PEDIATRICS NURSING INTERVENTIONS AND SKILLS
and is willing to permit
Informed Consent should include:
 nature of the illness or condition
 proposed care or treatment
 potential risks, benefits, and alternatives
 what might happen if the patient chooses not
to consent
Three Conditions that should be met by health care
providers to obtain valid informed consent:
person must be:
 capable of giving consent; he or she must be
over the age of majority
 must receive the information needed to
make an intelligent decision
 must act voluntarily when exercising
freedom of choice without force, fraud,
deceit, duress, or other forms of constraint or
coercion
Surgical or diagnostic procedure where separate
informed permissions must be obtained:
 Major surgery
 Minor surgery (e.g., cutdown, dental
extraction, biopsy, suturing a laceration)
 Diagnostic tests with an element of
risk (bronchoscopy, angiography, cardiac
catheterization, bone marrow aspiration)
 Situations that require patient or parental
consent (blood transfusion, thoracentesis or
paracentesis, radiotherapy)
Situations that require patient or parental consent:
 Photographs for medical, educational, or
public use
 Removal of the child from the health care
institution against medical advice
 Postmortem examination, except in
unexplained deaths, such as sudden infant
death, violent death, or suspected suicide
 Release of medical information
Decision making involving the care of older children
and adolescents should include:
1. patient’s assent
2. parent’s consent
Assent  4.
 means the child or adolescent has been
informed about the proposed treatment,
procedure, or research 
a health care provider to perform it
Assent should include the following:
 Helping the patient achieve a developmentally
appropriate awareness of the nature of his or
her condition
 Telling the patient what he or she can expect
 Making a clinical assessment of the patient’s
understanding
 Soliciting an expression of the patient’s
willingness to accept the proposed procedure
age-appropriate methods
 Videos
 peer discussions
 Diagrams
 Written materials
____________________________________________
age of majority
 the age at which a person is considered to
have all the legal rights and responsibilities of
an adult
emancipated minor 
 one who is legally under the age of majority
but is recognized as having the legal capacity
or social status of an adult
"medically emancipated” conditions:
 sexually transmitted infections
 mental health services
 substance abuse and addiction
 pregnancy
 contraceptive advice
____________________________________________
PREPARATION FOR DIAGNOSTIC AND THERAPEUTIC
PROCEDURES
Child life specialists address the psychosocial
concerns that accompany stressful life experiences
by:
 promoting optimal child development
 minimizing adverse effects
significant ways the child life specialist can have a
positive impact on the health care experience for the
child and family:
1. therapeutic play
2. procedural preparation and support
3. developmentally appropriate education
promoting normalcy
  Monitor
 Electrodes
PSYCHOLOGIC PREPARATION  Specimen
Things nurses should consider in individualizing the
Significance/effects of preparing children for preparatory process:
procedures
 decreases their anxiety 1. child’s temperament
 promotes their cooperation 2. existing coping strategies
 supports their coping skills and may teach 3. previous experiences
them new ones
 facilitates a feeling of mastery in experiencing Stress point coping 
a potentially stressful event  can be used to determine the child’s most
stressful or upsetting part of previous
Purpose of readmission teaching programs: procedural experiences
 to educate the pediatric patient and family by
offering hands-on experience with:  simple coping strategies:
a. hospital equipment  relaxing, breathing, counting, squeezing a
b. the procedure performed hand, or singing
c. departments they will visit
exact timing of the preparation for a procedure
most effective preparation: varies with:
 the provision of sensory-procedural 1. child’s age
information  2. developmental level
 helping the child develop coping skills, such as 3. type of procedure
imagery, distraction, or relaxation.
Concurrent preparation 
General Guidelines for preparing children for  a strategy that can be used during a
procedures: procedure to explain what a child can
1. Determine details of exact procedure to be expect to occur and sense immediately before
performed it happens
2. Review parents’ and child’s present
understanding through open-ended Parental Presence and Support
questions.
3. Base teaching on developmental age and Parents
existing knowledge  greatest source of support for young children
4. Emphasize that no other body part will be  represents:
involved a. security
5. Avoid words and phrases with dual meanings b. protection
unless child understands such words. c. safety
d. comfort
Words and Phrases to Avoid:
 Shot Explanations needed before performing a procedure:
 Bee sting  what is to be done
 Stick  what sensations the child may feel
 Organ  what is expected of the child
 Test  why the procedure is being done
 Edema
 incision, cut Supportive care
 stretcher, gurney  continues during the procedure and can be a
 Dye MAJOR FACTOR in child’s ability to cooperate
 Pain
 deaden, numb Distraction
 Fix  a powerful coping strategy during painful
 Take (take your temp, take your bp) procedures
 put to sleep, anesthesia
 Catheter Behavior
  children’s primary means of communication
and coping and should be permitted unless it
inflicts harm on them or those caring for them
Play-Doh
 a remarkably versatile medium for pounding
and shaping
Dramatic play
 provides an outlet for anger and places the
child in a position of control, in contrast to the
position of helplessness in the real situation
Puppets
 allow the child to communicate feelings in a
nonthreatening way
PLAY ACTIVITIES FOR SPECIFIC PROCEDURES
Fluid Intake:
 Make ice pops using child’s favorite juice.
 Cut gelatin into fun shapes
 Use small medicine cups; decorate the cups.
 Have a tea party; pour at a small table.
 Color water with food coloring or powdered
drink mix
Deep Breathing:
 Blow bubbles with a bubble blower.
 Blow bubbles with a straw (no soap).
 Blow on a pinwheel, feather, whistle, balloon
 Practice band instruments
 Take a deep breath and “blow out the
candles” on a birthday cake
Range of Motion and Use of Extremities:
 Play “tickle toes”; have the child wiggle them
on request.
 Play Twister game or Simon Says.
 Play pretend and guessing games (e.g.,
imitate a bird, butterfly, or horse).
 Have tricycle or wheelchair races in safe area.
 Climb wall with fingers like a “spider.”
Soaks:
 Play with small toys or objects (e.g., cups,
soap dishes) in water.
 Wash dolls or toys.
 Pick up marbles or pennies* from bottom of
bath container.
 Make designs with coins on bottom of
container.
 Pretend a boat is a submarine by keeping it
immersed.
Injections:
 Let child handle syringe, vial, and alcohol
swab and give an injection to doll or stuffed
animal
 Draw a “magic circle” on area before
injection;
 draw smiling face in circle after injection but
avoid drawing on puncture site.
 Have child count to 10 or 15 during injection
Ambulation:
 Give child something to push
 Have a parade
Extending Environment (e.g., for Patients in Traction):
 Make bed into a pirate ship or airplane with
decorations.
 Put up mirrors so patient can see around
room.
 Move bed frequently to playroom, hallway, or
outside.
Things that are involved in the process of patient
education:
 giving the family information about the child’s
condition
 the regimen that must be followed and why
 other health teaching as indicated
goal of this education: to enable the family to modify
behaviors and adhere to the regimen that has been
mutually established
General Principles of Family Education
1. Establish a rapport with the family.
2. Avoid using confusing specialized terms or
jargon. Clarify all terms with the family and
use the term that is clear to the child.
3. When possible, allow family members to
decide how they want to be taught (e.g., all at
once or over a day or two). This gives the
family a chance to incorporate the
information at a rate that is comfortable.
4. Provide accurate information to the family
about the illness.
5. Assist family members in identifying obstacles
to their ability to comply with the regimen
and in identifying the means to overcome
those obstacles. Then help family members
find ways to incorporate the plan into their
daily lives.
General concepts applicable to most family
education sessions that are included:
1. Name of the procedure
2. Purpose of the procedure
3. Length of time anticipated to complete the
procedure
 4. Anticipated effects goals for using preoperative medications:
5. Signs of adverse effects  anxiety reduction
6. Assess the family’s level of understanding  amnesia
7. Demonstrate and have family return  sedation
demonstration (if appropriate)  antiemetic effect
 reduction of secretions

