in the specimen that could alter the test results.

FEE!ING AN! N= RI I0N ;utritional re6uirements may increase while infant or child is ill, but the ability to feed naturally may be impaired by illness or the child$s response to illness. "f e isting feeding patterns cannot be maintained, alternate methods may be necessary. Ga'a%e Feedi#% See Proced&re G&ideli#es %avage feeding is a means of providing food by way of a catheter passed through the nares or mouth, past the pharyn , down the esophagus, and into the stomach, slightly beyond the cardiac sphincter. Feedings may be continuous or intermittent. %avage feedings can provide a method of feeding or administering medications that re6uire minimal patient effort when the child is unable to suck or swallow ade6uately 0eg, premature neonates under >A weeks$ gestation or under F,3ED g. children with neurologic deficits or respiratory compromise1. %avage feedings provide a route that allows ade6uate calorie or fluid intake. they can also provide supplemental or additional calories. %avage feedings can prevent fatigue or cyanosis that is apt to occur from bottlefeeding. They can provide supplements for an infant who is a poor bottle-feeder. %avage feedings can provide a safe method of feeding hypotonic patients, patients e periencing respiratory distress 0respiratory rate greater than ED)minute1, patients with uncoordinated suck and swallow, intubated patients, debilitated patients, and patients with anomalies of the digestive tract. PR0CE!=RE G=I!ELINES I#fa#t Ga'a%e Feedi#% EL=IPMEN 2terile rubber or plastic catheter, rounded-tip, size 3-FA French 0*rgyle feeding tubes1 Clear, calibrated reservoir for feeding fluid 3-FD m8 syringe

2tethoscope 2terile water or normal saline Tape=hypoallergenic Feeding fluid, room temperature #acifier

N&rsi#% Actio# Ratio#ale Preparator( phase F. #osition child on side or back with a rolled diaper F. This position allows for easy passage of the cathete placed under shoulders. * mummy restraint may observation, and helps avoid obstruction of the airw be necessary to help maintain this position 0see page F>IE1. A. Measure the distance from the tip of the patient$s A. #remeasuring the catheter provides a guideline as to nose to ear to iphoid process of sternum and mark catheter. the length on the feeding tube with tape. >. +ave suction apparatus readily available. >. 2uctioning clears the airway and prevents aspiration occurs. Perfor$a#ce phase F. 8ubricate catheter with sterile water or normal F. !o not use oil because of danger of aspiration. saline solution. A. 2tabilize the patient$s head with one hand. use the A. other hand to insert catheter. a. Insertion through nares: 2lip the catheter into the a.This direction will follow the nares$ passageway i patient$s nostril and direct it toward the occiput in #ositioning in nares may cause partial airway obs a horizontal plane along the floor of the nasal route if there is critical airway compromise. cavity. !o not direct the catheter upward. 5bserve for respiratory distress. b Insertion through the mouth: #ass the catheter . through the patient$s mouth toward the back of his throat, with his head tilted slightly forward. >. "f the patient swallows, passage of the catheter >. 2wallowing motions will cause esophageal peristal may be synchronized with the swallowing. cardiac sphincter and facilitates passage of the cath !o not push against resistance. %ently try rotating occur with very little pressure. the tube if resistance is met. ?. "f there is no swallowing, insert the catheter ?. 7ecause of cardiac sphincter spasm, resistance may smoothly and 6uickly. #ause a few seconds, then proceed. 3. "n the infant, especially, observe for vagal 3. The vagus nerve pathway lies from the medulla thr stimulation 0ie, bradycardia Nslow heart rateO and thora to the abdomen. *bove the stomach, the left apnea1. unite to form the esophageal ple us. 2timulation of with the catheter will directly affect the cardiac and E. <hen the catheter has been inserted to the E. This prevents movement of the catheter from the pr premeasured length, tape the catheter to the preestablished correct position. *lternative method patient$s face 0see accompanying figure1. tape around the tube 4ust below the nostril, then sec with tape. 2ome movement of the tube may be seen

Steps in preparing adhesive tape to retain gavage tub

Gavage tube in jejunum J. Test for correct position of the catheter in the J. stomach( a."n4ect >-3 m8 air, via the catheter, into stomach. a.*ids in ensuring proper location of catheter. *t the same time, listen for the typical growling stomach sound with a stethoscope placed over the epigastric region. b *spirate in4ected air from the stomach. b.This prevents abdominal distention. . c.*spirate small amount of stomach content. c.Failure to obtain aspirate does not indicate impro *spirate could be tested for acidity. may not be any stomach content or the catheter m with the fluid. d 5bserve and gently palpate the abdomen for the d."f improper placement occurs and the catheter ent . tip of the catheter. *void inserting the catheter patient may cough, fight, and become cyanotic. & into the infant$s trachea. 0*n infant$s anatomy immediately and allow the patient to rest before a makes it relatively difficult to enter the trachea tube again. because the esophagus is behind the trachea.1 e.Further secure the tube to the patient$s cheek by e.*dhesive should not loosen easily and should be using tape or 5psite. *void using paper tape, may be e posed to secretions. which loosens if e posed to secretions or formula. C. The feeding position should be right side lying, C. This position allows the flow of fluid to be aided by with head and chest slightly elevated. *ttach the the pacifier will rela the infant, allowing for easier reservoir to catheter and fill with feeding fluid. as provide for normal sucking needs. 2ucking will h 'ncourage the infant to suck on a pacifier during and provide a positive association between sucking feeding. +old the infant when possible. I. *spirate the tube before feeding begins to assess I. This is done to monitor for appropriate fluid intake for residual contents and to remove any air. overfeeding that can cause distention. ;otify the he a."f over one-half of the previous feeding is large residual. !ocument any residual amount after obtained by aspiration, withhold the ne t

feeding. !o not return aspirate to the stomach. ;otify the health care provider of the large residual volume. b "f a small residual of formula is obtained, return . it to the stomach and subtract that amount from the total amount of formula to be given. !ocument any residual contents. FD The flow of the feeding should be slow. !o not FD The rate of flow is controlled by the size of the feed . apply pressure. 'levate the reservoir E-C inches . smaller the size, the slower the flow. "f the reservoi 0F3-AD cm1 above the patient$s head. pressure of the fluid itself increases the rate of flow a.Feedings given too rapidly may interfere with a.The presence of food in the stomach stimulates p peristalsis, causing abdominal distention, digestive process to begin. *lso, when the tube is regurgitation and, possibly, emesis. incompetence of the esophageal-cardiac sphincte b Feeding time should last appro imately as long regurgitation. . as when a corresponding amount is given by nipple, 3 m8)3-FD minutes or F3-AD minutes total time. FF <hen the feeding is completed, the catheter may FF Clamp the catheter before air enters the stomach an . be irrigated with clear water. 7efore the fluid . distention. Clamping also prevents fluid from dripp reaches the end of the catheter, clamp it off and into the pharyn , causing the patient to gag and asp withdraw it 6uickly or keep in place for the ne t feeding. FA !iscard the feeding tube and any leftover solution. .

