Problem No.

2: Nursing Care of a Family When a Child Needs Diagnostic or Therapeutic

Modalities
MEANING/ DESCRIPTION

Diagnostic and Therapeutic Modalities in Children

❖ Illness can be particularly stressful if many diagnostic and therapeutic procedures are
necessary for diagnosis or care.
❖ With less time for teaching and preparation than was once available, good planning and follow-
through are essential.
❖ Supporting a child and family during a diagnostic procedure can not only aid in an efficient
diagnosis but also may help establish a trusting relationship between the family and healthcare
providers that will make all future interactions more successful.

2020 National Health Goals Related to Keeping Children Well

❖ Reduce hospitalizations for asthma among children under age 5 years from a baseline of
41.4% to a target level of 18.1%.
❖ Increase age-appropriate vehicle restraint systems in children aged 4 to 7 years from a baseline
of 43% to a target level of 47%.
❖ Increase the number of adolescents who have had a wellness checkup in the past 12 months from
68.7% to 75.6%.
❖ NOT GOING TO BE TESTED OVER 2020 NHG’S

Modifying Procedures According to a Child’s Age and Developmental Stage #1

❖ Consider a child’s age and potential understanding of procedures when planning the
number and order of tests and the way they will be performed.
o Infant- we want to keep painful or uncomfortable procedures to an absolute minimum, to
avoid Messing with Developmental stages such as trust versus mistrust.

o Toddler and preschooler- tent to resist any kid of diagnostic testing because they don’t want
to deal with any uncomfortable, painful procedures, scary or anything that’s unfamiliar to
them, for this age group you want to give a short explanation of what to expect and want to
wait until it’s close to the time of the procedure that way the child is not just sit there and
worry about what’s going to happen.

o School-age children- School age children are concrete thinkers, they are
interested in theory and the reason why procedure Is being performed.

o Adolescent- They will act mature and Act like this doesn’t bother them, - but they still get
scared sometimes depending to procedure so make sure that you provide comfort, support
and good explanations.

ASSOCIATED PROBLEMS

 Inability to communicate
 Inability to monitor own care and manage fear
 Nutritional Needs
 Fluid and electrolyte balance
 Systemic response to illness
 Age specific-disease
 Inability to communicate
 Very young children do not have the vocabulary to describe symptoms.
 Children younger than 5 years of age have a great deal of difficulty describing a headache.
 By the time, the children reach school age, most can describe symptoms with accuracy.
 They may intensify their concerns if they believe someone expects symptoms to be more serious.
 They may minimize symptoms if they are afraid that an illness will interfere with an activity they
want to do; thus, it is important to evaluate a child's symptoms as much by observation.
 Inability to monitor own care and manage fear
 School-age and younger children cannot monitor their own care because they may not know which
medicine or procedure they are scheduled to receive.
 Children have fears that adults do not experience.
 By 8 to 9 months, the infant years of separation above all else; the toddlers and preschooler enlarge
their fears to include separation, the dark, intrusive procedure, and mutilation of body parts.
 The school-age child and adolescent may be concerned about the loss of body, loss of life, and loss
of friends.
 Children in a strange environment, such as hospitals, have not learned coping skills yet and so
require more support and active intervention to manage their stress and fears.
 Nutritional needs
 There are major physiologic differences in the way illnesses affect children compared with adults.
 Children have greater metabolic demand, breathe in more air per pound of body weight than adults,
have higher surface to body mass ratio, and are at greater risk for insensible fluid loss when they are
sick.
 Children need more nutrients (calories, protein, minerals, and vitamins) per pound of body weight
than adults because their basic metabolic rate is faster. They must maintain body tissues and allow
for growth.
 Infant requires 120kcal/kg body weight per day while an adult requires 25-30 kcal/kg of body weight
per day.
 Fluid and electrolyte balance
 In a newborn, extracellular water is closer to 40%. This means that infant does not have much water
stored in cells and is more likely to lose a devastating amount of body water with diarrhea or
vomiting.
 Systemic Response to illness
 Because a child's body is continually growing, young children tend to respond to disease
systematically rather than locally.
 The child with pneumonia may not be admitted to the hospital because of cough but because of
accompanying symptoms such as fever, nausea, vomiting, diarrhea.
 Systemic reactions can delay diagnosis and therapy and can increase fluid and nutrient loss which
compound initial illness.
 Age-specific diseases
 Most adults have achieved immunity to common infectious diseases; children, however are very
susceptible to illnesses, such as mumps, measles, and chickenpox.