SURGICAL PROCEDURES
Intraoperative Care
Preoperative Care
role of the pediatric operating room nurse:
IMPORTANT CONCERN:  to advocate for care of the patient in surgery
 restriction of food and fluids before surgery to through the verification of procedure and
avoid pulmonary aspiration during anesthesia laterality, implants, skin preparation,
necessary instrumentation, and supplies
Results of fasting too long:
 discomfort Postoperative Care
 headache
 dehydration Postanesthesia complications:
 hypoglycemia  airway obstruction
 can delay recovery and hospital discharge  postextubation croup
 laryngospasm
nurse’s responsibility if surgical procedures are  bronchospasm
DELAYED:
 to communicate with the surgical team to important aspects of immediate postoperative care:
adjust fasting guidelines appropriately  Monitoring the patient’s oxygen saturation
and providing supplemental oxygen as needed
Stress points before and after surgery:  maintaining body temperature
 admission process  promoting fluid and electrolyte balance
 blood tests
 administration of preoperative medication (if malignant hyperthermia (MH)
prescribed) - a potentially fatal pharmacogenetic disorder
 transport to the operating room of muscle metabolism
 mask on the face during induction
 stay in the postanesthesia care unit Symptoms of MH:
 hypercarbia (increasing end-tidal carbon
Reasons why children are at higher risk of ineffective dioxide)
response to anesthesia and complications in the  elevated temperature
recovery period:  tachycardia
 higher anxiety in the preoperative period  tachypnea
associated with stranger anxiety (infants)  acidosis
 separation anxiety (toddlers and  muscle rigidity
preschoolers)  hyperkalemia
 fear of injury or death (adolescents)  rhabdomyolysis

Benefits of well-prepared children and parents along Treatment of MH:

with parental presence during induction of  immediate discontinuation of the triggering
anesthesia: agent
 reduced anxiety for children and parents  hyperventilation with 100% oxygen
 lower doses of postoperative analgesia  IV dantrolene sodium
 lower incidence of severe emergence delirium
symptoms Major nursing responsibility after surgery
 decreased postoperative maladaptive  managing pain
behaviors
 shorter discharge time for short procedures Nonpharmacologic postoperative recovery
interventions:
  use of distraction, videos, interactive game
applications, and therapy dogs Areas where it typically occur:
 Occiput
Compliance or adherence  Ear lobes
- refers to the extent to which the patient’s  Sacrum
behavior coincides with the prescribed  Heels
regimen in terms of taking medication,  scapula
following diets, or executing other lifestyle
changes Interventions found to prevent pressure ulcers in
critically ill children:
most successful approach in compliance:  Assessing the patient’s skin from head to toe
a. Clinical judgment on admission and each shift.
b. Self-reporting  Turning children every 2 hours
c. Direct observation  Using pillows, blanket rolls, and positioning
d. Monitoring appointments devices
e. Monitoring therapeutic response  Using draw sheets to minimize shear
f. Pill counts  Using pressure reduction surfaces
g. Chemical assay  Allowing moisture reduction through the use
of dry-weave diapers and disposable
Postoperative Care: underpads
 Inspect operative area.  Using skin moisturizers
 Check dressing if present  Conducting nutrition consults
 Assess skin color and characteristics.
 Assess level of sedation and activity. Causes of peptic ulcer:
 Assess for evidence of pain.  Medical devices such as:
 Assess for bladder distention o pulse oximeter probes
 Observe for signs of dehydration. o bilevel
 Check bowel sounds. o continuous positive airway pressure
 Check dressings for bleeding or other masks (CPAP masks)
abnormalities. o oxygen cannulas
 Monitor vital signs as ordered and more often o orthotics
if indicated. o casts

Compliance Strategies: Friction

1. Organizational Strategies
- involve the care setting and the
therapeutic plan
2. Treatment Strategies
- relate to the child’s refusal or inability
to take the prescribed medication
3. Behavioral Strategies
- designed to modify behavior directly
 occurs when the surface of the skin rubs
against another surface
Prevention of friction injury:
 use of customized splinting or foam-padded
boots over the heels
 gel pillows under the heads of infants and
toddlers
 moisturizing agents
 protective, transparent barrier dressings over
susceptible areas
 soft, smooth bed linens and clothing