N=RSING ALER I#ter$itte#t %a'a%e feedi#% is co$$o#l( preferred to i#d,elli#% %a'a%e feedi# catheter $a( coil a#d k#ot) perforate the sto$ach) a#d ca&se #asal air,a( o-str&ctio#) &lceratio#) irri $e$-ra#es) i#co$pete#ce of esopha%eal-cardiac sphi#cter) a#d epista/is* Ho,e'er) if i#ter$itte#t pla tolerated a#d the i#d,elli#% $ethod is &sed) the catheter sho&ld -e cla$ped to pre'e#t loss of feedi#% o #e, catheters ca# re$ai# i# place for &p to :M da(s* 4=se alter#ate sides of the #ares ,ith each t&-e ch alert#ess to the a-o'e pro-le$s sho&ld -e stressed* I#d,elli#% $ethod $a( -e preferred ,ith a# older Follo,-&p phase F. 7urp the patient. 0The patient may not burp if air F. *de6uate e pulsion of air swallowed or ingested du was aspirated from the tube following the feeding.1 decrease abdominal distention and allow for better feeding. A. #lace the patient on his right side for at least F A. To facilitate gastric emptying and minimize regurg hour. >. 5bserve the patient$s condition after feeding. >. 7ecause of vagal stimulation as mentioned above. bradycardia and apnea may still occur. ?. ;ote vomiting or abdominal distention. ?. !ue to overfeeding or too rapid feeding. &egurgitat occur in the premature infant as the musculature of tract is rela ed and allows for easy refle . 3. ;ote the infant$s activity. 3. Fatigue or peaceful sleep offers insight as to toleran E. *ccurately describe and record procedure, E. 5bserve for readiness of the infant to feed by nippl including time of feeding, type of gavage tube activity and sleep-wake cycle in relation to feeding feeding, type and amount of feeding fluid given, amount retained or vomited, how the patient

tolerated feeding, and activity before, during, and after feeding. Gastrosto$( Feedi#% See Proced&re G&ideli#es %astrostomy feeding is a means of providing nourishment and fluids by way of a tube that is surgically inserted through an incision made through the abdominal wall into the stomach. "t is the method of choice for those re6uiring tube feedings for an e tended period of time 0usually longer than ? to E months1. %astrostomy feedings provide a safe method of feeding a hypotonic or debilitated patient or one who cannot tolerate alternative methods. 2pecific indications may include duodenal atresia, tracheoesophageal fistula, omphalocele, and neurologic in4ury. %astrostomy feedings may provide a route that allows ade6uate calorie or fluid intake in a child with chronic lung disease or in one who does not have continuity of the %" tract, such as in esophageal atresia, chronic reflu , or aspiration processes. %astrostomy tubes can also allow better decompression of the stomach 0because of the large tube size1 after a surgical procedure. PR0CE!=RE G=I!ELINES Gastrosto$( Feedi#% EL=IPMEN <arm feeding fluid #acifier &eservoir syringe or funnel 2yringe for aspirating N&rsi#% Actio# Ratio#ale Preparator( phase F %astrostomy tube may be in one of three F . positions between feedings( . a. 8owered and open for drainage. a. Constant decompression. b.5pen, connected to reservoir 0funnel, b.To serve as safety valve outlet to prevent syringe1 that is elevated ?-E inches 0FDesophageal reflu and increased stomach F3 cm1. pressure. c. Clamped. c. Most ,normal- physiologic setup. preparation for home care or tube removal. A The nurse may be directed to check A This is done to monitor for appropriate . residual stomach contents before any . fluid intake, digestion time, and feeding. overfeeding that can cause distention. a. *ttach syringe and aspirate stomach contents.

b.Measure volume. c. &esidual fluid may be returned to stomach or discarded, depending on the amount. d.*ssess the skin around the tube for e coriation and signs and symptoms of infection. > * H-tube that is connected at the point > To provide simultaneous decompression . where reservoir and gastrostomy tube 4oin . during feeding. may be used during feeding. ? <hen feeding is about to begin, the ? <hen the patient is comfortable and . patient should be placed in a comfortable . rela ed, feeding fluid will flow more position in bed=either flat or with head easily into stomach. #acifier will satisfy slightly elevated. "f condition permits, the normal sucking activity, provide e ercise nurse or family member should hold the for 4aw muscles, and rela musculature as patient. * pacifier can be given. well as provide pleasure normally $ote: The child may have a gastrostomy associated with feeding. tube feeding button, in which case insert the special tube into the button and follow the feeding procedure in the performance phase. Perfor$a#ce phase F *ttach reservoir syringe to the tube 0if not F #revents air from entering tube 0and then . already open to continuous elevation1, and . stomach1, which may cause distention. fill reservoir syringe with feeding fluid. /nclamp the tube. A 'levate tube and reservoir to ?-?>)? inches A This elevation level will allow for slow, . 0FD-FA cm1 above the abdominal wall. !o . gravity-induced flow. #ressure may cause not apply pressure to start flow. a backflow of fluid into the esophagus. > Feed slowly, taking AD-?3 minutes. Fill > Too rapid a feeding will interfere with . reservoir with remaining fluid before it is . normal peristalsis and will cause empty to avoid instillation of air. abdominal distention and backflow into ? Continue to provide the infant with reservoir or esophagus. . pleasant feelings associated with feeding 0i.e. pacifier1. 3 <hen feeding is completed( 3 . a. "nstill clear water 0D.>-F ounce NFD->D . a. This rinses tubing and will prevent m8O1 if the tube is to be clamped. *pply clogging. clamp before water level reaches end of reservoir. b.8eave tube unclamped and open to b.Feeding fluid is allowed to return to the continuous elevation. reservoir if the infant cries or changes position, and thus decreases pressure in the stomach. E Commonly, when oral feedings are E This allows the infant to learn or . started, they are given simultaneously with. reestablish the sucking-swallowing process

gastrostomy feedings.

as well as to build up tolerance to eating without compromising nutritional intake.