POSSIBLE MEDICAL/NURSING SOLUTION/PREVENTION

Overview:
 Nursing Responsibilities #1 & #2
 Nursing Responsibilities: Restraints
 Nursing Responsibilities: Recovery
 Measurement of Vital Signs
 Common Diagnostic Procedures
 Specimen Collection
Nursing Responsibilities #1
❖ Obtaining informed consent
 It is a physician’s job to explain the suggested treatment, alternatives to that treatment, risks and
benefits and potential for injury related to suggested treatment – Physician explain procedure and answer
family questions
 Nurse is responsible for getting the sign consent, chart been filled out and patient and family
is ready for procedure
NOTE: Emancipated minors- legally they have the same rights as adults they can consent or
refuse their medical care. Same with adolescents that live on their own or that or married OR
serving with the armed forces

❖ Explaining procedures-
 Make sure you explain procedures clearly an answer any questions appropriately as a general
guide A child needs a detailed description of what to expect,

 EXAMPLE: finger stick with the glucose test: you would say “I’m going to clean your
finger and you’ll feel a small pin prick. “you would also explain why the procedure is
being performed You would explain that the doctor needs to look at their blood to see
why your so sick.

 Where is procedure will be done: You want to prepare the child for anything specific
EXAMPLE: If they need to go for X Ray explain the room to them.

 Any unusual sensation

EXAMPLE: the alcohol that I’m going to use to clean your finger will be cold.

 Any pain involved you need to make sure they know beforehand.
EXAMPLE: I am starting an IV you will state the needle will sting, but I will put some
cream on 1st to dull the feeling,

 You will want to explain the equipment, the room, and length of time the procedure will take.
Any special care after the procedure

 You will want to use the appropriate language.

EXAMPLE: don’t say “TEST” with school age children because they might associate that
with a pass/ fail situation. The word TEST could make the child wonder if they passed a
procedure, causing them anxiety. If unfamiliar with procedure never guess about a
procedure or answer that to child because it can confuse them even more and causes
trust issue, if you don’t know the answer tell them you will find out and come back to
them.

❖ Scheduling
 If the child is not NPO you want to make sure that you schedule meals and play time
to decompressed In between Scheduled procedures. On the flip side if they are on fluid
restriction/NPO, for multiple procedures we want to get them done as quickly as possible and together, so
 that we can get that child eating and drinking ASAP.

❖ Preparing child and family

 Physically and psychologically for procedure we want to reduce the anxiety as much as we can,
our job is to let them know what to expect.
 Monitor vital signs Blood pressure, heart rate, oxygen saturation etc.

❖ Accompanying child
 We want parents to accompany the child as much as possible, because it lowers the child stress
level. The parent cannot Accompany the child to the OR but can wait in the waiting room you want to
make sure that you provide good directions, comfort and support to the parents.

❖ Providing support
 Provide support verbally, presence Build trust with the parents, family, and child. Provide a
comforting touch to the child hand on the arm, rub their back.

Nursing Responsibilities #2
❖ Procuring necessary equipment
❖ Ensuring safety
 Safety #1 especially with infants and very Young children, identification is huge always make sure
that they have their arm bands on.

EXAMPLE: if you need to move their current armband, to put in a new IV you will want to cut off the arm
band and immediately put on another extremity. For infant they have one on the ankle and arm, older children
it’s usually only in one place. You will Immediately tape it to the opposite extremity and request a new band.
the child will always need a form of identification on them.

