Nursing Interventions for Pediatric Patients

Pediatric Variations of Nursing Interventions

• The goal when preparing children for procedures is to decrease anxiety, promote cooperation and support coping skills.
• Psychological preparation should include age-specific guidelines based on developmental characteristics.
• It is important to establish trust, provide support, ensure parental presence, and provide explanation to the child before procedures.
• When performing procedures, expect success, involve the child, provide distraction, encourage expression of feelings, provide positive support, use play, and prepare the family.
• Goal when positioning for a procedure is to minimize movement and discomfort.
• Provide an explanation and simple guidance prior to the procedure and restraint if needed, with analgesia and/or sedation.

Specimen Collection

• For urine collection, clean-catch is an option versus sterile collection, and a 24-hour collection with collection bags may be used.
• Blood samples can be collected via finger or heel stick, or through indwelling catheters.
• Respiratory secretions may be collected via sputum and nasal washings, or swabs (nasopharyngeal or throat).

Medication Administration

• Medication dosage is determined based on kilogram of body weight or body surface area (BSA)
• Identification and checking the dosage is important before preparing the family and child for medication administration.
• Oral medications may be administered via syringe or medicine spoon in a semi-reclining position.
• Intramuscular injections should be given at appropriate site to a limit of 0.5-1 mL, using pain reducing measures.
• Subcutaneous and intradermal injections should be given with 26-30 gauge needles to a limit of 0.5ml.
• Intravenous routes require checking the site and may utilize syringe pumps.
• Other administration routes include Rectal, and Optic, otic, and nasal (drops and ointments), using techniques to gain cooperation while considering infection control.

IV Devices

• IV devices include peripheral lock, heparin lock, and saline lock.
• Central venous access devices include short-term non-tunneled catheters, long-term tunneled catheters, and implanted infusion ports.
• Peripherally inserted central catheters (PICCs) are also used

Management of Peripheral IV Lines (PIVs)

• Securing and protecting PIVs is important, as well as knowing when to remove them.
• Complications of PIV lines include infiltration and extravasation.

Measurement of Intake and Output

• Accurate measurement is essential; fluids should be measured using a diaper-weighing technique where approximately 1 g of wet diaper weight equals 1 ml of urine.
• Special needs should be considered for children who are receiving nothing by mouth (NPO).

Alternative Feeding Techniques

• Alternative Feeding Techniques include Gavage feedings through nasogastric or orogastric tubes, Gastrostomy tube feedings, Duodenum or jejunostomy feedings, and may be continuous-drip or intermittent (bolus) feedings.
• During alternative feeds, the head should be elevated, and the child is sitting or lying on the right side and a pacifier may be used.
• A quiet, calm environment and consistent feeding techniques are important.

Parenteral Feedings

• Parenteral Feedings provide nutrition through a filtered central IV route, including total parenteral nutrition (TPN) and lipid infusion.
• Nursing responsibilities include checking correct fluid, monitoring continuous infusion using a pump, monitoring IV site and dressing, general assessment I&O, laboratory values, and family teaching.

Procedures Related to Elimination

• Procedures Related to Elimination include Enemas, with purpose and techniques (age and weight appropriate).
• Also used are Isotonic solutions, Polyethylene glycol-electrolyte lavage solution, Ostomy management (purpose/techniques), Skin and stoma care, and Family teaching and home care.

Child with Musculoskeletal or Articular Dysfunction

• Soft tissue injury includes injuries to muscles, ligaments, and tendons, common causes of trauma are sports injuries and mishaps during play.
• A contusion (bruise) is damage to soft tissue that causes escape of blood into tissues (ecchymosis) resulting in black and blue discoloration.
• In addition, swelling, pain, and disability may occur. Crush injuries are also a concern.
• Sprains involve trauma to a joint from a ligament partially or completely torn or stretched by force (Scale of 1 -4), and may have associated damage to blood vessels, muscles, tendons, and nerves.
• Presence of joint laxity indicates severity with rapid onset of swelling with disability.
• Strains are microscopic tears to a musculotendinous unit, swollen and painful to the touch, and are generally incurred over time

Therapeutic Management of Soft Tissue Injuries

• Therapeutic Management includes Rest, ice, compression, and elevation (RICE).
• Also includes ICES – ice, compression, elevation and support (splint), Rest the injured part, and Ice immediately (maximum 30 minutes at a time)
• Expect blood vessels to shrink with a Rebound effect.
• Wet elastic bandage for compression, elevation of the extremity, and Immobilization and support (casts or splints). Surgical intervention may be required

Fractures

• Fractures are a common injury in children, but they heal faster and better, so children require less time for immobilization.
• Methods of treatment are different in pediatrics than in older adult population, and they are rare in infants, except with motor vehicle crashes or falls.
• Epiphyseal plate is the weakest point of long bones, frequent site of damage during trauma, and may affect future bone growth.
• Fractures to this area can have detrimental effects, and Treatment may include open reduction and internal fixation to prevent growth disturbances with a splint area.

Types of Fractures

• Plastic deformation occurs when the bone is bent but not broken, and a flexible bone can be bent 45 degrees or more prior to breaking and straighten slowly but not completely, producing some deformity but without the angulation.
• Buckle, or torus, fracture is produced by compression of the porous bone, which appears as a raised or bulging projection at the fracture site.
• Greenstick fracture happens when a bone is angulated beyond the limits of bending, where the compressed side bends and the tension side breaks, causing an incomplete fracture.
• Complete fracture divides the bone fragments, but these fragments often remain attached by a periosteal hinge.
• Clinical Manifestations of Fracture are Generalized swelling, Pain or tenderness, Deformity, Diminished functional use, with May have bruising, severe muscular rigidity, crepitus.