Follo,-&p phase F Check dressing and skin around point of F 2kin breakdown is caused by continued . tube entry for wetness. Clean skin and . e posure to stomach contents that may be apply skin barrier 0petrolatum, Maalo , leaking out around the tube causing aluminum paste, etc.1. 'nsure that there is e coriation and infection. Constant pulling no pull on the tube. on the tube can cause widening of skin opening and subse6uent leakage. A 8eave the patient dry and comfortable. "f A To promote rela ation and improved . unable to hold the patient during feeding, . digestion of feeding. this may be a good time to hold, fondle, and provide warmth and love. #lace on right side or in Fowler$s position. > *ccurately describe and record procedure, . including time of feeding, type and amount of feeding fluid given, amount and characteristics of residual 0if any1 and what was done with it, how the patient tolerated the feeding, any abdominal distention, and activity after feeding. N=RSING ALER If the patie#t p&lls o&t %astrosto$( t&-e) co'er osto$( site ,ith a sterile dressi#% a#d tape i$$ediatel() #otif( health care pro'ider a#d acc&ratel( record e'e#ts* Co$$&#it( a#d Ho$e Care Co#sideratio#s %astrostomy feedings are commonly maintained for an e tended period of time. "f a child is receiving these tube feedings at home, nursing responsibilities include the following( each the child 4if a%e appropriate6 a#d his fa$il( a-o&t %astrosto$( feedi#%s* o *natomy of tube placement. o *mount and timing of feedings. o 2igns and symptoms of problems=tube obstruction or displacement, distended stomach, infection. *ppropriate actions to be taken if problems occur=call home care nurse or health care provider. Teach use of e6uipment( syringes, feeding bag, feeding tubing. Teach the use of control pump 0for continuous feedings or slow boluses1. Teach care of the gastrostomy tube=how to clamp, observe for leakage. Teach stoma care=clean area with soap and water, observe for breakdown, apply skin barrier. "nstruct about formula=proper mi ing if not reconstituted. need to refrigerate if opened. discard any unused and nonrefrigerated formula after ? hours. each $eas&res to take i# a# e$er%e#c(*

#rocedure to follow if the tube falls out=cover site with sterile gauze dressing, and call health care provider or proceed to emergency room. o Troubleshooting for nonfunctioning e6uipment=ensure that the pump is plugged in and turned on, tubing is unclamped, not kinked. abdomen is not distended. o #roper phone numbers available to have as a resource or to obtain assistance. #erform regular home visits to assess nutritional and hydration status of the child, check tube placement and stoma site, and modify the care plan as needed.
o

PR0CE!=RE G=I!ELINES NasoNeN&#al a#d Nasod&ode#al Feedi#%s EL=IPMEN 2terile radiopa6ue silicone or polyvinyl naso4e4unal 0;K1 or nasoduodenal 0;!1 tube, >I inches 0F m1 0appropriate size for child1. may have weighted tip Tape p+ paper or p+ probe &eservoir 0syringe or bag1 for feeding #ossibly, an infusion pump Three-way stopcock 2yringe=D.3 m8 normal saline solution or sterile water '6uipment for nasogastric 0;%1 tube insertion. introducer catheter Cardiac monitoring e6uipment N&rsi#% Actio# Preparator( phase F *pply cardiac monitoring leads. . Ratio#ale

F To allow for continuous monitoring of . heart rate and rhythm. The vagus nerve pathway lies from the medulla through the neck and thora to the abdomen. *bove the stomach, the left and right branches unite to form the esophageal ple us. 2timulation of these nerve branches with the catheter will directly affect the cardiac and pulmonary ple us. A Tube is generally inserted by a health care A . provider 0with or without fluoroscopy1. . a. Measure from glabella 0prominent point between eyebrows1 to the heel for estimated length. b. Measure and mark the remaining length b. This serves as a double-check to ensure of tubing and record. that the tube has not advanced farther than intended. > #lace patient on right side with his hips > Facilitates passage of the tube. &estraints

. slightly elevated. %entle restraint or soft mittens may have to be applied.

. prevent the infant from pulling out the tube before the tip passes the pylorus. !o not place on left side. ? The tube is inserted by threading the ;K or ? 5ral insertion may cause increased . ;! vinyl catheter into a ;o. FD French . salivation, air swallowing, and feeding catheter and introducing both regurgitation. The ;% tube acts as an through the nostril into the stomach. The introduction catheter and may not be feeding tube is then withdrawn, and the ;! needed because ;! or ;K catheters come or ;K feeding tube is allowed to advance with an internal guidewire to aid in through the pylorus. placement. 3 *void inserting the tube into the patient$s 3 "f improper placement occurs and the . trachea. . catheter enters the trachea, the patient may cough, fight, and become cyanotic. &emove the catheter immediately and allow the patient to rest before attempting to insert the tube again. E Check intestinal aspirate for p+ every F-A E <hen aspiration fluid reaches a p+ of 3-J . hours. The infant may be positioned on . or bile-colored fluid is obtained, the tip of right side, back, or abdomen. <hen the the tube has passed the pylorus and tube is past the pylorus, abdominal duodenum into the 4e4unum. posteroanterior and lateral @-rays are taken to confirm that the tip of the catheter is at the ligament of Treitz. &emove the guidewire. "f the p+ results are inconclusive or the ;K is difficult to place, it may be placed under fluoroscopy. J * small ;% feeding tube may be passed J "f gastric residual is significant, it will . through the other nostril at this time and . interfere with prescribed feeding. ;otify left indwelling. This is used to check the health care provider. 0? m8)kg reflu stomach for residual fluid and regurgitation in stomach is usually tolerated.1 !o not through the pylorus. remove ;% tube because it will adhere to ;K tube during withdrawal and pull out the ;K tube also. C ;! and ;K feedings can generally be C . started following this progression( . a. !e trose 3B in water initially. b. +alf-strength formula with low b. 8ow-solute formulas include 2M*, osmolality for E-FA hours. +igher 2imilac, 'nfamil 0AD cal)>D m81. osmolarity formulas for older children. c. Full-strength, low-osmolality formula for c. 8ow-osmolality formula is used to infants and high-osmolality formula for prevent loss of fluid into intestine and older children. possible necrotizing enterocolitis. d. The volume of feeding is increased at a d. F3D m8)kg fluid re6uirement is slow rate until daily calorie and fluid generally used 0FAD-F?D cal)kg1 in re6uirements are being administered. patients with dehydration or failure to thrive.