SKIN CARE AND GENERAL HYGIENE Shear

Peptic ulcers
 a form of pressure injuries, are localized
damage to the skin and/or underlying soft
tissue due to decreased perfusion as a result
of increased pressure
 the result of the force of gravity pushing down
on the body and friction of the body against a
surface, such as the bed or chair.
Prevention of shear injury:
 using lift sheets when repositioning a patient
 elevating the bed no more than 30 degrees
for short periods
  elevating the knees to interrupt the pull of Causes of decreased appetite:
gravity on the body toward the foot of the  Pain or discomfort
bed  Nausea and vomiting
Epidermal stripping  Emotional concerns
 results when the epidermis is unintentionally  Loss of control
removed when tape is pulled off the skin
well-tolerated foods:
 gelatin
 diluted clear soups
Prevention of epidermal stripping injury:  carbonated drinks
 using no tape when possible or securing  flavored ice pops
dressings with laced binders (Montgomery  dry toast
straps) or stretchy netting (Spandage or  crackers
stockinette).
 Using porous or low-tack tapes (e.g., CONTROLLING ELEVATED TEMPERATURE
Medipore, paper, hydrogel),
 using alcohol-free skin sealants (No Sting  Set point—The temperature around which
Barrier Film) body temperature is regulated by a
 picture framing wounds with hydrocolloid or thermostat-like mechanism in the
wafer barriers (e.g., DuoDERM, Coloplast, hypothalamus
Stomahesive) and then taping on top of the  Fever (hyperpyrexia)—An elevation in set
barrier point such that body temperature is regulated
at a higher level; may be arbitrarily defined as
____________________________________________ rectal temperature above 38°C (100.4°F)
 Hyperthermia—Body temperature exceeding
BATHING the set point, which usually results from the
body or external conditions creating more
Areas requiring special attention: heat than the body can eliminate, such as in
 ears heat exhaustion, heatstroke, aspirin toxicity,
 between skinfolds seizures, or hyperthyroidism
 neck
 back Physiologic benefits of Fever:
 genital area  increased white blood cell activity
 interferon production and effectiveness
 antibody production
ORAL HYGIENE  enhancement of some antibiotic effects such
as penicillin
Mouth care
- an integral part of daily hygiene and should be Treatment:
continued in the hospital - Antipyretics
- NSAIDs (Ibuprofen)

FEEDING A SICK CHILD Traditional cooling measures

 Provide finger foods for young children - wearing minimum clothing
 Involve children in food selection and - exposing the skin to air
preparation whenever possible - reducing room temperature
 Ensure a variety of foods, textures, and colors. - increasing air circulation
 Make food attractive and different - applying cool, moist compresses to the skin
 Praise children for what they do eat.
 Do not punish children for not eating by Infection Control
removing their dessert or putting them to
bed. Nosocomial Infections:
 Health-care associated
Loss of appetite  Clostridium Difficile
- a common symptom to most childhood  Staphylococus Aureus
illnesses  CLABSI’s (Central Line Associated Bloodstream
Infections)
  CAUTI’s (Catheter Associated Urinary Tract o Bladder catheterization
Infections)
 Surgical site infections  Place it in a sterile specimen bottle.
 Label ( Name of pt., Date and Time of
Standard Precautions: collection
 Universal (Blood and Body Fluids) precautions  Send to lab. within 30 minutes after collection
 Hand washing
 Gloves, goggles, gown, or mask Stool Specimen
 Prevent contamination:  Should be collected without contamination of
 Blood urine
 Body fluids(secretions and excretions, except  Place it in a sterile specimen bottle
sweat)  Label ( name of the pt., date and time of
 nonintact skin collection)
 mucous membranes  Send it to laboratory as soon as possible after
collection (not more than 2 hours).
Transmission-Based Precautions:
- Highly transmissible Blood Specimen
- Epidemiologically important pathogens
1. Central Venous Catheters
A. Airborne Precautions  A small volume of blood must first be
 Airborne transmissions of infectious withdrawn and discarded to clear the
agents line of any IV fluids, heparin, or other
 Airborne droplet nuclei fluids.
 Small-particle residue <5mm  discard 1.5-2 times the fill volume
 Remain suspended in the air for long
periods 2. Peripheral veins
 Common: Measles, Varicella,  Collected as quickly as possible
Tuberculosis  After the needle is withdrawn,
pressure is applied to the puncture
B. Droplet Precautions site until bleeding stops.
 Contact of the conjunctivae or the  if in the antecubital fossa, pressure
mucous membranes of the nose or should be applied with the arm
mouth extended, to reduce bruising.
 Large-particle droplets >5mm  if bruising or hematoma develops,
 Transmission requires close contact apply warm compress.
 Do not remain suspended in air, travel
only short distances 3. Arterial vessels
 3-10 feet  Blood gas measurements
 using the brachial, radial or femoral
C. Contact Precautions arteries
 Direct or Indirect contact  assess adequate circulation before
 Direct contact arterial puncture
o Skin to skin  Allen’s test - assesses the circulation
 Indirect contact of the radial, ulnar, and brachial
o Transmission thru a arteries
contaminated object
4. Capillary methods
 Fingerstick or heelstick
Collection of Specimens  finger - use the 2nd or 3rd finger
 wipe once, before beginning
Urine Specimens collection
 The age of the child will affect the collection  heelstick - 6 months below
techniques as well as the developmental  serious complication for heelstick -
considerations. necrotizing osteochondritis
o Urine collection bags  no deeper than 2mm, at the outer
o Clean catch specimens aspect of the heel.

Respiratory Secretion Specimens
 Required for the diagnosis of respiratory
infections.
 Must be produced by deep cough, not just
spitting oral secretions into a container.
 Infants and small children - gastric washing
(lavage) may be used to collect the specimen.
 Should be collected early morning.
Medication Administration
 Right Patient
 Right Medication
 Right Dose
 Right Time
 Right route
 Verify the indication for use
-The differences between adult and pediatric dosing
of medications are related to physiologic differences.
-Newborns and premature infants are particularly
vulnerable to the harmful effects of drug due to:
 Immature enzyme systems in the liver
 Lower concentration of plasma proteins
 Immature functioning of kidneys.
-Children metabolized drug more rapidly than adults.
-Nurses are accountable for the medications that they
administer.
-An important part of that responsibility is:
 Having a working knowledge of drug actions
and potential side effect
-Pediatric dosages are most often expressed in:
 Units of measure per body weight (mg/kg)
-In chemotherapy:
 Precisely dosed using body surface area