 Big thing with safety is the used with restraints- the use of a restraint is always to protect the
child from injury, always use alternative methods first such as family present, use of sitters,
distraction, RETRAINTS should only be used as a last resort! They need to be removed as
soon as possible.
SAFETY WITH RESTRAINTS
TYPE OF TYPE OF
METHOD
RESTRAINT RESTRAINT
For a wheelchair, use a vest restraint. Attach straps to the frame of the
wheelchair with enough slack so the child has some mobility. For a cart, fasten
Promote safety
a restraining belt and raise the side rails
while transporting
Wheelchairs children to and
Even with restraints in place, never leave a child unattended in hallways
and carts from a healthcare
outside departments in a wheelchair or on a cart. Not only is this unsafe
facility procedure
because the child may attempt to get down from the cart or wheelchair but also
department
the anxiety of waiting in a strange department for a procedure without a
support person with them may be too acute for young children to handle.
Use disposable restraints, gauze, or soft muslin tape. Soft muslin tape “gives” a
little if the child exerts pressure against it so it will not pull too tight and reduce
circulation or cause pain. Tie the restraint as shown in Figure A.
Secure one arm or
leg for a If a child struggles against restraints, fold several layers of soft gauze around
Clove-hitch
procedure, such the wrist or ankle under the restraint. Secure the restraint to the underpart of the
restraints
as an intravenous bed. Never tie restraints to side rails; when a side rail is lowered, it will jerk the
infusion child’s arm or leg and possibly cause an injury.

Release arm and leg restraints whenever someone can be with the child to keep
the limb in the desired position.
Restrain children Fasten the ties at the back of the jacket. Tie strips attached to the sides of the
Jacket younger than 6 jacket under the mattress to keep the child in one position (see Fig. B). Assess
restraints months in a that the restraint is not pressing against the neck or could be causing
supine position interference with a child’s airway.
Prevent children Dress the baby in a long-sleeved shirt to prevent irritation from the restraint.
from touching the Slip a commercial restraint such a NoNoSleeve up over the infant’s arm and
Elbow
head or face (e.g., secure it by the Velcro strips (see Fig. C). Assess the infant’s fingers to ensure
restraints
following facial the sleeve is not too tight that it interferes with circulation
surgery)
Temporarily Use this only for the duration of the procedure because it is a total body
immobilize young restraint. Follow the steps shown in Figure D.
children for a
procedure If the child is exceptionally strong, a few safety pins can be used to hold the
Mummy or involving the restraint even more firmly in place.
blanket head, neck, or
restraints throat (e.g., For the infant who needs continuous observation for respiratory function, fold
during insertion the mummy restraint so the chest is exposed. For newborns or infants, use a
of a nasogastric Papoose Board, a commercial restraint used in the same way as a full or
tube or blood mummy restraint (see Fig. E)
drawing)
❖ Providing care after procedures
 You want to see how well they reacted by observation in history, allow the child to explain what
happened to them It helps them retrace the procedure in their mind. This allows them to talk about it and
overcome any fear, providing therapeutic play After the procedure helps reduce anxiety
❖ Following infection precautions
 if there’s a dressing we want to make sure that we’re keeping it clean and dry also during the procedure
we need to make sure we keep a sterile field.
❖ Assessing response to procedure
❖ Collecting specimens
 Tissue samples obtain during the procedure you want to make sure that they are properly labeled and
sent to the lab right away.
❖ Documenting
 Always document what you have done

Nursing Responsibilities: Restraints

 Fig. A (clove hitch restraint)

 Fig. B (jacket restraint)
 Fig. C (NONO sleeve or commercial elbow restraint)
 Fig. D (Mummy restraint) – for newborn/ infant’s weekend swaddled in and leave one foot
out to get our heel stick
 Fig. E (Papoose boards restraint)
 Nursing Responsibilities: Recovery
PASSING SCORE IS AT LEAST 10 WITH LEVEL OF CONSCIOUSNESS SCORE NO
LOWER THAN 4