I Medications may be given by way of ;! I Flush tubing with small amounts of . and ;K tubes if prescribed. * three-way . normal saline solution or sterile water stopcock will have to be placed at the after medication is administered to ensure connection of the ;K tube and the line from that the infant receives entire dosage the feeding fluid. *lternative method for prescribed, to prevent any sediment from administering oral medications is by remaining in the tubing, and to prevent passing an oral-gastric or ;% feeding tube. tube clogging. #ills should be crushed in this way, the stomach and process of finely. digestion and absorption are not bypassed. Perfor$a#ce phase F ;K feedings are generally given by F Commonly preferred method to minimize . continuous slow drip. . the satiety-hunger cycle and largevolume instillation. A The setup used is similar to the pediatric A . ".:. infusion using an infusion pump and . small 0FDD-A3D m81 closed chamber for reservoir. a. &eservoir chamber and tubing should be a. To prevent growth of bacteria. changed every C-A? hours. b. &ecord input every hour. Fill reservoir as b. To ensure a constant flow and needed, with no more than ? hours worth minimize overinfusion directly into the of feeding fluid. 4e4unum or duodenum. > Feeding is given at room temperature. . *void cold fluid, which may cause infant discomfort. "f breast milk is used, gently knead the reservoir periodically to mi settled-out fat content. Follo,-&p phase F 7e constantly alert for mechanical F Tube clogging due to inade6uate rinsing. . problems( . Tube advancing too far into 4e4unum. a. Check for abdominal distention resulting check protruding tube measurement. from the patient$s inability to handle Fluid overload, causing aspiration. ingested amount of fluid by( P#alpating abdomen. P5bserving for ripple of intestines. PMeasuring abdominal girth every >-C hours. PChecking residual formula in the stomach every >-C hours. P!iscarding or refeeding residual formula as prescribed. b. Check stools for occult blood and blood glucose as ordered to determine tolerance of feeding fluid. c. Check emesis and stools for gross blood and report to physician immediately=

may be a sign of necrotizing enterocolitis. A #osition the patient in recumbent position. A 8ess likely for dumping syndrome to . . occur. > 5bserve the patient closely to avoid > !iarrhea. as the tube passes through the . potential dangers as the tube passes the . pylorus, it becomes stiff because of the pylorus. change in p+. * stiff tube has been a. Close attention to amount, type, reported to cause intestinal perforation. "f concentration, and osmolality of feeding tube becomes clogged or dislodged, it fluid is stressed. must be removed. b. Check heart rate and blood pressure. ? +old, fondle, and give positive stimulation ? This procedure limits the normal . to the patient, if conditions permit. . pleasures associated with feeding. The 3 *ccurately document condition of the patient needs attention to oromotor needs. . patient and the procedure, including type and amount of feeding given, amount of residual and characteristics, and any signs of impending patient distress or problems. ;aso4e4unal 0;K1 or nasoduodenal 0;!1 feedings are means of providing full enteral feedings by way of a catheter passed through the nares, past the pharyn , down the esophagus, through the stomach, through the pylorus into the duodenum or 4e4unum. !uodenal or 4e4unal feedings may decrease the risk of aspiration and can minimize regurgitation and gastric distention because the feeding bypasses the stomach and pylorus. ;! and ;K feedings provide a route that allows for ade6uate calorie or fluid intake 0a full enteral feeding1 by way of continuous drip. ;! or ;K feedings may also provide a route for administration of enteral medications. ;! or ;K feedings can provide a method of feeding that re6uires minimal patient effort when the child or infant is unable to tolerate alternative feeding methods 0low birth weight, increased respiratory effort, intubated patient1. FL=I! AN! ELEC R0LY E "ALANCE "asic Pri#ciples "nfants and small children have different proportions of body water and body fat than adults. "od( Fl&ids E/pressed as Perce#ta%e of "od( >ei%ht FL=I! A!=L Male 4O6Fe$ale 4O6I#fa#t 4O6 Total body fluidsED 3? J3 "ntracellular ?D >E ?D ' tracellular AD FC >3 o The body water of a neonate is appro imately CDB of body weight compared with that of an average adult man, which is appro imately EDB.

The normal neonate demonstrates a rapid physiologic decline in the ratio of body weight to body water during the immediate postpartum period. o #roportion of body water declines more slowly throughout infancy and reaches the characteristic value for adults by about age A. Co$pared ,ith ad&lts) a %reater perce#ta%e of the -od( ,ater of i#fa#ts a#d s$all childre# is co#tai#ed i# the e/tracell&lar co$part$e#t* o "nfants=appro imately one-half of the body water is e tracellular. o *dults=appro imately one-third of the body water is e tracellular. Co$pared ,ith ad&lts) the ,ater t&r#o'er rate per &#it of -od( ,ei%ht is three or $ore ti$es %reater i# i#fa#ts a#d s$all childre#* o The child has more body surface in relation to weight. o The immaturity of kidney function in infants may impair their ability to conserve water. 'lectrolyte balance depends on fluid balance and cardiovascular, renal, adrenal, pituitary, parathyroid, and pulmonary regulatory mechanism. Co$$o# A-#or$alities of Fl&id a#d Electrol(te Meta-olis$ S="S ANCEA"N0RMALI YCA=SE CLINICAL LA"0RA 0RY AN! MANIFES A I0N!A A MAK0R F=NC I0N >ater Medium of :olume deficit o #rimary= 5liguria, weight Concentrated urin body fluids, azotemia, elevated inade6uate water loss, signs of chemical dehydration hematocrit, intake changes, body o 2econdary including dry skin hemoglobin level, temperature, and mucous and erythrocyte co =loss following lubricant vomiting, diarrhea, membranes, and %" obstruction lassitude, sunken fontanelles, lack of tear formation, increased pulse rate, decreased blood pressure :olume e cess o Failure to <eight gain, :ariable urine peripheral edema, volume, low spec e crete water in the presence of normal signs of pulmonary gravity of urine, congestion decreased hemato intake such as in cardiac disease or failure or renal disease o <ater intake in e cess of output Potassi&$ "ntracellular #otassium deficit o ' cessive 2igns and symptoms 8ow plasma fluid balance, loss of potassium variable, including potassium level 0Q regular heart weakness, lethargy, m'6)81 may be due to vomiting,
o

rhythm, muscle and nerve irritability

o

#otassium e cess

diarrhea, prolonged irritability, normal in some cortisone, abdominal distention situations. corticotropin or and, eventually, hypochloremic diuretic therapy, cardiac arrhythmias alkalosis. 'C% diabetic acidosis changes 2hift of potassium into the cells such as occurs with the healing phase of burns, recovery from diabetic acidosis ' cessive :ariable, including 'levated potassiu plasma level administration of listlessness, confusion, heaviness potassiumof the legs, nausea, containing solutions, e cessive diarrhea, 'C% release of potassium changes. and, due to burns, severe ultimately, paralysis and cardiac arrest kidney disease, adrenal insufficiency

Sodi&$ 5smotic pressure, muscle and nerve irritability

2odium deficit

2odium e cess

<ater intake +eadache, nausea, 2odium plasma le abdominal cramps, may be high 0R F? in e cess of e cretory capacity, confusion alternating m'6)81, normal, o replacement of fluid with stupor, diarrhea,low 0QF>3 m'6)8 lacrimation, loss without sufficient sodium. salivation, later e cessive sodium hypotension. early polyuria, later losses oliguria "nade6uate Thirst, oliguria, 'levated sodium weakness, muscular plasma level 0R F? water intake pain, e citement, dry m'6)81, high plas especially in the presence of fever or mucous membranes, volume sweating. increased hypotension, tachycardia, fever intake without increased output. decreased output !iarrhea 0especially in infants1, diabetes mellitus, starvation, infectious disease, #rogressively increasing rate and depth of respiration =ultimately becoming 9ussmaul
o

