Nursing Care of A Child Undergoing Diagnostic Techniques and Other

Therapeutic Modalities

Objectives:
1. Assess children regarding their developmental stage and knowledge level before beginning
diagnostic or therapeutic procedures.
2. Identify common nursing interventions used in the health care of children to aid diagnosis and
therapy.
3. Evaluate expected outcomes for achievement and effectiveness of care.

NURSING RESPONSIBILITIES WITH DIAGNOSTIC AND THERAPEUTIC TECHNIQUES

● Helping obtained informed consent as needed
● Explaining the procedure to the child and his or her parents to be certain they are well
informed
● Scheduling the procedure
● Preparing the child physically and psychologically
● Obtaining equipment for the procedure
● Accompanying a child to a treatment room or hospital department where the procedure will
be performed
● Providing support during the procedure
● Ensuring adherence to standard precautions
● Assessing a child's response to the procedure
● Providing care to a child and specimens obtained once the procedure is completed
● Overseeing or cooperating with other health care disciplines to ensure the safety and efficacy
of all procedures.

Obtaining informed consent

Consent to perform a procedure must be obtained if a procedure carries any risk that would not be
present if it were not performed. For a parent to sign a consent from, he or she must be
knowledgeable about the content of the procedure and the risks of having or not having it
performed. Although obtaining consent is the physician's responsibility, seeing that it is obtained is
a nursing responsibility.
Acting as an advocate for a family if they do not understand the consent form, the procedure, or the
risks of the procedure is an important nursing role. Be certain the rights of emanciated minors are
respected and that in single parent families, the custodial parent is the one who has given the
permission.
Explaining procedure
● Be certain to use appropriate language when explaining procedures
● Be careful not to use words that might be confusing during explanation without defining
them.
● Try to associate the procedure with something with which the child is already familiar and
comfortable
● Try not to use the word "test" in explanations because school age children associate the word
"test" with a pass/fail situation. This can make them unduly worried after a procedure about
whether they have "passed" it
● If you are unfamillar with what a procedure entails, do not guess
● Encourage parents to stay with a child during most procedures, because they can be
extremely helpful in reducing a procedures threatening aspects.

Scheduling
Most diagnostic procedures are scheduled on a ambulatory basis.
● Try to arrange for the child to have time for meals and some free play time between
procedures
● If food or fluid must be restricted for procedures, monitor the child’s degree of discomfort
and physiologic need related to this; advocate as necessary for a time lapse between
examinations or improved coordination in scheduling to decrease the time spent without food
or fluid.

Preparing the child and family physicali and psychologically

Physical preparation varies depending on what procedure is to be
performed. For many procedures, especially those that may be painful, conscious sedation may be
used.
Conscious sedation refers to a depressed level of consciousness induced by intravenous
administration of a sedative such as midazolam in combination with a narcotic such as morphine
sulfate and perhaps a hypnotic such as propofol.
● About 60 mins before the procedure the children may be given oral chloral hydrate both to
relieve apprehension and make them feel sleepy.
● While under conscious sedation children able to maintain their ability to breathe
independently and also respond appropriately to verbal commands such as to lift their head.
They feel no pain, however, because of the analgesic administered.
● Before conscious sedation is begun, emergency equipment including respiratory and
pharmacologic measures must be readily available. The child's level of consciousness and
 ability to respond, heart rate, RR, blood pressure and oxygen saturation are monitored during
the procedure.
● Using conscious sedation is very effective to allow children to accept a potentially painful
procedure emotionally and physically.

Accompanying the child

If a procedure will be done at a different site from the primary care clinic or hospital unit with which
a child' is comfortable, ideally a nurse who the child knows should accompany the child to the
department and remain with the child for the procedure, or at least until the child has met a primary
person who will be with him or her during the assessment.

Modifying procedures according to the child’s age and developmental stage

Infant- the number of painful or uncomfortable procedures done on infants should be kept to a
minimum to avoid interfering with an infant's developing sense of trust.
– Help parents understand why these procedures are being limited so they do not think their
infant's care is being compromised by so few diagnostic procedures.