Administration of Medication Checking Dosage

 Formula: D/SxVol -Administering the correct dosage of a drug is a
shared responsibility between the provider who
1. Oral Administration orders the drug and the nurse who carries out that
2. Intramuscular Admin. order.
o Anterolateral apect of the thigh or -High-alert medications should be double checked
Vastus Lateralis muscle with another nurse before giving them to the child.
o Deltoid Drugs  that require such safeguards:
o 90 deg. angle  Antiarrhythmics
3. Subcutaneous Admin.  Anticoagulants
o 45 deg. angle  Chemotherapeutic agents
o 90 deg. angle (obese)  Insulin 
4. Intradermal Admin.  Epinephrine
o Administered into the dermis  Opioids
o longest absorptiontime of all  Sedatives
parenteral routes Another category of high-alert medications are the:
o 10-15 deg. Angle  Look-alike, sound-alike
5. Intravenous Admin
- Effect is almost instantaneous. Identification
- Check the site for patency -Before the administration of any medication, the
o Peripheral Intermittent Infusion child must be correctly identified using to identifiers
Device - heparin lock -With an infant, young child, or nonverbal child, the
o Central Venous Catheters parentr guardian can verify the child’s identity.
o Intraosseous Infusions
Oral Administration
Administration of Medication -is preferred for giving medications to children
because of the ease of administration
Determination of Drug Dosage
-Solid preparations are not recommended for younger
-Nurses must have an understanding of the:
children because of the danger of aspiration.
 Safe dosage of the medication
-Some liquid preparations may have an unpleasant
 Action
after-taste
 Possible side effect
 Taste can be camouflaged by mixing the
 Signs of toxicity
medication with a small amount of juice and
-Dosage for pediatric medication is usually presented
applesauce.
as:
 In pharmacies, flavored syrup, syrpalta can be
 Recommended dose range
provided for this purpose. 
 Based on age
 Weight
 Body surface area
Preparation
Plastic disposable calibrated oral syringe
-The most accurate means of measuring small amount
of medication  Risk for aspiration:
-It also serve as a convenient means for transporting
and administering the medication  medication
Rx Medibottle
-more effective in delivering unpleasant-tasting oral
medication to infants than an oral syringe.
-this device allows an infant to suck juice or other
liquids from a nipple attached to a specially designed
bottle.
Paper cups
-unsuitable for liquid medications because they
collapse easily, are likely to have irregularly shaped or
crumpled bottoms, and retain considerable amounts
of thick medications.
Teaspoon
-Inaccurate measuring device and is subject to error
Syringes
-preferred device for dosing accuracy
Available to accurately measure and administer the
drug:
 Hollow-handled medicine spoon
 Calibrated in milliliters
Should be avoided:
 Household spoons
 Measuring spoon
Dropper
-another unreliable device for measuring liquid
-the volume of a drop varies according to the viscosity
of the liquid measured
For children who have difficulty swallowing tablets or
pills, it may be crushed.
-some pills can be crushed and mix with applesauce or
small amount of juice
-some drugs with an enteric or protective coating or
formulated for small release should not be crushed
-some drugs may be hazardous if the powder
becomes aerosolized with crushing.
Administration  position safely.
-the nurse must take care to prevent aspiration.
-the child must be placed in semireclining position
-it is best to place the syringe along the side of the
tongue and administer slowly in small amount
-If an infant up to 11 months of age and children with
neurologic impairments, blowing a small puff of air in
the face frequently elicits a swallowing reflex.
-Medicine cups can be used effectively for children,
toddlers, and older infants who are able to drink from
a cup.
 Aiming at the back of the throat when giving
 Crying
 Child lying flat
Intramuscular Administration
Selecting the Syringe and Needle
-the volume of medication prescribed for
intramuscular injection in small children necessitates
selection of syringe that can measure small amounts
of solution.
-Syringes along with specially constructed needles,
minimize the possibility of inadvertently administering
incorrect amounts of a drug because of dead space
(which allows fluid to remain in the syringe and
needle after the plunger is pushed completely
forward)
-Measures that minimize the effect of dead space:
1. When 2 drugs are combines in the syringe,
always draws them up in the same order to
maintain consistent ration between the drugs
2. Use the same brand of syringe
3. Use one-piece syringe units.
-Needle length must be sufficient to penetrate the
subcutaneous tissue and deposit the medication into
the body of the muscle. 
Determining the Site
-Factors to consider when selecting site of IM
injection on an infant/child include the following:
 The amount and viscosity of the medication to
be injected
 The amount and general condition of the
muscle mass
 The frequency or number of injections to be
given during the course of treatment
 The type of medication being given
 Factors that may impede access to or cause
contamination of the site
 The child’s ability to assume the required
-1ml is the maximum volume that should be
administered in a single IM site to small children and
older infants.
Ventrogluteal site
-have been found to have fewer local reactions and
fever
-fewer systemic reactions and greater parental
acceptance
-free from major nerves and blood vessels
-large muscle with less subcutaneous tissue
Deltoid muscle
-small muscle near axillary and radial nerves
-can be used for small volumes of fluid in children as
young as 18 month old
-less pain and fewer side effects  is almost instantaneous
Administration
-Repeated use of a single site has been associated
with fibrosis of the muscle with subsequent muscle
contracture
-Injections close to large nerves, sciatic nerve, have
been responsible for permanent disability -
dorsogluteal is no longer recommended for IM
injection of child under 10 years old
-Aspiration during IM vaccine administration is no
longer recommended.
 In deltoid or vastus lateralis is not indicated
because there are no large blood vessels
 It is still indicated before injection of
medication such as penicillin.
IM injection techniques:
1. Straighter the path needle insertion
2. Less displacement and shear to tissue
=less discomfort
-If medication is given around the clock, the must
must wake the child.
Subcutaneous and Intradermal Administration
-Examples of subcutaneous injections:
 Insulin
 Hormone replacement
 Allergy desensitization
 Some vaccines
-Examples of Intradermal Injection:
 Tuberculin testing
 Local anesthesia
 Allergy testing
-Technique to minimize the pain associated with
these injection:
 Changing the needle if it pierced a rubber
stopper on a vial
-Common site:
 Center third of the lateral aspect of the upper
arm
 The abdomen
 The center third of the anterior tight.
-Avoid the medial side of the arm where the skin is
more sensitive.
Intravenous Administration
This method is used for giving drugs to children who:
 Have poor absorption as a result of diarrhea,
vomiting, or dehydration
 Need a high serum concentration of a drug
 Have resistant infections that require
parenteral medication over an extended time
 Need continuous pain relief
 Require emergency treatment
-When drug is administered intravenously, the effect
Factors to consider when preparing and
administering drugs to infants and children by the IV
route:
 Amount of drug to be administered
 Minimum dilution of drug and whether child is
fluid restricted type of solution which drug
and whether child is fluid restricted
 Length of time over which drug can be safely
administered
 Rate limitations of child, vascular system, and
infusion equipment
 Time that this or another drug is to be
administered
 Compatibility of all drugs that child is
receiving intravenous
 Compatibility with infusion fluids
-Before any IV infusion, check the site for patency 
 which includes flushing easily without
resistance and brisk blood return
NEVER’S:
 Never flush against resistance
 Never administered medications in the same
IV tubing with blood products
 Only one antibiotic at a time
Peripheral Intermittent Infusion Device
-an alternative when extended access to vein is
required without the need for continuous fluid
-This allows the child more freedom than being
connected to a continuous infusion 
-it is most frequently used for intermittent infusion of