"icar-o#ate *cid-base #rimary balance bicarbonate deficit

/r p+ usually E.D #la bicarbonat

respiration. flushed, AD m'6)8 warm skin. o #la weakness. p+ Q J.>3 disorientation progressive to coma #rimary o 8oss of !epressed /rine p+ usually bicarbonate e cess respiration, muscle plasma bicarbona chloride through A3 m'6)8 0>D m' vomiting, gastric hypertonicity, suction, or the use hyperactive refle es, in adults1, plasma tetany and, R J.?3 of e cessive diuretics. e cessive sometimes, ingestion of alkali convulsions "nfants and children are more vulnerable to dehydration than adults. o The basic principles relating to fluid balance in children make the magnitude of fluid losses considerably greater in children than in adults. o Children are prone to severe disturbances of the %" tract that result in diarrhea and vomiting. o Houng children cannot independently respond to increased losses by increased intake. They depend on others to provide them with ade6uate fluid.

shock or cardiac failure producing tissue ano ia

Co$$o# Fl&id a#d Electrol(te herap( Repair of pree/isti#% deficits that $a( occ&r ,ith prolo#%ed or se'ere diarrhea or 'o$iti#%* o !eficits are estimated and corrected as soon and as safely as possible. o "nitial therapy is aimed at restoring intravascular and intracellular fluid volume to relieve or prevent shock and restore renal function. "ntracellular deficits are replaced slowly over an C- to FA-hour period after the circulatory status is improved. Pro'isio# of $ai#te#a#ce re2&ire$e#ts* o Maintenance re6uirements occur as a result of normal e penditures of water and electrolytes due to metabolism. o Maintenance re6uirements bear a close relationship to metabolic rate and are ideally formulated in terms of caloric e penditure. Correction of concurrent losses that may occur by way of the %" tract as a result of vomiting, diarrhea, or drainage of secretions. &eplacement should be similar in type and amount to the fluid being lost. &eplacement is usually formulated as milliliters of fluid and millie6uivalents of electrolytes lost. I#tra'e#o&s Fl&id herap( ".:. therapy refers to the infusion of fluids directly into the venous system. This may be accomplished through the use of a needle or by venous cutdown and insertion of a small catheter directly into the vein. ".:. therapy is used to restore and maintain the child$s fluid and electrolyte balance and body homeostasis when oral intake is inade6uate to serve this purpose.

I*1* fl&id therap(* "nfusion pumps are often used in pediatrics to provide a controlled, constant rate of infusion. 7ecause infants and children are vulnerable to fluid shifts, the rates need to be monitored carefully. !&ri#% a# I*1* i#f&sio#) e'er( ho&r) check+ o &ate of infusion. o :olume delivered. o "nfiltration, because many pumps will continue to infuse solution even if infiltration has occurred. CAR!IAC AN! RESPIRA 0RY M0NI 0RING Cardiac and respiratory monitoring refers to electrical surveillance of heart and respiratory rates and patterns. "t is indicated for patients whose conditions are unstable, patients with cardiac or respiratory disorders, and patients receiving anesthesia or conscious sedation. N&rsi#% Ma#a%e$e#t 2elect a monitor that is appropriate for the child$s needs. This will depend on the child$s age and ability to cooperate, purpose for monitoring, information desired, and e6uipment available. 2tabilize the device to reduce the amount of mechanical noise and for safety considerations. 'nsure the e6uipment is functioning well and there are no frayed cords. Red&ce the child.s a#/iet(+ o #rovide age-appropriate e planations of the e6uipment. o <hen possible, involve the child in care, including change of electrodes. Select lead place$e#t sites accordi#% to e2&ip$e#t specificatio#s+ o Cardiac $o#itors fre2&e#tl( &se three leads located at+ &ight upper chest wall below the clavicle. 8eft lower chest wall in the anterior a illary line. 8eft upper chest wall below the clavicle.

o o

o o

Respirator( $o#itors fre2&e#tl( &se three electrodes located+ 5n either side of the chest 0anterior a illary line in fourth or fifth intercostal space1. * reference electrode placed on the manubrium or other suitable distal point. Appl( electrodes -(+ Cleaning the appropriate areas on the chest with alcohol. #lace pregelled, disposable electrodes to dry skin. #lug the leads into the lead cable at appropriate insertion points. Make sure that the monitor alarms are in the ,on- position. +igh and low alarm limits should be set according to the child$s age and condition so that apnea, tachypnea, bradycardia, and tachycardia can be readily detected. *void skin breakdown by changing lead placement sites as needed. Clean and dry old sites, and e pose them to air. Check i#te%rit( of the e#tire s(ste$ at least o#ce per shift* Carefully inspect lead wires and cable for breaks and proper attachment. "f malfunction is suspected, change e6uipment and notify the engineering department or manufacturer immediately. Co#ti#&e to co&#t respirator( a#d apical rates at least o#ce per shift* Compare with monitor rates to verify accuracy of e6uipment. "t must be remembered that monitors cannot substitute for close observation and nursing assessments of the child. Ap#ea $attresses or pads that &se se#si#% de'ices $a( -e &sed for i#fa#ts) eli$i#ati#% the #eed for electrodes* *lthough less susceptible to cardiovascular artifact, these devices may record physical impact, vibrations, or body movements as breaths. 5lder infants can easily roll or crawl off the pad.

PR0CE!=RE G=I!ELINES I#tra'e#o&s Fl&id herap( EL=IPMEN Needle $ethod ".:. solution o The kind of solution is specified by the health care provider. o For small children, A3D-m8 bottles should be used for purposes of safety. ".:. pole, pump device ".:. administration set, pump tubing Micropore filter 2yringe, 3 or FD m8=appro imately M-A)> filled with normal saline solution 7utterfly needle or catheter of appropriate gauge

The size of the needle depends on the age and size of the child, the size and location of the vascular access, and the type of fluid to be administered *lcohol pads, dry pads 7etadine or other antibacterial cleansing solution ;ormal saline solution 2mall tourni6uet or rubber band +ypoallergenic 0silk or cloth1 tape, M inch, F inch, A inches #added armboard %auze bandage for securing the e tremity to the armboard &estraining devices=bath blanket, e tremity restraint, covered sandbags 0The type of restraint depends on the child$s age, level of cooperation, and the location of the ".:. to be started.1 2afety razor 0if scalp vein is to be used1
o