Toddler and preschooler- give children at this age short explanations of what to expect, close to
the time of the procedure so that little time can be spent worrying over it.

School age and adolescent- they are interested in the theory and reason for procedures. Do not be
misled into thinking a child age would not appreciate an explanation or a comforting hand on
shoulder during a procedure.

Promote safety during procedure

Safety is important component of all patient care. Children’s immaturity, which makes them unable
to form mature judgements, leaves them vulnerable to harm unless their caretakers give specal
consideration to promoting safety

Use of restrain
The purpose of restrain is to keep the child safe during procedure, restraints must always be used
with care, because if improperly applied or used, they can cause more harm than help.
– Check restraint every 15mins to see if they are not occluding circulation
– Remove the restraint every hour so the body part can be exercised.
Providing care after procedure
● After procedure, assess how well a child reacted to the procedure by both observation and
history. Allowing children to explain what happened helps them retrace the procedure in their
mind so they can conquer their fear of it.
● Be certain tissue samples obtained after procedure such as bone marrow aspiration are sent
to the proper department for analysis as soon as possible
● Guard against specimens being dropped or improperly labeled
● If conscious sedation was used, be sure children are wake before they are discharge home or
return to an inpatient hospital unit.

– Protective measures to limit movement may be necessary for restraining children in the
health care setting. They can be a short-term restraint to faclitate examination and minimize
the child's discomfort during special tests, procedures, and specimen collections. Restraints
can also be used for a longer period of time to maintain the childs safety and protection from
injury.

General Considerations
● Protective devices should be used only when necessary and after all other considerations are
exhausted, never as a substitute for careful observation of the child.
● Cannot be used on a continuous basis without an order. Continuous use requires justification
and full documentation of the type of restraint used, reason for use, and the effectiveness of
the restart used. Ongoing monitoring, documentation, and renewal of the order, with the
length of time the restraint will be in place, are required.
● The reason for using the protective device should be explained lo the child and parents to
prevent misinterpretation and to ensure ther cooperation with the procedure. Children often
interpret restraints as punishment.
● Teach the child and family about specific devices they may be using in the hospital (ie, side
rails) and after discharge (ie, mitts, elbow restraints).
● Any protective device should be checked frequenty to make sure it is effective and is not
causing any ill side effects. It should be removed periodically to prevent skin irritation or
circulation impairment. Provide range of motion and skin care routinely.
● Do not cover an IV site with a restraint when possible.
● Protective devices should always be applied in a manner that maintains proper body
alignment and ensures the childs comfort.
● Any protective device that requires attachment to the child’s bed should be secured to the
bed springs or frame, never the mattress or side rails. This allows the side rails to be adjusted
without removing the restraint or injuring the child’s extremity.
 ● Any require knots should be tied in a manner that permits their quick release. This is a safety
precaution.
● When a child must be immobilized, an attempt should be made to replace the lost activity
with another from of motion. For example, although restrained, a child can be moved in a
stroller, wheelchair, or in bed. When arms are restrained, the child may be allowed to play
kicking games. Water play, mirrors , body games, and blowing bubbles are helpful
replacements.
● Restraints should be removed as soon as the child is no longer considered a danger to self or
others or when medical devices are no longer in place.

Common diagnostic procedures

1. Electrical impulse studies- are those that include electrical conduction children have special
preparation for studies such electrocardiograms or electroencephalogram because they have
warned not to play with electric wires and may worry about being burned or electrocuted. They can
be reassured that the electricity passes from their body to the machine not the other way around.
Electrodes are attached to the body by paste, which is easily removable. If possible give the child a
portion of the test strip afterward as a souvenir.

2. X ray studies- are used to inspect internal body tissue. These range from the simple x ray to the
more complicated computed tomography scan or dye contrast study.
Flat plate x rays- are used both to diagnose illness and check
them to the x ray department, you will not allowed to stay in the room while the picture is actually
taken. If it is necessary for you to remain the room to restrain a child, do not do this without lead
apron and lead glove protection.

