Peds, part 6: Principles - Informed Consent, Medication Administration, Hospitalization, & Concept of Death
by Meris Shuwarger BSN, RN, CEN, TCRN December 20, 2021 Updated: December 07, 2022 7 min read
This article wraps up the principles of the pediatric nursing section, focusing on informed consent, medication administration, hospitalization, and how children of various stages of growth comprehend the concepts of illness and death.
The Pediatric Nursing series follows along with our Pediatric Nursing Flashcards, which are intended to help nurses and nursing students learn and retain information about caring for pediatric patients. The flashcards are a clear, complete study tool and a helpful reference for practicing RNs, PNs, and other medical professionals.
Informed consent is the formal authorization from the child’s parent or guardian for an invasive procedure or for participation in research. A minor may not give consent — consent must be obtained by someone who can weigh the benefits and the risks then legally provide their consent, which means a parent or legal guardian.
- Emergencies. For example, to preserve life or limb consent is not required. In this situation, it is assumed that any rational caregiver would give consent to preserve their child’s life. This is known as “implied consent.”
- Emancipated minors can give informed consent. An emancipated minor is a minor who has gone to the court and petitioned to be legally considered an adult. As such, they can consent for themselves because they are legally considered to be an adult.
- Mature minors (14 – 18 years old) can provide consent for limited conditions (for example, STI testing and treatment, contraception services, substance abuse help, mental health services). It is important to check the laws of the state. In some states, mature minors may be able to provide consent for some services but not others.
Assent is a child’s voluntary agreement to accept treatment or participate in research. But this does not mean they can accept that treatment or participate in research — a parent or guardian still makes the final decision (informed consent). For example, if a 13-year-old wants to start the HPV vaccine series, but their parents don’t want them to, they cannot receive the vaccination.
The moment the child turns 18, they may give their own informed consent.
Here are some best practices for administering oral medications to children.
Always use a calibrated device (dropper, syringe, medication cup) when measuring the amount of medicine to administer. These calibrated devices have the proper measurements noted on them.
Never use a kitchen teaspoon to give medicine, because this is not an accurate measurement device and the incorrect dose may be administered by mistake.
Always measure liquids at eye level for accuracy. This is due to the medication’s meniscus. Remember that perspective on the level of a liquid is going to change based on whether it is viewed from above, at, or below eye level. Always be at eye level to measure a dose of liquid medication.
Never call a medication “candy”!
Do not blow in a child’s face to “startle them into swallowing” as this puts them at risk for aspiration and choking.
If authorized by the provider, medication can be mixed with a small (1 tsp.) amount of liquid (e.g., formula or breast milk) or soft food (e.g., applesauce). Do not mix medication in a full baby bottle because it is difficult to gauge exactly how much of the medication a child gets if they don’t finish all of the contents in the bottle.
Flavorings may be available to make the medication more palatable. Check with the provider or pharmacist.
When medicating infants, hold them in a semi-upright position, gently press down on their chin to open their mouth, position the dropper or syringe on the side of the mouth (in the buccal pocket, between the cheek and the gum), then stroke the side of their neck to stimulate swallowing. That will allow the medicine to drip down their throat and make swallowing easier. It is important never to squirt anything down an infant’s throat, which would put them at risk for aspiration, choking, or vomiting. Note that for some medications, a special dosing nipple can be used.
Hospitalization of children
Kids love routine. And they love their day-to-day activities. When they are taken from their routine and put in a hospital environment, it is disruptive to their day-to-day lives, and it can have a bigger impact on them than it would on an adult.
These are some best practices for the nursing care of hospitalized children. Remember: it is important to meet kids where they are developmentally.
Encourage parental presence and participation
This is especially important for younger children. Kids will look for their mom or dad or their guardian to make sure that this is an okay place to be; they want that reassuring presence in the hospital.
Administer topical anesthetics before painful procedures
Administer topical anesthetics (e.g., EMLA, a topical lidocaine cream) and pre-procedural sedation medications before painful procedures as ordered. Note that EMLA cream should be applied 1 hour prior to the procedure and covered with occlusive dressing. For example, when preparing a child for surgery, the nurse will need to start an IV. For an adult, they may simply start the IV with a “Sorry, big pinch.” For a child, the process may be more intricate: a nurse enters the room; they indicate where they want to start the IV; they put the EMLA cream on the child’s hand and cover it up with a Tegaderm (transparent) dressing then leave the room; an hour later, they return and do the IV and the child feels no pain, nor, ideally, do they associate the IV as something “painful.”
Explain procedures using age-appropriate language
Rather than say, “I’m here to get your blood pressure,” which might frighten the child with the potentially scary words “blood” and “pressure,” a more age-appropriate thing to tell a child is, “I’m going to give your arm a big hug.” Children do not need to know medical terminology unless they are older and interested in that sort of thing.