C&tdo,# $ethod ".:. solution, ".:. pole, ".:. administration set *lcohol wipes +ypoallergenic 0silk or cloth1 tape, M inch, F inch, A inches #added armboard !ry wipes %auze bandage Sterile c&tdo,# tra( o The tray should include the following e6uipment( medicine cups, sterile treatment towels, wound towel, syringes, A3 gauge 3)C-inch needle and catheter, F-AD gauge F-inch needle, knife handle and SF3 blade, forceps, scissors, gauze sponges, ?-D black silk suture, needle holder *ssorted sizes of sterile polyethylene tubing and 8uer adapters 3-D black silk suture with a straight-eye needle FB-AB procaine ;ormal saline solution Tourni6uet 2terile gloves &estraining devices N&rsi#% Actio# I#serti#% a# I*1* li#e Preparator( phase F. 5btain the ".:. solution. Ratio#ale

F. *lthough the type of solution and the rate of flow are prescribed, the nurse should be aware of the composition of common parenteral solutions and should know how to calculate maintenance therapy. A. Check the ".:. fluid for sediment or A. Contaminant is most easily identified with contaminant by holding the container the container in this position. "f sediment is

up to the light. 'nsure light-sensitive observed, the solution should be discarded. ".:. fluids are properly contained and covered. >. Check the container for cracks. >. "f a flash of light can be seen through the bottle, it has a razor-thin crack and should be discarded. ?. *ttach a micropore filter to the end of ?. * D.?3-Tm filter prevents entry into the vein the infusion tubing that attaches to of larger particles, air emboli, and most the catheter hub. /se aseptic bacterial and fungal organisms e cept some techni6ue. #seudomonas organisms. * D.AA-Tm filter prevents entry of any organisms but re6uires the use of an ".:. pump. 3. &emove the seal from the ".:. 3. !o not use the solution if the seal has been container without touching the rubber broken. "t is not necessary to cleanse the top. sterile, rubber top with alcohol unless it has E. Following product information, insert been accidentally contaminated. the end of the administration set into the container$s opening. Fill the tubing with solution. J. #erform the procedure in the J. *lthough it is usually best to move the child treatment room unless another to a different room for the procedure, some location is re6uested by the patient or children will be less fearful if the procedure his family. is performed in the familiar surroundings of their own rooms. C. #romote the cooperation of the child. C. The procedure will be less traumatic if the The family may be present if desired. child is cooperative and does not resist. a. Infant: #rovide with a pacifier. b.%oung child: *void placing ".:. into the dominant e tremity 0ie, the hand used to suck the thumb1. c. &lder child: ' plain the procedure and its purpose. d.Adolescent: %ive choice as to the location of the ".:. if possible. I. #osition the child for comfort. FD.&estrain the child as necessary. FD #rotective devices may be necessary to . prevent the child from dislodging the ".:. needle or catheter. The type and size of such devices should be appropriate for the child$s age and the position of the ".:. a. Infant or young child: &estraints may include mummy wrappings, 4acket or elbow restraints, or small sandbags. b.&lder child: The e tremity to be b. Toes and fingers should be visible to avoid used should be comfortably compromising blood flow. The restraint

restrained on the armboard. Free e tremities may also re6uire light restraints to remind the child not to move.

board must be padded and the main pressure points 0heel, palm1 padded with gauze. 7efore strapping an e tremity to the armboard, back the adhesive with tape or gauze wherever it touches the skin.

Perfor$a#ce phase F. The persons starting the ".:. and F. 2tandard precautions. holding the infant should wear gloves and other protective e6uipment 0gown, mask, and goggles1 if blood splattering is anticipated. A. *ssist as necessary. A. The nurse may insert the ".:., based on facility policy. >. <hen applying the tourni6uet, a >. To ensure easy and rapid removal of the second rubber band is placed tourni6uet. crosswise under it. To remove the tourni6uet, grasp the unstretched rubber band, pull up, and cut the tourni6uet 0see accompanying figure1. ?. Check the restraints at intervals, and ?. The restraints may become loose after a ad4ust them as necessary. period of time and must be secured to ensure the child$s safety. They may also become too tight and re6uire loosening to maintain ade6uate circulation. Follo,-&p phase F. Comfort and reassure the child. F. The procedure is usually disturbing for the child. This should be acknowledged. "f crying and upset, the child should be reassured that this behavior is acceptable. A. &egulate the ".:. rate by way of a A. #ump infusion devices should always be pump. used in ".:. rate regulation of infants and children. >. &ecord( Type of solution being used &eading on the container or reservoir &ate of flow Time that the infusion began ;ame of the physician or nurse who started the ".:. 2ite of administration &eaction of the child to the procedure. Irri%ati#% a# I*1*

F. "rrigate the ".:. as necessary if an F. "rrigation may be re6uired to dislodge small occlusion or infiltration is suspected. clots in the catheter or to maintain the "rrigate intermittent infusion devices infusion rate of a sluggish ".:. every C hours. A. %ather e6uipment( 2yringe with F-> m8 normal saline solution or heparinized saline
2everal alcohol wipes >. Clamp off the ".:. solution. ?. !isconnect the ".:. tubing at the catheter insertion site. 9eep it sterile by covering the tip with a cap. 3. &emove the needle from the syringe. E. Connect the syringe to the tubing at the catheter insertion site or stopcock. J. 2lowly in4ect the normal saline J. solution or heparinized saline. "f the catheter cannot be flushed, it may be occluded or infiltrated and removal may be necessary. C. !isconnect the syringe, and reconnect the ".:. tubing to the needle insertion site. I. /nclamp the ".:., and regulate the flow of the solution. FD.Check fre6uently to make certain that the ".:. is functioning properly and there is no apparent infiltration. Re$o'i#% a# I*1* li#e F. %ather e6uipment( 2cissors, gloves A- L A- gauze s6uare *dhesive bandage A. 2top the ".:. infusion when prescribed or if it has obviously infiltrated. >. ' plain the procedure to the child >. 0depending on his age1. ?. &emove the tape and armboard from ?. the e tremity. 3. *pply gloves. 3. E. 8oosen the tape around the catheter, E. holding it firmly in position so it does

%reat force of in4ector should be avoided because this may cause the vein to rupture or the catheter to become dislodged from the vein.

To enlist cooperation. To provide open access to ".:. site. 2tandard precautions. Careless dislodgment of the catheter may cause bleeding and bruising.

not slip out. J. +old the A- L A- gauze lightly over the insertion site, and remove the needle 6uickly and carefully.

