Chapter 37

• Before performing procedures


  Carefully evaluate a child’s age and developmental stage as well as any special needs a child may have.
• Even the most common and painless procedures create a certain amount of stress for children and parents.
• Before initiating the procedure

  Assess a child’s level of anxiety associated with a procedure as well as the child’s knowledge concerning a technique.
• An important nursing goal is to perform procedures and complete interventions with the least amount of anxiety possible.

  1. Plan specific ways to prepare children in advance
  2. Apply the best communication techniques
• It is necessary to function in several roles simultaneously:

  1. organizing supplies
  2. performing (or assisting with) the procedure
  3. providing active support to the child and parents
  4. observing and then documenting the child’s reactions.
• Stress related to hospitalization occurs across the life span. A greater awareness regarding psychological trauma for children and their parents that can occur with hospitalization and that can undermine the child’s recovery is a major focus of research.
• Reducing the number of hospitalizations is likely to reduce the overall stress; however, when this cannot be accomplished, the next step is aimed at reducing the number of diagnostic or therapeutic procedures children have to undergo.
• The use of new information technology devices (NITDs) allows healthcare providers to engage, educate, and communicate with patients and families and reduce anxiety related to hospitalization.
• Informed consent is a process in which the healthcare provider discloses or explains a proposed medical treatment, along with the risk(s), benefit(s), and alternative(s) for that treatment.
• Informed consent is legally required and must be obtained before any procedure or treatment that has a risk of causing injury to the child is performed.
• Each procedure or treatment must have a documented consent..
• Although obtaining consent is the provider’s responsibility, ensuring 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.
• According to Katz and Webb (2016), informed consent is valid when the following criteria are met:

  • Disclosure of information to patients or their surrogates

  • Assessment of patient and surrogate understanding of the information and their capacity for medical decision making

  • Obtaining informed consent before treatments and interventions
• A minor who is emancipated by the state is considered to have the same legal rights as an adult and may consent to treatment.
• In emergent or life-threatening situations, when a legal guardian or parent is unavailable to consent, the Emergency Medical Treatment and Active Labor Act mandates that a medical screening examination and delivery of appropriate medical care for the pediatric patient are never withheld or delayed.
• When a legal guardian refuses to consent to medical care or transport that is necessary to save the child’s life, law enforcement may be needed.
• Obtaining assent to maintain the child's autonomy


  1. Helping the patient achieve a developmentally appropriate awareness of the nature of his or her condition

  2. Telling the patient what he or she can expect with tests and treatment(s)

  3. Making a clinical assessment of the patient's understanding of the situation and the factors influencing how he or she is responding (including whether there is inappropriate pressure to accept testing or therapy)

  4. Soliciting an expression of the patient's willingness to accept the proposed care
• Assent


  Obtained much like consent, to maintain the child's autonomy
• After any procedure, asking children to describe what sensations they experienced can help them work through possibly frightening situations (often called “debriefing”) and can also increase your knowledge of common procedures.
• As a general guide, before a procedure, a child needs a detailed description of what to expect, such as “I’ll clean your finger. You will feel a small pinprick.”
• Use age-appropriate language when explaining procedures and be careful not to use words that might be confusing during an explanation, such as “transducer” or “electrode,” without defining them in age-appropriate terms.
• Try to associate the procedure with something you know the child is already familiar and comfortable with, such as describing an X-ray machine as “a big camera.”
• Try not to use the word test in explanations because school-age children associate the word test with a pass/fail situation. Wondering if they “passed” a procedure can make them unduly worried afterward.
• If you are unfamiliar with what a procedure entails, do not guess the answers to a child’s questions because nothing is more confusing than being told two different versions of an answer to the same question.
• When possible, encourage parents to stay with their child during the procedure, if possible, as they can be extremely helpful in reducing the threatening aspects of a procedure.
• If a child is having more than one diagnostic procedure in a day, try to arrange for the child to have time for meals and some free play time between the procedures.
• Advocate as necessary for sufficient periods of time between examinations so a child can eat or for decreased time between procedures so the time spent without food or fluid is limited.
• In all instances, explain both the preparative and actual procedures and allow the child to ask questions because appropriate explanations aid in reducing anxiety and fear.
• Parental presence is essential when a child is undergoing a procedure because it reduces the child’s stress.
• Always use cart straps and side rails for safety because safety is a priority during all procedures performed on children.
• Children do well with diagnostic and evaluative procedures as long as they have adequate support from a familiar provider or parent with them. Try to provide support both verbally and nonverbally.
• It is important to 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.
• The number of painful or uncomfortable procedures done on infants should be kept to an absolute minimum to avoid interfering with an infant’s developing sense of trust.
• Always keep parents informed of what type of procedure the infant may need to undergo.
• Advocate for parents to remain during procedures to offer support.
• Infants become dehydrated quickly, so the time they can remain nothing by mouth (NPO) for procedures should not exceed 6 hours (4 hours for breast milk and 6 hours for formula.
• Give toddler and pre-schooler short explanations of what to expect close to the time of the procedure so that little time can be spent worrying.
• School-age children are concrete thinkers and so are interested in the theory and reason for procedures.
• Adolescents may project an air of maturity or sophistication beyond their years to remain in control of themselves in the face of frightening procedures.