Allow choices when possible
Anything that a child can have control over is going to be a benefit to how they perceive their hospitalization experience. For example, something as simple as a choice of juice: “Do you want orange juice or apple juice?” Don’t just give them the juice, let them choose.
Use therapeutic play techniques for younger children
In children’s hospitals, child-life specialists are trained how to use play and dolls and art and books — anything that will help a child understand what is going on — to explain things in a way that makes sense to the child and will best support them at their developmental age.
For example, for a younger child, use a doll to demonstrate procedures. Maybe put a cast on the doll’s arm that will look like the cast the child will get. Before a child receives a coronavirus vaccination, find a (needle-less) syringe and let the child touch it, feel it, play with it. Maybe take turns giving vaccines to their stuffed animals. This helps them to understand what is going to happen, and it will encourage them to express any fears and concerns about the actual procedure.
Allow children to touch medical equipment when possible
As in the example above, let the child get to know the syringe before they are administered a shot. Perhaps offer the child a closer look at a stethoscope: “Here’s my stethoscope. I’m going to use it to listen to your chest and your tummy. Do you want to touch it before we start?” This way, they can see that the device is not scary, and it’s not going to hurt them.
Encourage peer interaction for school-age children and adolescents
As noted, when a child is taken out of their school environment and away from their school-age peers this can be disruptive. In terms of their Erikson stage (“Industry vs. Inferiority”), at this age a child’s sense of identity could be harmed. At this stage in their development they are thinking: “This is who I am, and this is how I see myself. I love school and you’ve just taken me out of it.” One way to alleviate this potential distress is if the school sends cards so the child may feel as if they are still involved. Let them do their schoolwork in the hospital.
Perform painful procedures in a different room
Perform painful procedures in a treatment room so that the child’s room can remain a relatively pain-free site. The child’s hospital room should be a therapeutic environment, not one that they fear. So if it is time to start an IV, or put a Foley catheter in, or do any kind of painful or invasive procedure, we should take the child to a treatment room.
Concept of illness and death for children
The way children understand the concepts of illness and death vary based on their age, similar to how their thought process varies as they grow up.
Infants and toddlers
Infants and toddlers don’t really have a concept of death. They may experience separation anxiety, however, so it is important to stick to their familiar home routine as much as possible.
Preschoolers have the (amazing) capability for magical thinking. That may lead them to see death as temporary. On the other hand, because of their ability for magical thinking, they could also view death or illness as something that is their fault: “I caused this. My thoughts or actions caused this.” Magical thinking can be a positive and a negative in this instance.
Preschoolers may also exhibit regression. This is very common for any sort of stressor for kids this age. For instance, a fully toilet-trained child might suddenly begin wetting the bed (enuresis — soiling the bed at night).
Around the age of six years, a child starts to understand that death is permanent. This may lead them to exhibit disruptive behavior — if someone close to them has died, or if they’re experiencing an illness in their own life, they could act out as a way of processing things.
Adolescents have an adult understanding of illness and death. Remember that at this point in their development, their body image is extremely important — experiencing an illness or injury could disrupt the way they see their body image, which could be disruptive to their growth and development. No matter the situation, encourage the adolescent to express their thoughts and concerns.
It is also very important to maintain contact with peers (see, again, Erikson and his description of the adolescent stage: Identity vs. Role Confusion). If an adolescent is hospitalized, allow friends to come visit if it’s appropriate. Encourage that support so that the young person still feels like they have a role in their peer group.