▪ After procedure - recovery: we want to make sure that we're meeting our criteria for discharge
either from PACU or inpatient unit or even home
▪ Some children can be discharged in a little 30 minutes
o As long as they are: Blood pressure, heart rate and respiratory weight should be age
appropriate and they should be reasonably free from pain
▪ Awake, oriented, patent air way
▪ Respiratory status is without retraction, strider or wheezing and is on 95% or
greater on room air
▪ PACU assessments and scored the criteria will vary from facility to facility but remember the
bolded passing score for EXAM

Measurement of Vital Signs

❖ Temperature:
o Temporal artery thermometer- put the thermometer flush on the forehead midway
between the hair Line in brow, press down on the button keeping the device flush to the skin
Until you reach the hairline.
o Tympanic- the nurse will need to straighten the ear canal. In children younger than 2
years old to straighten the ear canal you would pulled down and children older than 2
years old.
o Axillary thermometers- you must make sure that the temperature monitor is in the
axilla and the center and hold the child’s arm down to the side to keep it sealed, this
allows the thermometer Stay firmly in place. These work better for infants, bigger kids
not so much because they can move more.
o Oral thermometers- the nurse must assess beforehand, if the child had something cold
or hot to eat or drink this will affect the temperature of the oral thermometer.
 Taking Tympanic Membrane and Axillary Temperature

Taking Blood Pressure Measurement

❖ Pulse rate
o Young children: the radial pulse is hard to palpate, we will want to do in an apical pulse,
you will listen through the stethoscope and listen for a full minute.
o Infant: the point of maximum intensity for the Apical pulse (where heartbeat can be heard
most distinctly)- can be heard just above and outside the left nipple, at third or fourth
intercostal space, it will be more lateral to the midclavicular line. As the child grows by
age 7 the pulse Will be located more at the midclavicular line, at the fourth or fifth
intercostal space.
❖ Respiratory rate
o Respiratory rate should be measured; this should happen before the young child or infant
becomes upset for instance crying.
o Count respirations
o Infant: while they’re being held by the parent or family member or laying in a
crib. Infants tend to breath with their abdominal muscle muscles, you may
count respirations by watching the movements of the abdominal muscles as
well as counting chest movements. Count for a full minute.
o For an older child count respiration while they are seated on the lap of a parent or seated in a
chair.
❖ Blood pressure
o Blood pressure should start being measured around 3 years of age, usually after well child
check- up, unless it’s specifically indicated for another reason. The nurse will want to offer an age
appropriate explanation, 1st let the child play with the cuff and squeeze the ball at the end for a
minute, then explain that it’s going to hug their arm, this explanation is good because a hug is
generally a good thing and it’s not scary.
o Biggest thing with blood pressure in children You must have the right size cuff, pick up
that is 2 wide or 2 big will give a lower read out and because that is too narrow or too tight Will
give a high reading.
o In infants the cuff must be no more than 2/3 of the upper arm and not less than ½ in Length
of the upper arm. If a child’s arm is not free for BP due do IV lines, cast, or a wound, nurse
May take a blood pressure on the upper thigh or on the lower leg specially in an infant
making sure that you get the popliteal artery on the infant.
o When assessing the BP you want to pay attention to the pulse pressure, which is the
 difference between the diastolic and systolic readings, because an unusually wide pulse
pressure which is more than 50 millimeters of Mercury, or a pulse pressure that is narrow
which less than 10 millimeters of Mercury. These can suggest congenital heart disease.

Common Diagnostic Procedures

❖ Electrical impulse studies

o ECG or EEG
❖ ECG- (Electrocardiography)
❖ EEG (Electroencephalography)
o Both are painless procedures and can be scary for the child Because they see the wires
being connected to them, because young children have been told not to touch wires, so
this becomes scary for them.