medication
-the catheter remain in place and flushed with saline
before and after infusion of the medication, to
maintain patency.
Midline Catheter
-are peripheral catheters that are placed in one of the
larger vein of the upper arm
-appropriate for short-term use, lasting 2-6 weeks
-not a central venous catheter 
-TPN (infuse through central catheter) or other drug
known to irritate the peripheral vein should not be
administered   TPN
Central Venous Catheter
-used in children who have acute or chronic illnesses
who require:
 Repeated blood sampling or medication
 Long-term chemotherapy
 Intensive care
 frequent hyperalimentation or antibiotic
therapy
-it is because large central veins allow more rapid
diffusion of fluids and medications
-it has a great risk of bloodstream infection
Short-term or nontunneled central venous catheters
-are used in acute care, emergency, and intensive care
unit.
-catheters are made of polyurethane
-places in large veins:
 Subclavian
 Femoral
 Jugular
-insertion is by surgical incision or percutaneous
threading
-Chest radiography should be take to verify that the
catheter tip is properly located in large central vein
before administration of fluids or medication
Peripherally inserted central catheters
-used for short-term and moderate-length therapy
-it consist of silicone or polymer material   Concurrent problem involving that extremity
-common insertion site:
 Median
 Cephalic
 Basilic vein
-when the antecubital veins have been punctured
repeatedly, they are not considered candidate for this
type of catheter
Factors influence selection of the type of central
venous access device (CVAD):
 Reason for placement of catheter
 Length of therapy
 Risk to the patient in placement of the
catheter
 Availability of resources to assist the family in
maintaining the catheter.
Long-term CVAD
-include tunneled catheters and implanted infusion
ports
-they may have single, double, or triple lumen
-several lumen catheters allow more than one therapy
to be administered at the same time.
-Reason to use multilumen catheters:
 Repeated blood sampling
 Administration of blood products or infusion
of large quantities or concentrations of fluids
 Administration of incompatible drugs or fluid
at the same time
 And central venous pressure monitoring
Maintenance of the catheter:
 Dressing changes
 Flushing to maintain patency
 Prevention of occlusion or dislodgement
2 most common complications of central venous
catheter:
 Infection
 Catheter occlusion
Intraosseous Infusion
-it should be obtained if venous access cannot be
readily achieved after three unsuccessful attempts or
90 sec in a pediatric resuscitation
-venous access id complicated by:
 Peripheral circulatory collapse
 Hypovolemic shock
 Cardiopulmonary arrest
-it provides a rapid, sfe, and lifesaving alternate route
for administration of fluids and medications until
intravascular access is possible.
Contraindications for placement of an intraosseous
catheter:
o Skin rash
o Bone fracture
o Osteogenesis imperfecta
o Osteosarcoma
Prefer site for children of all ages:
 Below the tibial tuberosity
In newborn:
 Distal third of the femur
 Distal tibia - alternative 
What need to do or to watch during infusion:
 Monitor the extremity closely for oozing or
swelling of fluid in the insertion site
o Give particular attention to the
dependent tissue of the leg
o Extravasation of fluid from the bone
marrow may be hidden under the leg
 Check for swelling of the entire lower leg
when the intraosseous bone marrow needle is
in the tibia or ankle, and check upper leg
when the intraosseous needle is in the femur.
-Compartment syndrome has resulted from an
infiltrated intraosseous line
-Other complications:
  Fractures
 Skin necrosis
 Osteomyelitis
 Cellulitis  distal site and avoid the child’s favored hand to
MAINTAINING FLUID BALANCE
MEASUREMENT OF INTAKE AND OUTPUT
It is a nursing responsibility to keep an accurate I&O
record on children in certain situations:
 Receiving IV therapy
 Recently underwent major surgery
 Receiving diuretic or corticosteroid therapy
 With severe thermal burns or injuries
 With renal disease or damage
 With congestive heart failure
 With dehydration
 With diabetes mellitus
 With oliguria
 In respiratory distress
 With chronic lung disease
> The volume of fluid in milliliters is equivalent to the
weight of the fluid measured in grams.
> The specific gravity as a measure of osmolality
assists in assessing the degree of hydration.
Remember: 1 g of wet diaper weight = 1 ml of urine
Disadvantages of the weighed-diaper method of fluid
measurement:
 an inability to differentiate one type of loss
from another because of admixture
 loss of urine or liquid stool from leakage or
evaporation  other restraints and tape and maintains skin
 additional fluid in the diaper from absorption
of atmospheric moisture 
Special Needs When the Child Is Not Permitted to
Take Fluids by Mouth
> To prevent the temptation to drink, fluids should not
be left at the bedside.
> Oral hygiene is especially important 
Limiting fluids: To make certain the child does not
drink the entire allotted amount early in the day, the
total daily amount is calculated, then divided to
provide fluids at periodic intervals throughout the
child’s waking hours.
PARENTERAL FLUID THERAPY
Site and Equipment
older children: superficial veins of the forearm should
be used, leaving the hands free.
veins in extremities: it is best to start with the most
reduce the disability related to the procedure.
small infants: a superficial vein of the hand, wrist,
forearm, foot, or ankle is usually most convenient and
most easily stabilized
transilluminator
 also known as near-infrared imaging
 aids in finding and evaluating veins for access
cephalic vein in the proximal forearm 
 may be the optimal vein for ultrasound-
guided placement
NOTE: The length of the catheter may be directly
related to infection or embolus formation; the shorter
the catheter, the fewer the complications.
> Determining the best catheter for the patient early
in the therapy provides the best chance of avoiding
catheter-related complications.
SECUREMENT OF A PERIPHERAL INTRAVENOUS LINE
> Catheters must be stabilized for easy monitoring
and evaluation of the access site, to promote
delivery of therapy, and to prevent damage,
dislodgement, or migration of the catheter
commercial site protector
 its ventilation holes prevent moisture  from
accumulating under the dome.
 designed to protect the IV site and allow for
visibility of the site.
 minimizes use of padded boards, splints, or
integrity.
> The thumb is never immobilized because of the risk
of developing contractures with prolonged limitation
of
movement.
SAFETY CATHETERS AND NEEDLELESS SYSTEMS
Needleless IV systems
 designed to prevent needlestick injuries
during administration of IV push medications
and IV piggyback medications.
3 general types of needleless systems:
a. Negative displacement systems
  cause a backflow of blood into the
catheter when a syringe is
disconnected.
b. Positive displacement systems
 a valve system that pushes a small
 amount of IV fluid back into the cap
when disconnecting which  prevents
inadvertent catheter occlusion.
c. Neutral displacement systems
INFUSION PUMPS
> It is important to calculate the amount to be infused
in a given length of time, set the infusion rate, and
monitor the apparatus frequently (at least every 1 to
2 hours) to make certain that the desired rate is
maintained, the integrity of the system remains intact,
the site remains intact and the infusion does not stop.
MAINTENANCE
Maintenance recommendations were made for
central venous catheters:
 Use transparent dressings to allow site
visualization.   pump pressure
 Replace any dressing when damp, visibly
soiled, or loose. Routinely replace transparent
dressings every 7 days and gauze dressings
every 2 days unless the risk of central catheter
dislodgement outweighs the benefits of the
dressing change.
 During dressing changes, use chlorhexidine to
cleanse skin surrounding central lines and use
chlorhexidine, tincture of iodine, an iodophor,
or alcohol surrounding peripheral lines. 
 Chlorhexidine-impregnated sponge dressings
should be used for short-term central
catheters in patients older than 2 months
when central line–associated bloodstream
rates are not decreasing with other efforts,
such as chlorhexidine skin cleansing,
maximum sterile barrier precautions during
insertion, and staff education.
 Do not apply ointments to the insertion site
 Replace IV administration sets at the following
frequencies:
  • Continuous infusions of crystalloids at no