Hi, I'm Meris with Level Up RN, and in this video, we're going to be wrapping up the principles of pediatric nursing section. So this is the last video in that playlist, but there is a lot more peds content for you coming up. So I'm going to be following along using our pediatric nursing flashcards. These are available on our website leveluprn.com. If you already have a set of your own, I would invite you to follow along with me. And if you don't have a set for yourself, run, don't walk to the website and grab one because I promise you it's going to help you a lot in your classes. All right, let's get started. So first up, we're going to be talking about the difference between consent and assent. So when we talk about informed consent, what this means is that we have gotten formal authorization from a child's caregiver, from their parent or their guardian, for an invasive procedure or participation in research. So this is what you typically think of when we talk about getting consent from a patient, right? When we have someone who is a minor, the only person who can give informed consent, who can weigh the benefits and the risks, and legally provide their consent is going to be the parent or guardian, the legal guardian. So examples of some exceptions, though, because there's an exception to every rule, including this one. So in the case of an emergency such as to preserve life or limb, you don't have to get consent from a parent, right. We have what we call implied consent. It is assumed that any rational caregiver would give consent to preserve their child's life. So in the case of a true emergency, like, let's say, the child was in a car crash on a bus, right, a school bus, and the parents or caregivers are not there. We're still going to treat the child, right. We're still going to do what we can to prevent loss of life or limb because of implied consent. Now there are also some cases where minors can give their own consent. An emancipated minor, emancipated, meaning freed-- so this is a minor who has gone to the court and petitioned them to be legally considered an adult. An emancipated minor can consent for themselves because they are legally considered to be an adult, so the same rules don't apply in this instance. And then there's some other very specific instances. So mature minors, meaning 14 to 18 years old, they can provide consent for a few limited conditions: STI testing and treatment; contraception services; substance abuse treatment, so seeking treatment for substance abuse itself; and some mental health services. In those instances, mature minors over the age of 14 can provide their own consent. One thing I want to say here is check the laws of your state. In your state, mature minors may be able to provide consent for other services compared to other states, but that's all going to be up to your specific state and their laws. So it's important to note those, especially if you're practicing with children as a nurse. Now, what is assent? So assent is what kids can do. They can give their voluntary agreement to accept treatment or participate in research. So in this instance, though, the parents still make the final decision. So, for instance, maybe the child wants to participate in something. They want to have some sort of a treatment, but the parent doesn't. The parent gets the final say. A good example of this would be vaccination. If a
13-year-old wants to start the HPV vaccine series, but their parents don't want them to have that, they cannot get that, right. That's so going to be left up to the informed consent of the parent. Now, the moment they turn 18, that child can do whatever they want and give their own informed consent.
Okay, moving on, we're going to talk about medication administration, specifically best practices for administering oral medications to children. So we have a lot of information here and some big bold red text. And here's the most important stuff to know when you are giving an oral medicine to a child - this is really good family teaching - you need to use a calibrated device, meaning that it has the proper measurements on it. So when we say give a teaspoon of this liquid, really, what that means is give five milliliters of this liquid, don't actually go and get a teaspoon like a kitchen teaspoon. That's not a measuring device, right? That's not going to be accurate. We would want to use like a measuring teaspoon or, better yet, a syringe where we can say, give five milliliters of this liquid instead. So a dropper, a syringe, a medication cup, all of those are going to be calibrated and that's what we should be using. Another thing is that we need to measure liquids at eye level. That has to do with the meniscus. Remember that my perspective on where the level of a liquid is, is going to change based on if I am above, at, or below eye level. So we want to get down, be at eye level when we measure with that liquid out. We don't call medication candy. We don't blow in an infant's face. This used to be the best practice we would say, to blow in their face to startle them into swallowing. But it's actually a risk factor for choking. And then if we need to, medication can be mixed with a small amount of liquid like formula or breast milk, or even a solid food like applesauce, a small amount like a teaspoon or a tablespoon of it. We are not mixing this in a whole bottle, right, because then it's really difficult to gauge how much of that a child got if they only drank half of that bottle or something similar. So we would never mix it in a whole bottle or a whole serving of applesauce. Just about one teaspoon of that. Flavorings can be available. That's going to be up to the pharmacy itself, so check with them. But with infants, this is so important. If you're giving a liquid medication, you might think that you should just kind of squirt it down their throats, like down their tongue or something along that line. But really, you want to sit them upright and you want to put that syringe along the side of the mouth in this buccal pocket here, right, in between the cheek and the gum. It's going to drip down their throat here. They're going to be able to swallow it. But it's not going to just like shoot down the back of their throat, because that would put them at risk for aspiration, for choking, for vomiting, triggering that gag reflex. We don't want to do that.
All right. Moving on to hospitalizations. So these are some best practices for the nursing care of hospitalized children. Kids love routine. They love their day-to-day activities, right. And when we take them from that routine and put them in a hospital environment, it can be really disruptive to their day-to-day lives and can have a bigger impact on them than it would on an adult. So we have some best practices here. All right. We want parental presence as much as possible, especially for those younger kids, because they're going to look for mom or dad or whoever their guardian is to make sure that this is an okay place to be, right. So we love that we want to have that reassuring presence in the hospital. We also want to give topical anesthetics before painful procedures. So typically this is EMLA cream, E-M-L-A, EMLA cream, which is like a topical lidocaine cream. So I remember vividly being in the hospital before having surgery when I was nine years old, I think. And they needed to start an IV. Well, for me as an adult, they would just start the IV, right. "Sorry, big pinch." Start the IV. As a kid, they came in, they saw where they wanted to start the IV, they put the EMLA cream on my hand and covered it up with a Tegaderm dressing. They then left the room. Okay, cool. We didn't do anything that hurts. It's just sitting here. I remember looking at it, kind of poking it. It looked like a big blister kind of. I thought that was really cool. Then about an hour later, they came in and actually did the IV, and I felt zero pain. No pain at all. So I didn't associate that IV as being painful. I also held nice and still for them, and I was easily distracted by my mom because nothing was hurting me at that time. We need to explain things with age-appropriate language. So if I come in and say to a child, "I'm here to get your blood pressure." What did they just hear? Blood and pressure. Scary words, right? So age-appropriate terms, if you know a peds nurse, you have probably heard them say, "I'm going to give your arm a big hug," right? That's more age-appropriate. They don't need to know the medical terminology unless they are older and interested in that sort of a thing. We want to allow choices when possible. This is not always going to be the case, right. Just like with parenting, we can't always give choices. But when we can, let's give them that choice. "Do you want orange juice or apple juice?" Right? Don't just give them the juice. Anything that they can have control over is going to be a benefit to how they are perceiving this experience.