Nursing Management: Fractures

• Check for hemorrhage in patients with fractures, and if the child is alert and has no hemorrhage, nursing interventions are directed towards calming and reassuring the child and parents.
• The history about how the injury happened is needed so support and mobilize the injury.
• Assess Pain → PQRST, check pulse on affected extremity, and Assess the extent of injury – the 6 P’s (Pain, Pulse, Pallor, Paresthesia, Paralysis, and Pressure)
• Cast application techniques involves Explaining procedure, Educating family about process, Educating the child at their developmental age, Showing all options to them- and letting them pick their color.
• Use distraction methods, Turn on cartoons, Read to them and Assess extremities for Risk for decreased circulation before the cast is applied.
• Hip spica (plater) cast can take 24-48 hours to dry, and Synthetic cast takes 5-20 mins to dry. When moving affected extremity, never use your fingers
• Never use a blow dryer to dry it faster, and use a fan instead.

The Child in a Cast

• The extremity may continue to swell to the extent that the cast becomes a tourniquet.
• You have to know to check for hot spots because A hot spot can mean infection
• Assess circulation status by assessing 6 P's and Check for compartment syndrome.
• During this stage Signs of compartment syndrome include pain, pulselessness, pallor, paresthesia, paralysis, pressure.

Cast Care

• When moving affected extremity, never use your fingers (Uneven pressure when it's not fully dry).
• Don't use a blow dryer but use a fan, and Look for hot spots.
• Check circulation status → assess 6 P's by checking for compartment syndrome.
• To properly care for an individuals cast, you must Keep environment safe, by making sure to Teach parents to check circulation, remove tripping hazards (pets), and teach them how to use assistive devices.
• After care include specially designed car seats and restraints being available, making sure to Teach them to not put things inside the cast.

Congenital Defects

• Skin care is vital because the Skin under the cast might look different; just make sure to Not peel skin or shave.
• Congenital conditions included Developmental dysplasia of the hip (DDH), Congenital clubfoot, Metatarsus adductus (varus), Osteogenesis Imperfecta, Slipped Capital Femoral Epiphysis, and Idiopathic Scoliosis

Developmental Dysplasia of the Hip (DDH)

• Known formally as congenital hip dysplasia or congenital dislocation of the hip, it can cause Abnormal development of hip during utero, infancy, or childhood.
• Sign's in infants, who are younger than 4 weeks old include Shortened limb on affected side, Restricted abduction of hip on affected side, Unequal gluteal folds when infant prone, or Positive ortolani test.
• In older infants and child's, you can identify this defects by seeing Affected leg shorter than the other, Telescoping or piston mobility of joint, or Positive Barlow test.
• Other Signs of DDH include if The child walks you and Marked lordosis.

Therapeutic Management: DDH

• With this condition, Importance of early intervention is always vital because the Longer treatment is delayed, more severe the deformity.
• This will start off with a Newborn to age 6 months, and go to surgical intervention if the child gets older.
• You can use Pavlik harness for abduction of hip, to allow time for the acetabular roof to grow, but if this treatment has been delayed, you have to do operative reduction, tenotomy, or osteotomy.

Nursing Management: DDH

• Always Identify early signs of DDH and Teach parents to apply and maintain reduction device.
• The child may has to wear this device for 22-24 hours/day or Never take device off if baby never comes off or can come off for bath time.
• Important care tips are to check skin under straps at least 2-3 times a day, massage healthy skin at least once a day to increase circulation, don't apply any lotions or powders underneath the straps, and make sure you don't adjust the device.

Congenital Clubfoot

• Congenital Clubfoot, is a deformity of the ankle and foot, that causes for different ankle and foot deformities.
• This defects can be mild, postural, true clubfoot, and occurs in boys twice as often as girls.
• This defect is associated with an increased incidence of hip dysplasia (DDH); and has to be detected prenatally.

Congenital Clubfoot Management

• For management of clubfoot you need to use serial casting with aLong leg cast, and must maintain foot in position and use a Heel cord tenotomy.
• You also have to maintain use of Browne splint and do weekly manipulation and cast.
• Nursing care tips involves checking skin daily, reinforcing a plan and clarifying everything, and telling them to encourage normal growth.

Metatarsus Adductus

• Metatarsus Adductus. also know as Metatarsus Varus, is most common congenital foot deformity that Angulates at tarsometatarsal joints.
• This causes "Pigeon toed” gait that is treated with the stretching of the heel .
• Nursing care management: Teach parents how to stretch forefoot and Instruct parents in cast care and observation of corrective device.

Osteogenesis Imperfecta (ΟΙ)

• Osteogenesis Imperfecta is a group of heterogeneous inherited disorders of connective tissue which that can be characterized by excessive fragility and bone defects.
• It may also cause some defective periosteal bone formation and reduced cortical thickness of bones.
• Other key indicator is Hyperextensibility of ligaments since one of the 12 described types is a Autosomal dominant inheritance.

Osteogenesis Imperfecta (ΟΙ) Cont...

• Another Type is Type II, which causes severe bone fragility with multiple fractures at birth and Type III, which leads to normal scherla but severe progressive deformities.
• For therapeutic care you must Provide Primarily supportive care with a Biphosphate therapy.

Slipped Capital Femoral Epiphysis

• Slipped Capital Femoral Epiphysis is can be treated with braces and splints.
• You have to May rule out OI if multiple fractures and and teach to caution with handling to prevent fractures.
• It is best to tell them that they need additional hands to help since the patient Cannot hold their legs while diapering may cause fractures