Dye contrast studies- visualize a body cavity some type of radiopaque dye may be swallowed or
injected into the cavity and then examined on x ray. Barium contrast studies, for example, are used
to observe the outline of the Gl tract. Barium may be swallowed to outline the upper Gl tract or
instilled by enema to outline the lower portion. Caution the child that barium even if flavored does
not taste terribly good.

3. Computed tomography- is an x ray procedure in which many views of an organ or body part are
obtained to represent what the organ would look like if it were cut into thin slices. The procedure
may require injection of an iodine-based contrast medium. The machinery is complex, large and
potentially frightening. Children must lie still during the long procedure to avoid creating shadows
on the film. To help them still for an extended period, they may be given a sedative to make them
sleep. You can assure parents that although the radiation exposue from CT scans occurs over long
period, such low doses are used the actual exposure is less than during a regular x ray.

4. Magnetic Resonance Imaging- combines a magnetic field, radiofrequency and computer

technology to produce diagnostic images to aid in the diagnosis of disorders. The child lies on a
moving pallet that is pushed into the core of the machine-the magnet. When magnetic field
surrounding the child is turned on, it causes tissue atoms to line up in a parallel fashion.

5. Ultrasound -is a painless procedure in which pictures of internal tissue and organs are produced
by sound waves, it is noninvasive, children accept ultrasound easily and may even enjoy watching
the oscilloscope screen during the procedure. The transducer that is used on the body surface to
pick up internal images can be compared to a television camera.
– Explain to parents that ultrasound is not a x ray and appear to have no long term effects, so it
can be repeated over and over for serial determination:
– Tell the child that the gel will be applied to the skin over the body part to be studied to aid
sound conduction. The gel feel cool and sticky

6. Nuclear medicine studies-

Radiopharmaceuticals are radioactive combined substances that when given orally or by injection,
flow to designated body organs.
Assure parents that the dose of radiation is no greater than that use for a diagnostic x ray.

Direct visualization procedure

Endoscopy- used as an emergency measure to remove objects such as quarters or safety pins
swallowed by children. The child is NPO for 4 hours before the procedure. They may need sedative
so they can lie quietly
● After the procedure monitor for signs of edema to be not interfer with vital functioning such
as respiration
● Check for gag reflex before offering any fluid

Bronchoscopy- is the direct visualization of the larynx, trachea, and bronchi. It is used to children
who have aspirated a foreign object such as peanut or to take culture and biopsy.
● Before procedure a child is given with atropine by injection to reduce bronchial secretions
and to encourage bronchial relaxation
 ● A sedative is administered
● Observe respiratory function and airway for at east 4 hours after the procedure
● Assess gag reflex before offering fluid
● An ice bag applied to the neck to help relieve edema

Colonoscopy- is endoscopic exam of the large intestine with a flexible fiberscope inserted through
the anus and advanced as far as the ileocecal valve. Air is then infused to expand the bowel walls.
The technique allows the colon walls to be visualized, photographs can be taken for analysis.
– Before the procedure children are given a clear liquid diet for 24 hours
– They are given isotonic saline laxative that causes diarrhea so the bowel is clean
– Children may pass a great deal of flatus in the first 12 hours because of air introduced during
the procedure

Aspiration studies- removal of body fluid such as lumbar puncture and bone marrow aspiration. A
child may need sedative so he or she can lie quietly.

COLLECTING SPECIMENS FOR ANALYSIS

Blood specimen- when feasible, blood specimen should always be obtained away from a child's
bed. Applying band-aid afterward to cover the needle site provides physical as well as
psychological support.