C. *pply pressure to the site immediately and hold until bleeding stops. I. *pply adhesive bandage. I. The bandage should not be applied until all FD.Comfort the child as re6uired. bleeding has stopped to minimize the FF.;ote the fluid level on the container possibility of prolonged or unnoticed or reservoir, and complete recordings. bleeding. FA.&ecord that the ".:. was discontinued. For additional information relating to ".:. therapy, including criteria for selecting a suitable vein for venipuncture, guidelines for administering an infusion using the antecubital fossa, and complications of ".:. therapy, refer to Chapter E, ".:. Therapy. S AN!AR!S 0F CARE G=I!ELINES Pediatric I*1* herap(

J. *lcohol wipes should not be used for removing ".:. catheters because the stinging of alcohol on the puncture site causes unnecessary discomfort. "f the intracath or plastic needle is not intact, notify the health care provider. C. To aid clotting.

>he# cari#% for a child &#der%oi#% I*1* therap(+ Check ".:. site hourly, noting skin color and evidence of swelling. Compare to the opposite e tremity or look for asymmetry. Feel area for sponginess. 5bserve for leakage. Check the ".:. tubing and e6uipment hourly. 2top the infusion if any cracks are noted in the tubing or there is discoloration of the ".:. fluid. &ecord the reading on the container or reservoir, amount of fluid absorbed in the hour, flow rate. Check for blood return in the tube by stopping ".:. fluid flow. "t may be normal not to see blood return due to small catheter size. Make certain the child is ade6uately and safely restrained. Check function of pump rate set versus amount infused. Maintain accurate intake and output record and A?-hour totals. !escribe consistency and appro imate volume of all stools and vomitus. <eigh child at regular intervals using the same scale each time. *n increase or decrease of 3B body weight in a relatively brief time period is usually significant. Monitor electrolytes 0see Table ?>-?, page F?F>1. &eport evidence of electrolyte imbalances( decreased skin turgor, marked increase or decrease in urination, fever, sunken or bulging fontanelles, sudden change in vital signs, diarrhea, weakness, lethargy, apathy, pyrogenic reactions, and arrhythmias.

"f the child is e periencing severe reactions, the ".:. should be discontinued and the solution saved for possible analysis. Change the ".:. container and tubing every A? hours or as per facility policy. "f infiltration occurs, remove the ".:., raise the affected e tremity, apply heat to the site, and restart the ".:. at an alternative site. ;otify the health care provider if irritation develops or to ic medication has infiltrated.

Foot#ote This information should serve as a general guideline only. 'ach patient situation presents a uni6ue set of clinical factors and re6uires nursing 4udgment to guide care, which may include additional or alternative measures and approaches. CAR!I0P=LM0NARY RES=SCI A I0N Cardiopulmonary resuscitation 0C#&1 involves measures instituted to provide effective ventilation and circulation when the patient$s respiration and heart have ceased to function. "n children, the most common initial cause is respiratory distress. =#derl(i#% Co#sideratio#s Cardiac Arrest 2igns=absence of heartbeat and absence of carotid and femoral pulses. Causes=asystole, ventricular fibrillation, or cardiovascular collapse. Respirator( Arrest 2igns=apnea and cyanosis. Causes=obstructed airway, depression of the central nervous system, neuromuscular paralysis. #ersonnel should be trained in up-to-date C#& maneuvers and be certified in 7asic 8ife 2upport at least every two years. E$er%e#c( Preparatio# 'very hospital should have a well-defined and organized plan to be carried out in the event of cardiac or respiratory arrest. 'mergency carts should be placed in strategic locations in the hospital and checked daily to ensure that all e6uipment is available. E2&ip$e#t 'mergency cart=assembled and ready for use. #ositive-pressure breathing bag with nonrebreathing valve and universal F3-mm adapter. Mask 0premature neonate, child, adult sizes1. 5ropharyngeal airway tubes, sizes D to ?. 8aryngoscope with blades of various sizes. ' tra batteries and light bulbs for laryngoscope.

'ndotracheal tubes with connectors 0complete sterile set, A.3 to C mm inner diameter1. #ortable suction e6uipment and sterile catheters of various sizes. 7ulb syringe, !e8ee trap. 5 ygen source=portable supply gauge and tubing, masks of various sizes. Cardiac board 0>D L 3D cm1. E$er%e#c( dr&%s+ o 2odium bicarbonate. o 'pinephrine 0*drenalin1. o "soproterenol 0"suprel1. o ;ormal saline solution 0for dilution1. o !iphenhydramine 07enadryl1. o !iazepam 0:alium1. o +ydrocortisone sodium succinate 02olu-Cortef1. o !igo in 08ano in1. o ;alo one 0;arcan1. o Calcium gluconate. o Calcium chloride FDB. o !e trose 3DB. o 8idocaine 0@ylocaine1. o *tropine. o #henytoin 0!ilantin1. o "nsulin. o #rocainamide 0#ronestyl1. o #ropranolol 0"nderal1. o !opamine 0"ntropin1. o 7retylium tosylate 07retylol1. o :olume e panders 0lactated &inger$s solution, normal saline solution1. "ntracardiac needles, AD and AA%, A>)C to >F)C inches long. ".:. e6uipment, including infusion set, ".:. fluids. Tourni6uet, armboards, tape. 2calp vein needles of various sizes. %loves, mask, gown, other protective barriers. ;asogastric tubes of various sizes. 2yringes and syringe needles of various sizes. "ntraosseous needles. 8ongdwell catheters of various sizes. Three-way stopcock. Cutdown set. #ole. 8abels. *lcohol wipes. Tongue blades. 2terile ?- L ?- gauze pads. 2terile hemostat.

2terile scissors. 7lood specimen tubes. 'lectrocardiograph 0'C%1, monitor, lead wires, and lubricating 4elly. !efibrillator and paddles 0pediatric and adult1.

Artificial 1e#tilatio# Mo&th-to-Mo&th ech#i2&e I#fa#ts a#d (o&#% childre#+ o 2lightly e tend neck by gently pulling chin up and forward and the head back 0chin lift or 4aw thrust1. #lace a rolled towel or diaper under the infant$s shoulder, or use one hand to support the neck in an e tended position. !o not hypere tend the neck because this narrows the airway. o Check the mouth and throat, and clear mucus or vomitus with finger or suction, if visible. o Take a breath. o Make a tight seal with your mouth over the infant$s mouth and nose. o %ently blow air from the cheeks, and observe for chest e pansion. %ive a total of two slow breaths. o &emove your mouth from infant$s mouth and nose, and allow the infant to e hale. o "f spontaneous respiration does not return, continue breathing at a rate and volume appropriate for the size of the infant 0usually AD times)minute or F breath every > seconds1. 0lder childre# a#d adolesce#ts+ o Clear mouth of mucus or vomitus with fingers or suction. o +ypere tend neck with one hand or a rolled towel 0head tilt, chin lift, or 4aw thrust1. o Clamp the nostrils with the fingers of one hand, which also continues to e ert pressure on the forehead to maintain the neck e tension. o Take a deep breath. o Make a tight seal with your mouth over the child$s mouth. o Force air into the lungs until the chest e pansion is observed. o &elease your mouth from the child$s mouth, and release nostrils to allow the child to e hale passively. %ive a total of two slow breaths. o &epeat appro imately FA to F3 times)minute or F breath every ? to 3 seconds if spontaneous breathing does not occur. Ha#d-0perated 1e#tilatio# !e'ices &emove secretions from mouth and throat, and move chin forward. *ppropriately e tend the neck with one hand or place a diaper roll behind the neck. 2elect an appropriate size mask to obtain an ade6uate seal, and connect mask to bag.