❖ X-ray studies: are used to inspect internal aspects of the body, mostly bony structures.
o Flat-plate

 X-rays are for the bony structures. They can be used to diagnose and evaluate the
progress of certain illnesses, as well to assess the placement of devices such as a NG
tube. Usually children are okay with X Rays because you can compare it with a
camera, and it decreases their anxiety about the procedure.
 A child will receive a lead apron and thyroid shield to protect certain body parts
for exposure is not needed. Anyone remaining in the X Ray room will need to have
a lead apron as well. You’ll want to remove any objects that contain metal,
because they mess with the image.

o Dye contrast

 Dye contrast is used to visualize a body cavity, radio opaque died may be
swallowed, instilled by enema, or administered by IV, and then dye will be
revealed by X Ray.
  If the child must drink barium for an GI study, you can tell the child even if it’s
flavored it doesn’t taste good it’s like warm thick milk.
 Most important you will always check their allergy status before giving for
example seafood allergies or other food allergies.
 You want to prepare the child at the dye will feel warm and flush, this can be
frightening to the child.
 As a nurse we will not use the word “DYE” when describing this procedure,
because the child will worry That they could be dyed like an Easter egg or
they will actually die. You can call it a special medicine instead.
 Children become easily bored with this procedure because it’s a lot of waiting
around for the contrast dye to outline and reach a specific organ, have the child
bring an activity to occupy their time.
 For a child that is in NPO status using distraction is a good idea such as a
coloring book, A reading book, or game activity.

o Computed tomography (CT scan)

 This is a type of X Ray procedure where you can get many different views of a body
part, a dense structure appears to be white and a non-dense structure appears to
be gray to black on the film. These procedures may need a dye Injected Iodine
injection (Radio isotope), check for seafood or shellfish allergies. The child must
live very still during the procedure, sedation may be needed.
 Some parents are worried about the amount of radiation exposure explain that it’s a
long test, but it has such short doses of radiation. (Exposure is like X Ray).
o Magnetic resonance imaging (M RI)

 Combines a magnetic field a radio frequency and computer technology.

 These produce diagnostic images, MRI are used for such disorders such as, renal
and brain pathologies.
 The child will lay on a moving pallet That is pushed into the machine to wear the
magnet is when the magnet is turned on it makes a big booming noise, you will have
to prepare the child for the booming noise, as well as the feeling of
claustrophobia.
 This can be a long procedure If it’s not a cranial view being taken the child can use
headphones
 Because the MRI Is a huge magnet a child with a metal prosthesis or metal braces
are poor candidates for this procedure.
 Hairpins or makeup have a metallic base and must be remove as well as watches
were other jewelry. The nurse must consider the hospital gown as well Most hospital
 gallons have metal snaps the nurse will need to provide a specialized gown for this
procedure.

o Ultrasound

 Children are ultimately open to ultrasound because it’s painless, non-invasive, and
the child likes looking at the pictures of their insides. The nurse will inform the child that
you will be looking at internal tissue and organs.
 You will inform the child that you will apply a clear gel over the part and place the
transducer to see that issue in organs, this gel may feel cool and sticky.
 You can compare the transducer to a television camera to help the child understand.
 A parent may remain in the room during X Ray because it’s a non-invasive painless
procedure.
o Nuclear medicine studies

 These studies are Radioactive Combine substances not when given by injection or by mouth go
to their designated body organs. Then the scintillation machine (Geiger counter) is passed over
the organ where the substance outlines, so you can gather an outline or pattern of collected
material. This pattern can be reproduced on a screen image or photograph.
 Biggest concern with this is parents worry that their child will be exposed to a radioactive agent,
we must explain to the parents that the risk is minimal, when used correctly and it’s
a very small an amount going to a specific organ.