Venipuncture- the superficial vein of the dorsal surface of the hand or the antecubital fossa. In few
instances, the jugular or femoral vein can also be used. To reduce pain use distraction techniques
such as uing toys with flushing lights, blowing bubbles, or playing a game for toddlers and asking
distraction questions or plaving a movie for school age children

Capillary puncture- are often obtained for glucose and hematocrit determinations. Apply an
anesthetic cream before the procedure to reduce discomfort if needed: however, be careful when
applying this to a finger that the child doesn't lick this off and anesthetize their tongue or throat.
Technique for finger or heel capillary puncture

Purpose: to obtain blood sample from a peripheral capillary.

Procedure:
1. Wash your hands; identify child; explain the procedure.
2. Assess status of puncture site.
3. Analyze appropriateness of procedure, adjust plan to individual circumstances
4. Plan and give health teaching and preparation information as necessary
5. Assemble necessary equipment: gloves, alcohol swab, lancet, collecting capillary blood tube,
dry compress or cotton ball, adhesive bandage
6. Assess the temperature of the selected site. Fingertips and heels must be warm. Warm by
holding finger or heel in your hand for a moment or two. Warming heels or fingers by
immersing them in warm water or covering with a warm compress is not advised.
7. Select the exact puncture site: sides of tip of finger; right or left of medial artery of heel.
Allow child to choose finger if appropriate.
8. Apply gloves. Swab site with alcohol and allow to dry, Puncture with a quick thrusting
 8.
movement; wipe away first drop of blood with dry cotton ball.
9. Hold heel or finger lower than proximal extremity; touch capilary tube to blood drop and tip
to encourage flow. Do not squeeze tissue around bandage.
10. After filling required number of blood tubes, apply tiny compress to site; apply adhesive
bandage.
11. Label specimen appropriately and send to proper laboratory for analysis.
12. Evaluate effectiveness; efficiency; cost safety and comfort aspects of procedure; record
procedure and child's reaction.

Obtaining urine specimen

Urine may be collected with usual voiding, after the external meatus has been cleaned. By
catheterization or suprapubic aspiration.
Routine analysis- requires only a single voided specimen. The specimen will then be analyzed for
appearance, glucose, specific gravity, and microscopic analysis. Specimens must always be
collected in sterile containers to prevent contamination.
– Collecting device must be attached to the genitalia to collect urine.
– Wash the perineum to remove any fecal matter and then rinse with water and dry the site
(girls), wash the penis and rinse and thoroughly dry the same way (boys)
– Maintain dry skin that is free from powder, lotions and oils
– Offer the child something to drink to encourage voiding.

Preschooler and school age child-

– Provide a potty chair if one is available if not put a urine collection cap device on a toilet.
– Offer the child a glass of water or other fluid and ask apparent to reinforce the request to void
so that the child knows a parent approves.

Adolescent- are usually knowledgeable and cooperative about providing urine specimen.
– Adolescent girl may be embarrassed to mention they are menstruating so be sure to ask
about this before she voids, To prevent having a urine specimen contaminated by menstrual
blood. Ask the girl to wash her perineum well with soap and water and rinse and dry it to
remove menstrual blood.

24 hour urine specimen- to determine how much of a substance is excreted during a full day
– Ask the child to void and discard so that a specific time for the ensuing collection is known.
– Record the start of the collection period as the time of the discarded urine. Save all urine
voided for the next 24 hours and place it in one collection bottle.
– Record the time of the collection as being from the time of the discarded urine to the final
specimen added to the collection.
– To keep the bacterial count to a minimum, 24 hour collection containers are generally kept on
ice; after each voiding, pour the new specimen into the larger container which is kept
 refrigerated for the 24 hour period or until it can be transported to the laboratory for analysis.

Clean catch urine-is ordered when urine is needed for urinalysis and culture. The technique for
obtaining a clean-catch urine specimen from older child is the same as for the adult.
– To collect specimen from a young child, ask the child to void. During the child's voiding ask
the parent to collect a "midstream" sample into a sterile container
Suprapubic aspiration-withdrawal of urine from the bladder of a child who is not old enough or in
some other way cannot cooperate enough so that a clean-catch or catheterized specimen can be
obtained. It is done by inserting sterile needle into the bladder through anterior wall of the
abdomen.