less than 96-hour intervals, but at least every
7 days
  • Blood product or lipid emulsion sets within
24 hours of starting the infusion
  • Propofol sets every 6 to 12 hours and when
the vial is changed
 No recommendation was made on the
frequency of intermittent set changes.
 Include all needleless components (including
injection caps at thecatheter hub) in
administration set changes.
 In pediatric patients, peripheral IV catheters
may remain in place until a complication
occurs or the therapy is complete.
 Promptly remove temporary central catheters
or peripheral IV catheters as soon as they are
no longer needed.
COMPLICATIONS
Appropriate methods for assessment of the IV
patency:
a. Flushing the catheter
b. Observing for edema, redness, or streaking
along the vein
IV therapy in pediatrics can be difficult to maintain
because of mechanical factors:
 vascular trauma resulting from the catheter
 the insertion site, vessel size
 vessel fragility 
  the patient’s activity level
 operator skill and insertion technique
 forceful administration of boluses of fluid
 infusion of irritants or vesicants through a
small vessel.
Infiltration
 inadvertent administration of a nonvesicant
solution or medication into surrounding tissue
Extravasation
 inadvertent administration of vesicant
solution or medication into surrounding tissue
vesicant or sclerosing agent
 causes varying degrees of cellular damage
when even minute amounts escape into
surrounding tissue.
> Phlebitis or inflammation of the vessel wall may also
develop in children who require IV therapy
3 types of phlebitis:
a. mechanical - caused by rapid infusion rate,
manipulation of the IV
b. chemical - caused by medications
c. bacterial - caused by staphylococcal
organisms
erythema (redness) at the insertion site - initial sign
of phlebitis
Peripheral IV catheters - most commonly used
intravascular device
Heavy cutaneous colonization of the insertion site
 single most important predictor of catheter-
related infection with all types of short-term,
percutaneously inserted catheters
REMOVAL OF A PERIPHERAL INTRAVENOUS LINE
> Encouraging children to remove or help remove the
tape from the site provides them with a measure of
control and often fosters their cooperation
The procedures consists of:
 turning off any pump apparatus
 occluding the IV tubing  AEROSOL THERAPY
 removing the tape
 pulling the catheter out of the vessel in the
opposite direction of insertion
 exerting firm pressure at the site.
RECTAL ADMINISTRATION
 useful when a child is unable to take oral
medications due to vomiting, altered
gastrointestinal motility, or altered mental
status.
Advantages:
a. no need to coax a child to swallow unpleasant
tasting medications
b. relative ease of accessibility for giving
medications during an emergency if the
patient is unconscious or vomiting and there
is no venous access.
Factors in Absorption via Rectal Mucosa
 gut motility
 amount of time that the drug remains in the
rectum
 amount of stool present at time of drug
administration.
Contraindications:
 pt is neutropenic
 pt is immunosuppressed
 pt is thrombocytopenic
OPTIC, OTIC, AND NASAL ADMINISTRATION
eye medication: supine or sitting position
ear drops: prone or supine position
> To avoid uncomfortable stimulation of vertigo,
ensure that ear medications are at room temperature
before instilling.
> younger than 3 years of age, the external auditory
canal is straightened by gently pulling the pinna
downward and straight back.
> older than 3 years of age, pinna is pulled upward
and back
> After instillation, the child should remain lying on
the unaffected side for a few minutes. Gentle massage
of the area immediately anterior to the ear facilitates
the entry of drops into the ear canal.
nose drops: same manner in the adult pt
> After instillation of the drops, the child should
remain in position for 1 minute to allow the drops to
come in contact with the nasal surfaces.
 can be an effective method for administering
medication directly into the airway.
 This route of administration can be useful in
avoiding the systemic side effects of certain
drugs and in reducing the amount of drug
necessary to achieve the desired effect.
 Breath sounds and work of breathing should
be assessed before and after treatments.
metered-dose inhaler (MDI)
 a self-contained, handheld device that allows
for intermittent delivery of a specified amount
of medication.
spacer device
 attached to the MDI can help with
coordination of breathing and aerosol delivery
 allows the aerosolized particles to remain in
suspension longer.
NASOGASTRIC, OROGASTRIC, AND GASTROSTOMY
ADMINISTRATION
Advantage: the ability to administer oral medications
around the clock without disturbing the child
Disadvantage: the risk of occluding, or clogging, the
tube, especially when giving viscous solutions through
small-bore feeding tubes.
most important preventive measure: adequate
flushing after the medication is instilled
ALTERNATIVE FEEDING TECHNIQUES
Some children are unable to take nourishment by
mouth because of:
 anomalies of the throat, esophagus, or bowel
  impaired swallowing capacity
 severe debilitation
 respiratory distress; or 
 unconsciousness
These children are frequently fed by way of a tube
inserted orally or nasally
1. into the   tube can be left in place or inserted and
 stomach
 orogastric [OG] or NG gavage
 duodenum-jejunum
 enteral gavage
2. by a tube inserted directly into the  securely in place between feedings
 stomach 
 gastrostomy
 jejunum
 jejunostomy
Feeding resistance
 a problem that may result from any long-term
feeding method that bypasses the mouth
During gavage or gastrostomy feedings, infants are
given a pacifier.
 Only pacifiers with a safe design can be used
to prevent the possibility of aspiration.  Preparations
 Using improvised pacifiers made from bottle
nipples is not a safe practice.
Nonnutritive sucking has several advantages, such
as:
 increased weight gain   A receptacle for the fluid; for small amounts, a
 decreased crying
The possibility for error increases when the parenteral
solution is a fat emulsion, a milky-appearing
substance.
Safeguards to prevent this potentially serious error
include the following:
 Be sure that the feeding bag and all tubings
are cleaned on a regular basis, according to
the manufacturer’s recommendations.
 Use enteral-specific connectors (ENFit) that
are not compatible with Luer or needleless
connections used for IV tubing
 Use a separate, specifically designed enteral
feeding pump mounted on a separate pole
for continuous-feeding solutions.
 Label all tubing of continuous enteral feeding
with brightly colored tape or labels.
 Use specifically designed continuous-feeding
bags to contain the solutions instead of
parenteral equipment, such as a burette.
 Whenever access or connections are made,
trace the tubing all the way from the patient
to the bag to ensure that the correct tubing
source is selected.
GAVAGE FEEDING
 Infants and children can be fed simply and
safely by a tube passed into the stomach
through either the nares or the mouth
removed with each feeding
In older children
 usually less traumatic to tape the tube
For long-term enteral tube feedings
 the tube should be removed and replaced
with a new tube according to hospital policy,
manufacturer recommendations, specific
orders, and the type of tube used
Meticulous hand washing
 practiced during the procedure to prevent
bacterial contamination of the feeding,
especially during continuous-drip feedings. 
The equipment needed for gavage feeding includes
the following:
 A suitable tube selected according to the
child’s size, the viscosity of the solution being
fed, and anticipated duration of treatment 
10- to 30-ml syringe barrel or Asepto syringe
is satisfactory; for larger amounts, a 60-ml
syringe with a catheter tip is more convenient 
 A 10-ml barrel syringe to aspirate stomach
contents after the tube has been placed 
 Water or water-soluble lubricant to lubricate
the tube; sterile water is used for infants 
 Paper or other nonallergenic tape to mark the
tube and to attach the tube to the infant’s or
child’s cheek (and nose, if placed through the
nares) 
 pH paper to determine the correct placement
in the stomach 
 The solution for feeding
Polyethylene and polyvinylchloride types 
 lose their flexibility and need to be replaced
frequently, usually every 3 or 4 days.
Polyurethane and silicone tubes 
 remain flexible, so they can remain in place up
to 30 days.
Advantages of small-bore tubes
  reduced incidence of pharyngitis
 otitis media
 aspiration
 discomfort
Disadvantages include:
 difficulty during insertion (may require a stylet