o Direct visualization procedures

 Endoscopy

 A scope is passed through the mouth to determine the status of the GI

track and exam its Patency. It has become a common procedure to
determine GI Disorders in children.
 This procedure is also used as an emergency to remove objects such as
 quarters or toys that are lodged.
 Having each tube pass down their throat for a child is very scary, even
after they understand what the procedure will be like, child will still be
very uncomfortable. The nurse will need to provide Comfort and
reassurance.
 Most the time the child will be NPO 4 to 6 hours before the procedure.
 The child will need a sedative or mild sedation, said that the child will
remain still during the procedure.
 For school-age children because they are concrete thinkers and need to
know the why, you can ask the technician to keep an image or picture for
the child, so they can see the why.
 Because the Endoscope is passed through the throat it may cause
edema from the pressure (esophagus and pharynx). As a nurse will want
to watch these children for at least an hour after the procedure. You
want to ensure that there not having respiratory distress, or discomfort
when swallowing.
 Assessment, you will want to observe the child swallowing for the first
time after the procedure and ensure that the gag reflex has returned

 Bronchoscopy

 This is where we directly visualize larynx, trachea, and bronchi in

this is through a lit flexible optic tube.
 This procedure is used for a child who has aspirated a foreign object, to
instill medications, to take biopsies, to obtain specimens/cultures.
 That’s right will be sprayed with the local anesthetic to numb the
area and the child will be moderately sedated.
 You’ll want access to emergency equipment You’ll monitor all
vital signs and have Narcan on hand.
 Possible complications from this procedure, hemorrhage,
pneumothorax, and airway edema.
 Post-procedure complications they could have bronchospasms, stridor,
desaturation of respiratory stress, MONITOR THESE CHILDERN
CLOSELY!!!!
 After the procedure is finished you will continue to monitor
airway and vital signs, assessed gag reflex, and observe the first time that
they d

 Colonoscopy

 We will be examining the large intestine with a flexible fiberscope, that

 is inserted through the anus up to the ileocecal value. (it can go a long
way). Air is then infused to expand the walls to be visualized. Looking
for abnormalities and pictures can be taken for later visualization.
 This procedure can also be used to diagnose inflammatory bowel disease,
or to obtain biopsy.
 Before the procedure the child will be on a clear liquid diet for 24
hours, and then the child is asked you drink isotonic saline laxative so that
their bowel will be clean for the procedure.
 It will be difficult to get the child to drink all the laxative Because the child
will not want to have diarrhea. Also, we will have to keep a close lookout
for dehydration. Will have to be creative, make drinking this solution into a
game such as “Simon Says”.
 It’s a child cannot swallow all the laxative; a saline edema can be used, and
the child will be moderately sedated.
 Post procedure the child will pass a lot of gas within the first 12 hours, if the
procedure was done on ambulatory basis, they are usually sent home within
2 hours after procedure. They are kept NPO at this time to allow the bowel
to rest. (bowel takes a little while to wake up).
 You must teach the parents want to observe or at home and make a report of
abdominal pain, blood in stool, weakness, or pallor could be signs and
symptoms of an abdominal bleed, especially if there was a polyp removed for
a biopsy performed.
 Even with moderate sedation colonoscopies are difficult procedures, the
child will need a lot of praise afterwards for their cooperation.

 Aspiration studies
 This is the removal of body fluids with such techniques as, lumbar puncture
or bone marrow aspiration.
 These are always anxiety causing procedures for children!
 The size of the needle is very frightening to the child, hey chad will need a
sedative or moderate sedation this will help keep them still, you want to
support and restrain the child as necessary by talking in using touch.
 Assessment after procedure, you will look for bleeding at the site, and apply
pressure at site to stop bleeding as needed.
 After the lumbar puncture procedure, the child will need to remain quiet
with their head flat and lay flat to prevent a spinal headache.