Steps of suprapubic aspiration

1. Apply EMLA (Eutectic mixture of local anesthesia) cream to lessen the discomfort 30
minutes -1 hour before the procedure
2. Secure sterile syringe and needle and designated antiseptic solution
3. Clean the anterior abdominal wall with the antiseptic
4. Block the urinary meatus by pressure from a gloved finger to confine urine in bladder
5. Insert the needle on the syringe just above the pubis into the bladder
6. Aspirate urine through the needle into the syringe then withdraw the syringe and needle
7. Comfort the infant or child afterward because the sight of the needle is frightening, it may
cause some pain, and some restraint is necesry

Catheterization- infants and young children small feeding tube (#5 or #8) is used instead of urinary
catheter because such a thin tube passes readily through the meatus of even an infant

– Assess the urinary meatus for girls, for uncircumcise boys, gently retract the foreskin until the
urinary meatus is visualized.
– Explain to the parents how it is performed and why it is needed
– Distraction technique such as blowing bubbles or imagery may help the child to relax
– Caution children that the catheter will sting for an instant as it is inserted and they will have to
lie stil until the urine specimen is obtained.
– Offer support and praise to the child
– Preschool boys may need assurance that the procedure has no long-term consequences to
reduce their fear of castration.

Obtaining stool specimen

Stool specimen are frequently obtained to be analyzed for blood or ova and parasites. Be certain
stool specimens are sent to the laboratory promptly so they do not dry and have to be collected a
second time. If the specimen is for ova and parasites, see that it arrives in the laboratory in less
than 1 hour. Do not refrigerate ova and paraste specimens because destroys organisms to be
analyzed.
– Obtain specimen from children who are toilet trained by asking them to use a potty seat or by
placing a collector cap device on a toilet. Be certain you know the word the child uses for
stool
– To obtain from a child who is not toilet trained, scrape stool from a diaper using tongue
blades and place it in a stool collection cup.

Measuring Intake and Output

Fluid is essential element of nutrition because of the water supplied and because it can also be a
source of calories and vitamins.

Intake-
– Infants who are formula-fed is simply a matter of estimating the kind and amount of fluids
that were swallowed. For breast-fed infants is merely recorded as "breast-fed". If it is
necessary to estimate the amount more loosely than this, an infant can be weighed before
and after feeding
– with preschooler be certain to record fluids ingested during snacks as well as meals. Remind
them that soup, flavored ice such as popsicles and sherbet are liquids and should be
counted.

Output-
– Diapers can be readily used as a method of measuring urine output
– Weigh diaper before it is placed on an infant and record this weight conspicuously. Reweigh
the diaper after it is wet and subtract the difference to determine the amount of urine
present.
– To separate urine from bowel movements, teach older children to void first before trying to
move their bowels.

Measurements of Vital signs

Vital signs for children consists of temperature, pulse, respiration rate, blood pressure and pain
assessment. All of these need to be recorded both conscientiously and with knowledge of the
underlying condition so they can be analyzed meaningfully.

Temperature- tympanic membrane temperature are ideal for assessment in children because they
register within 2 seconds and therefore cause less fear in a child.
For below 3 years old- pulling down the earlobe to straighten ear canal
Above 3 years old- pulling up the pinna of the child

Pulse rate- apical pulse is taken in children younger than 2 year because their radial pulse is too
faint to be palpated accurately, in infant, the point of maximum intensity, of the point on the chest
wall where the heartbeat can be heard most distinctly, is just above the outside of the left nipple.

Respiratory rate- infants tend to breathe with abdominal muscles, therefore, it is accurate to take
respirations by counting movements of the abdomen as it is to count chest movements. Again, for
accuracy respirations should be counted for 1 full minute.

Blood pressure- included in the routine physical assessment of all children older than 3 years of
age. Be certain to pay attention to the pulse pressure, both unusually wide (more than 50mmHg)
and narrow (less than 10mmHg) ranges may suggests congenital heart disease.