or metal guide wire)
 collapse of the tube during aspiration of
gastric contents to test for correct placement
 dislodgement during forceful coughing
 migration out of position
 knotting
 occlusion
 unsuitability for thick feedings
Procedure
 Infants are easier to control if they are first
wrapped in a mummy restraint
Whenever possible,
 infant should be held and provided with a
means for nonnutritive sucking during the
procedure to associate the comfort of physical
contact with the feeding.
When this is not possible,
 infant or child lying supine or on the right
side; the head and chest should be elevated.
Feeding the child in a sitting position
 helps maintain placement of the tube in the
lowest position, thus increasing the likelihood
of correct placement in the stomach.
Useful in predicting feeding tube placement
 bedside assessment of gastrointestinal
aspirate color   small, flexible silicone device protrudes
 pH  slightly from the abdomen, is cosmetically
Best option for older children and when an accurate
height is unavailable
 is to adapt the nose-earmidxiphoid-umbilicus
measurement for NG or OG tube length
GASTROSTOMY FEEDING (G tube)
 is often used for children in whom passage of
a tube through the mouth, pharynx,
esophagus, and cardiac sphincter of the
stomach is contraindicated or impossible.
 also used to avoid the constant irritation of
an NG tube in children who require tube
feeding over an extended period
Gastrostomy tube
 may be placed with the child under general
anesthesia or percutaneously using an
endoscope with the patient sedated and
under local anesthesia (percutaneous
endoscopic gastrostomy).
Direct postoperative care of the wound site toward
prevention of infection and irritation.
If skin irritation is present, use barrier ointments such
as:
 zinc oxide, petrolatum-based ointment, and
nonalcohol skin barrier film to control leakage
 add absorptive powders and pectin-based skin
barrier wafers
Hydrogen peroxide
 use for routine site cleansing, has been
identified as one of the possible causes of
hypergranulation tissue, corrosion and
excessive drying of the tissue, and disruption
of wound healing.
Managing hypergranulation by:
 stabilizing the tube
 keeping the peristomal area dry by applying
polyurethane foam, and 
 using triamcinolone (0.5%) three times a day
 Silver nitrate may also be used for
hypergranulation.
For children receiving long-term gastrostomy
feeding, 
 a skin-level device (e.g., MIC-KEY, Bard
Button) offers several advantages.
Skin-level device 
pleasing, affords increased comfort and
mobility to the child, is easy to care for, and is
fully immersible in water
 requires a well-established gastrostomy site
and is more expensive than the conventional
tube
Feeding of water, formula, or pureed foods is carried
out in the same manner and rate as for gavage
feeding.
Mechanical pump
 may be used to regulate the volume and rate
of feeding
  After feedings, the infant or child is positioned
on the right side or in the Fowler position
If a Foley catheter is used as the gastrostomy tube,
apply very slight tension.
NASODUODENAL AND NASOJEJUNAL TUBES 
Require placement of a postpyloric feeding tube for
children at high risk for regurgitation or aspiration,
such as those with:
 gastroparesis
 mechanical ventilation, or 
 brain injuries
trained provider
 inserts the nasoduodenal or nasojejunal tube
because of the risk of misplacement and
potential for perforation in tubes requiring a
stylet.
Accurate placement is verified by radiography. 
Continuous feedings are delivered by a mechanical
pump to regulate their volume and rate.
 Bolus feeds are contraindicated.
Tube displacement is suspected in children showing
signs of feeding intolerance such as vomiting. 
 stop the feedings and notify the provider.
TOTAL PARENTERAL NUTRITION 
 provides for the total nutritional needs of
infants and children whose lives are
threatened because feeding by way of the
gastrointestinal tract is impossible,
inadequate, or hazardous.
Involves:
 IV infusion of highly concentrated
solutions of protein, glucose, and
other nutrients. 
The wide-diameter vessels selected are the superior
vena cava and innominate or intrathoracic subclavian
veins approached by way of the external or internal
jugular veins.
Major nursing responsibilities are the same as for
any IV therapy and include:
 control of sepsis
 monitoring of the infusion rate and
 assessment of the patient
Meticulous aseptic precautions
 should be used whenever the line is entered
or changed
Alterations of the TPN infusion rate can cause:
 hyperglycemia or hypoglycemia
General assessments, such as: 
 vital signs
 I&O measurements, and 
 checking results of laboratory tests
Hyperalimentation
 additional amounts of potassium and sodium
chloride are often required
 therefore observation for signs of potassium
or sodium deficit or excess is part of nursing
care
Hyperglycemia
 may occur during the first day or two as the
child adapts to the high-glucose load of the
hyperalimentation solution
 insulin may be required to help the body
adjust
 nursing responsibilities include blood glucose
testing
 To prevent hypoglycemia when the
hyperalimentation is disconnected, the rate of
the infusion and the amount of insulin are
decreased gradually
FAMILY TEACHING AND HOME CARE 
 family needs to learn how to feed the child
with an NG, gastrostomy, or TPN feeding
regimen
 Plan ample time for the family to learn and
perform the procedures under supervision
before they assume full responsibility for the
child’s care. 
 Refer the family to community agencies that
provide support and practical assistance. 
Oley Foundation
 is a nonprofit research and education
organization that assists persons receiving
enteral nutrition and home TPN.
PROCEDURES RELATED TO ELIMINATION  NuLYTELY
ENEMA
Isotonic solution
 used in children
Plain water is not used because, being hypotonic, it
can cause rapid fluid shift and fluid overload.
Fleet enema
 is not advised for children because of the
harsh action of its ingredients (sodium
biphosphate and sodium phosphate).   Hirschsprung disease
Commercial enemas
 dangerous to patients with megacolon and to
dehydrated or azotemic children
Osmotic effect of the Fleet enema may produce
diarrhea, which can lead to metabolic acidosis.
Additional complications such as:
 extreme hyperphosphatemia
 hypernatremia
 hypocalcemia
which may lead to neuromuscular irritability and
coma.
 The enema may be administered with the
child positioned on the left side, while lying
on absorbent chux pads.
Enema
 is an intrusive procedure and thus can be
threatening to children of all ages
 therefore developmentally appropriate
preparation and distraction is especially
important for the comfort of the child.
Preoperative bowel preparation solution
 given orally or through an NG tube is
increasingly being used instead of an enema.
Polyethylene glycol–electrolyte lavage solution
(GoLYTELY)
 mechanically flushes the bowel without
significant absorption, 
 thereby avoiding potential fluid and
electrolyte imbalances
 a modification of GoLYTELY
 has the same therapeutic advantages as
GoLYTELY and was developed to improve on
the taste. 
 Magnesium citrate solution
 Another effective oral cathartic
OSTOMIES
most frequent causes in infants are:
 necrotizing enterocolitis and
imperforate anus 
In older children, the most frequent 
causes are:
 inflammatory bowel disease,
especially Crohn disease (regional
enteritis), and 
 ureterostomies for distal ureter or
bladder defects
 Major emphasis in pediatric care 
 preparing the child for the procedure and
teaching care of the ostomy to the child and
family.
Simple, straightforward language is most effective
together with the use of illustrations and a replica
model. 
Children with ileostomies are fitted immediately after
surgery with an appliance to protect the skin from the
proteolytic enzymes in the liquid stool.
Ostomy equipment consists of a 
 one- or two-piece system with a
hypoallergenic skin barrier to maintain
peristomal skin integrity
Backing
 helps minimize the risk of skin breakdown
from moisture trapped between the skin and
pouch. 
Major aspect of stoma care
 protection of the peristomal skin
Protect the peristomal skin with a barrier substance 
 e.g., zinc oxide ointment [Sensi-Care] or a
mixture of zinc oxide ointment and stoma
powder [Stomahesive]).
Zinc-based product 
  helps protect healthy skin, heal excoriated  failure to pass flatus or stool
skin, and minimize pain associated with skin
breakdown. is brought to the attention of the physician, nurse, or
stoma specialist