Specimen Collection
❖ Blood specimens- especially terrifying for a child.
 You need to prepare the child before and during the procedure you will want to immobilize
the child.
 Immobilizing the child Is the best option because it becomes about safety.
 You want to take the child to the treatment room to get this procedure performed you do
not want to do it at that side because their bed is there safe place.

o Venipuncture
 ▪ For very small infants usually try to use the back of the hand, the AC (antecubital
space), sometimes you will need to place it in the scalp (SCALP IV is done
frequently on little babies).
▪ In no emergent blood draws you can apply anesthetic cream (EMLA cream), you will
also use distraction techniques Such as, flashing lights, blowing bubbles, playing a
game, asking questions for school age children such as, what is your favorite movie
what kind of sports you like.
▪ You will have to offer Explanation of the procedure: you will explain That I
need to take some blood from your hand I will apply cream that will help numb
and when I come back you will feel a small pinprick from the needle.
▪ Preschool age children Don’t have any concept of how much blood is in their body,
their fear is you’re going to take all their blood. You must explain to that child that
they have a lot of blood in their body, you must reassure them that they are safe.

o Capillary puncture

▪ The best place to get blood with the capillary puncture is the heel or the fingertip,
▪ In little babies they pretty much always use the heel.
▪ Capillary puncture: glucose, Bilirubin, H &H, CBC ect…
▪ You can apply the anesthetic cream, but if you apply it to the finger you must be
careful
because little kids put their hands in their mouth all the time. Child could end up
licking it off and numbing their tongue or throat.
You must use the side of the finger in not the middle and same for the heel b/c it’s
less painful.

❖ Urine specimens
o Routine - Only requires a single specimen, from a single void.
o Age appropriate - Collecting Urine Specimens from Infant

▪ Age appropriate ways of attaining Urine specimens, infants cannot void on

command or a toddler that has not been toilet trained. We will use the bag
specially on babies. The nurse will place cotton balls in the bag to prevent
leaking, you will squeeze the urine from the cotton balls, and you will pull it
into your syringe and send it off to the lab.
▪ For older children who are toilet trained - They Still may not be able to go on
command, you will need to provide a pan, or some type of device the child can
urinate into. Such as, a urine cap. Offer the child fluid such as water A child may
have to wait in the waiting room or an examination room Until they feel the urge
to void.
▪ Adolescence Are usually knowledgeable and cooperative When providing a urine
sample. Explain what is needed and usually it’s a clean catch urine sample. Girls
 wipe perineum from front to back.

o 24-hour

▪ 24-hour urine samples are usually done to indicate protein or glucose within the
urine.
▪ For infants they will have a bag placed in the year and will be collected over 24-
hour period, you will change the bag each time the infant urinates.
▪ For older children that can void in the toilet, you have that child Urinate into a
collection device or urine hat. The parents are then instructed to call for the nurse
So that she can Dump the urine into a larger device.
▪ Important You must have the accurate date and time of the 24-hour urine.

o Clean-catch

 A clean catch is a method of collecting a urine sample to be tested. The clean-catch

urine method is used to prevent germs from the penis or vagina from getting into a
urine sample.
o Suprapubic aspiration

 This is withdrawal of the urine through the bladder of a child that’s unable to give A
clean catch or an infant that’s old not old enough.
 You want to make sure that the child is prepared for the procedure also you will need
to comfort the child because the size of the needle will be frightening, this procedure
may cause some pain, so we will have to restrain the child.

STEPS:
• EMLA cream- apply 30 minutes to an hour before the procedure.
• You want to have a sterile syringe and needle.
• Nurse will clean the anterior abdominal wall with anti-septic
• You want to block the urinary meatus with pressure with a glove finger to
 confine the urine in the bladder. (the nurses just plugging the whole).
• The needle will be inserted, just above the pubis into the bladder, then the
nurse will aspirate the urine into the syringe then withdraw.
▪ As the needle is inserted it can cause discomfort by bladder spasm, you want to
explain the necessity of the procedure to the parents and why this method is being
used.
▪ This procedure is not widely used, and it is considered a last resort.

o Catheterization

▪ Catheterization is usually most accomplished in infants and young children, this

procedure is as the same as in adults, you want to use distractions such as bubbles
imagery to distract the child. It is important to explain why you were
touching the child’s private areas.