This one is so important. Use therapeutic play techniques. And in children's hospital, they actually have like child-life specialists who are specialists in how to use play and dolls and art and books, and all of these things to help a child understand what is going on, to explain things to them in a way that makes sense, and to just best support them at their developmental age. It is the coolest thing in the world. I think that that must be a fascinating job. But the example we have here would be for a younger child. We could use a doll to demonstrate procedures. Maybe we could even put a cast on the doll's arm that's going to look just like the cast a child will get, right. Something like that is going to be very beneficial. For my daughter, before getting her coronavirus shot. I brought home a syringe from the hospital. No needle, just the syringe. Right? And I let her touch it, feel it, play with it. And then, we took turns giving vaccines to her stuffed animals. It helped her to understand what was going to happen, and it helped her to express her fears and concerns about the procedure itself. Very important to meet kids where they are developmentally. All right. This one, it goes hand-in-hand. Allow a child to touch medical equipment when possible. Just like with my daughter touching that syringe, 'Here's my stethoscope. I'm going to use it to listen to your chest into your tummy. Do you want to touch it before we start?" That way, they can see that it's not scary, it's not going to hurt them, that sort of thing. I encourage peer interaction for school-age children and adolescents. Peer interaction is so important for adolescents. And also, when you take a child out of their school environment with their school-age, their Ericksen stage is Industry versus Inferiority. They love school. So when we take them out of that environment, it can be really disruptive to, "This is who I am, and this is how I see myself," right. I love school and you've just taken me out of it. So maybe that means that the school will send cards so that they can feel like they are still involved. Or maybe they're getting to work on their schoolwork in the hospital. All of that is going to help support them where they are.
And then this one is so important. And I kind of wish that they did this for adults too. Perform painful procedures in a treatment room so that the child's room can remain a relatively pain-free site. We want their hospital room to be a therapeutic environment, not one that they fear. So if we needed to start an IV, put a Foley catheter in, do some kind of painful or invasive procedure, we should take the child to a treatment room.
Okay, and lastly, let's talk about the concepts of illness and death based on a child's age. So this is going to vary wildly based on where the child is, just like how their thought process varies. But for infants and toddlers, they don't really have a concept of death, right? They may have separation anxiety, though, so we want to stick to their home routine as much as possible. Preschoolers have this awesome capability for magical thinking. So they may also see death as temporary, right? They may view it through this magical thinking lens as well. But because of that magical thinking, they could also view death or illness as being like, "I caused this. My thoughts or actions caused this." And that's because of that magical thinking. So it can be a positive and a negative in this instance. They can also exhibit regression. This is very common for any sort of stressor at this age. But, for instance, a fully toilet-trained child now suddenly wetting the bed. That would be an example of regression. School-age children. It isn't until about the age of six years old that a child is going to understand that death is permanent. So about the age of a school-age child is when they're going to start to understand the permanence of death. They may also exhibit disruptive behavior. So if someone close to them died, or if they're experiencing an illness in their own life, they could act out as a way of processing. That's right. And then lastly, we have adolescents. They have an adult understanding of death. But remember that that, "my body image is really important to me in this time. So if I am experiencing some kind of illness or injury that could disrupt my own body image, that could be really disruptive to my growth and development." So we would want to encourage expression of those thoughts and concerns. And we also want to have contact with our peers. "How I fit into my peer group is very important for my Erickson's stage here in adolescence." So we want friends to come visit if it's appropriate for the condition, right. We want to encourage those visits and that support so that.
"I still feel like I have a role in my peer group."
I hope this review was helpful for you. Be sure to stay tuned because I have a few quiz questions to test your knowledge of some key facts I provided in this video. First up, a child agrees to receive chemotherapy for bone cancer, but the parents provide the formal authorization. Which type of authorization is each family member providing? So what kind of authorization is the child and the parent giving? Next question, how should the nurse educate a caregiver to measure a liquid medication for their child? There's two key things I want you to remember about that. Third question here. A child requires a central line be placed. Where in the hospital should this placement take place? Where should it be done? And lastly, around which approximate age when a child understands the permanence of death? At what age do I understand that death is permanent? Let me know how you did in the comments. I can't wait to hear. Thanks so much, and happy studying.
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