 The nurse can apply zinc-based products over

topical antifungal and antibacterial agents if
infection is present.

No-sting barrier film 

 is a skin sealant that has no alcohol base and
can be used on open skin without stinging.

During adolescence, concerns for body image and the

ostomy’s impact on intimacy and sexuality emerge.
 The nurse should stress to teenagers that the
presence of a stoma need not interfere with
their activities.

Children with familial adenomatous polyposis 

 may require a colectomy with ileoanal
reservoir to prevent or treat carcinoma of the
colon. 

Peristomal skin care for these children is particularly

challenging because of:
 increased liquid stools
 increased digestive enzymes that may cause
skin breakdown, and 
 the stoma being at skin level rather than
raised. 

Additional care with this condition includes:

 close monitoring of fluid and electrolyte
status
 increased incidence of bowel obstruction

 Enterostomal therapy nurse specialist 

 is an important member of the health care
team and will have additional suggestions and
assistance with skin care information and
ostomy pouching options

FAMILY TEACHING AND HOME CARE 

 preparation of the family should begin as
early as possible in the hospital.
 The nurse instructs the family in the
application of the device (if used), care of the
skin, and appropriate action in case skin
problems develop. 

Skin breakdown or stomal complications, such as: 

 ribbonlike stools
 excessive diarrhea
 Bleeding
 prolapse