❖ Stool specimens

 Stools are used to analyze for bacteria, blood, or viral infections. Children that are potty
trained can use a toilet seat with a collection device. Then the nurse will transfer the stool to
a collection cup. For children that are not toilet trained such as infants you just scrape the
stool from the diaper.
 You must ensure that you send the stool samples promptly to the lab, you don’t want the
store to dry out, if you do not send stool to the lab promptly, you’ll have to get a second
collection and the child will need at least 24 hours to produce another stool.

Nutritional Care
❖ Fluid intake and output
 For infants and children mother in the hospital or going to be on strict I&O ‘s, we must
ensure that they are getting enough fluids. If a child is on IV fluids you want to monitor the
pump, at the start of your shift you will have to come in and clear your pump. You’ll want to
monitor how much the child is eating and drinking the child will be voiding into a pan and
stool will be collected and measured.
 For infants the nurse will weigh the diapers

❖ Enteral feedings
  Also called nasogastric tube feedings always to provide nutrition to infants that are
unable to suck or tires too easy while sucking, or for an older child that cannot chew or
swallow.
 She doesn’t want us to get in depth with these She just wants us to know How it works.
 This is a tube that goes through the nose or the mouth, into the stomach. It provides the
nutrition Straight into the GI system.
❖ Gastrostomy tube feedings

 These are inserted under general anesthesia, through the abdominal puncture site,
into the stomach. These are for children who cannot swallow or have esophageal
problems or need long term Internal feeding.

❖ Total parental nutrition (TPN)

 Administered through IV, this has become an important Therapy for children who
have GI illnesses but don’t let them absorb their chloric or fluid, for infants that have respiratory
illnesses that make the infant too tired to suck.

❖ Elimination
o Enemas

 Rarely used in children, unless they have a fecal impaction, Hirschsprung’s disease, for
part of preparation for surgery such as colonoscopy, you could also have had a barium
enema for diagnostic testing, you will want to give a very detailed explanation of what
the child will experience, you need to be mindful of the size of the child in the size of the
enema you will be using.
 Infants you will use less than 250 mL, you want to make sure you use a small soft
catheter 10 to 12 French. In place of an intimate tip This helps to prevent rectal
trauma.
 Preschooler Will be 250 to 300 mL
 School age child will be 300 to 500 mL
 Adolescence will be 500 mL
 We will always ensure that we lubricate the small soft catheter with a water-soluble
lubricant and only insert Only 2 to 3 inches in children, only insert one inch for infants.
  If using an enema bag, you will want to hold The bag one foot above the sigmoid
colon no more than 12 to 15 inches up from the bed.
 You will need to control the rate that which it flows (FLOW NEEDS TO BE
SLOWLY)
 Infants and children’s ages 3 to 4 can’t retain the solution, the nurse will need to hold the
that buttock together.
 If place in the pan it will need to be padded to prevent injury to the child.
 Late school age children Can retain the solution for about 5 to 10 minutes.
 For these children you want to make sure that the bathroom is available or a bed pan.

o Ostomy care

 In newborns this is usually created to relieve bowel obstruction from ileal

atresia, necrotizing enterocolitis, or imperforated anus.
 For older children could be from conditions such as, inflammatory bowel disease,
Crohn’s disease, and ulcerative colitis.
 The biggest most important thing is we want to do for ostomy care is to preserve the skin
and provide good hygiene. Stool is acidic, so we will need to preserve the abdominal
skin. Keep it clean! Take care of an ostomy is the same as an adult, you have to take an
account the child developmental stage So educating the parents will be essential for
younger children…assist child in caring for ostomy.

NURSING DIAGNOSIS
❖ Fear related to new and strange surroundings of the procedure
room related to anticipatory pain
❖ Pain related to a lumbar puncture procedure
❖ Deficient knowledge related to the technique for 24-hour urine collection
❖ Deficient diversionary activity related to hospitalization and lengthy procedures
❖ Imbalanced nutrition, less than body requirements, related to need for food restriction pre-
procedure and post procedure
❖ Risk of injury related to need for intrusive procedures

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