+old the mask snugly over the mouth and nose, holding the chin forward and the neck in e tension. 26ueeze the bag, noting inflation of the lungs by chest e pansion. "f there is no chest e pansion, realign the patient$s head and ad4ust the mask. retry. &elease the bag, which will e pand spontaneously. The child will e hale, and the chest will fall. &epeat FA to AD times)minute 0depending on the size of the child1. 7ecause this techni6ue is commonly difficult to master, it should be practiced in advance, under supervision.

I#dicatio#s of Effecti'e ech#i2&e :ictim$s chest rises and falls. &escuer can feel in own airway the resistance and compliance of the victim$s lungs as they e pand. &escuer can hear and feel the air escape during e halation. :ictim$s color improves. Ma#a%e$e#t of Co$plicatio#s Gastric diste#tio# 4occ&rs fre2&e#tl( if e/cessi'e press&res are &sed for i#flatio#6* o Turn victim$s head and shoulders to one side. o ' ert moderate pressure over the epigastrium between the umbilicus and the rib cage. o * nasogastric tube may be used to decompress the stomach. 1o$iti#%. o Turn patient on side for drainage. o Clear the airway with finger or suction. o &esume ventilations after the airway is clear and patent. Artificial Circ&latio# Ge#eral Pri#ciples Related to Artificial Circ&latio# ech#i2&e of Artificial Circ&latio# SI3E 0F PREPARA 0RY PHASE AC I0N PHASE !IS ANCE 0F RA E CHIL! C0MPRESSI0N A Neo#ate) F. #lace in supine F. Compress )> distance to the U pre$at&re position. midsternum spine or M >)? inch FDD)min or other,ise with both 0F.>-F.I cm1 s$all i#fa#t thumbs, A. 'ncircle the chest gently but with the hands, with firmly. thumbs over the midsternum 5& /se method for a larger infant, at a

Lar%er i#fa#t

rate of FDDFAD)minute. F. #lace on a firm, flat surface. A. 2upport the back with one hand or use a small blanket under the shoulders. >. #lace the tips of the inde and middle fingers of one hand over the midsternum. F. #lace on a firm, flat surface. A. 2upport the back by slipping one hand beneath it, or use a small blanket. >. #lace the heel of one hand over the midsternum, parallel with the long a is of the body.

F. Compress the M-F inch 0F.>-A.3 midsternum cm1 with the tips of the inde and middle fingers.

U FDD)min

S$all child

F. *pply a rapid F-F M inches 0A.3- CDdownward >.C cm1 FDD)min thrust to the midsternum, keeping the elbow straight. A. +old for appro imately D.? seconds. >. "nstantly and completely release the pressure so the chest wall can recoil. ?. !o not remove the heel of the hand from the chest. F. ' ert pressure FM-A inches 0>.C-3 CDvertically cm1 FDD)min downward to depress lower sternum, keeping elbows straight. A. +old for appro imately

Lar%er child) adolesce#t

F. #lace on a flat, firm surface, or place a board under the thora . A. #lace the heel of one hand on the lower half of the sternum, about F-FM inches 0A.3->.C cm1 from the tip of the

iphoid process and parallel with the long a is of the body. >. #lace the other hand on top of the first one 0may interlock fingers1. ?. #lace shoulders directly over child$s sternum, in order to use own weight in application of pressure.

D.? seconds. >. "nstantly and completely release the pressure so the chest wall can recoil. ?. !o not remove the hands from the chest.

Cardiop&l$o#ar( res&scitatio# i# childre#* I# the (o&#% child) the heel of the ha#d is placed o'er the lo,er ster#&$* I# older childre# a#d adolesce#ts) -oth ha#ds are &sed* * backward tilt of the head lifts the back in infants and small children. * firm support beneath the back is therefore essential if e ternal cardiac compression is to be effective.

* supine position on a firm surface is mandatory. 5nly in this position can chest compression s6ueeze the heart against the immobile spine enough to force blood into the systemic circulation. ' ternal cardiac compression must always be accompanied by artificial ventilation for ade6uate o ygenation of the blood. Compressions must be regular, smooth, and uninterrupted. *void sudden or 4erking movements. &ela ation must immediately follow compression. rela ation and compression must be of e6ual duration. 7etween compressions, the fingers or heel of the hand must completely release their pressure but should remain in constant contact with the chest. Fingers should not rest on the patient$s ribs during compression. #ressure with fingers on the ribs or lateral pressure increases the possibility of fractured ribs and costochondral separation. ;ever compress the iphoid process at the tip of the sternum. #ressure on it may cause laceration of the liver. I#dicatio#s of effecti'e tech#i2&e i#cl&de+ o * palpable femoral or carotid pulse. o !ecrease in size of pupils. o "mprovement in the patient$s color.

N&rsi#% Ma#a%e$e#t &ecognize cardiac and respiratory arrest. 2end for assistance and note time. I#itiate CPR+ o First ventilate the child$s lungs slowly two times, using appropriate techni6ue, then palpate the carotid or brachial pulse. "f a pulse is palpated, continue ventilatory support. o "f no pulse is felt, institute artificial circulation using appropriate techni6ue. o For an infant or child, interpose F breath after each series of 3 compressions. For a child over age C, interpose A breaths after each series of F3 compressions. o Continue repeating this cycle until help arrives. o "f alone, perform C#& as previously described for F minute, then call for help. *fter call, resume C#& until help arrives. >he# help arri'es+ o 5ne rescuer performs mouth-to-mouth resuscitation or institutes bag breathing. o *nother rescuer performs cardiac compressions. o * ratio of 3 compressions to F breath is maintained for both infants and older children. o Cardiac compression should not be stopped for respiration. 7reaths should be interposed on the upstroke of each fifth cardiac compression. A#ticipate a#d assist ,ith e$er%e#c( proced&res*

*ssist with intubation, monitoring, placement of intravascular access, administration of ".:. fluids, defibrillation, and other definitive measures. o #repare and administer emergency medications as prescribed. &ecord dose and time. o ;otify family of current management and C#&. After res&scitatio#+ o Care for the child as re6uired. o !etermine if family members have been notified and are being cared for. o &ecord all events. o &estock emergency cart.
o