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Fundamental aspects of children’s and young people’s nursing 

Fundamental aspects of children’s and young people’s nursing
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Fundamental aspects of children’s and young people’s nursing
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10.1093/med/9780199641482.003.0001
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date: 02 June 2020

Physical growth and its measurement

Pattern of growth

Growth proceeds in a continuous pattern but can be sporadic. The most rapid growth takes place in utero, during the first 2 years of life and in adolescence. However, the growth rate of an individual can accelerate or decelerate in response to illness, changes in nutrition, or environmental changes.

Length/height

  • An infant’s length increases by 12 cm during the first 6 months.

  • By 1 year the infant’s height has increased by almost 50% and by the age of 2 years the child is about half final adult height.

  • After 2 years the increase in height is 5–7.5 cm/year.

  • Adolescence then brings a ‘growth spurt’, following which height and weight are gained slowly until adult size is achieved.

Measurement

  • Measure an infant’s length on a measuring board (Fig 1.1). Place the baby’s head against the top of the board and the heels at the foot board.

  • Measure the height of a child when they are standing upright. The child should remove their shoes and stand as tall and straight as possible with their head in the midline and line of vision parallel to the floor. Most accuracy is gained by using a wall-mounted stadiometer (Fig 1.2).

Weight

  • On average, an infant gains 600–800 g in weight per month.

  • Birth weight doubles by 6 months.

  • Weight triples by 1 year.

  • From 2 years, weight is gained at ~3 kg/year.

Measurement

  • Infants should be weighed naked, and preferably at the same time of day if repeated measurements are needed.

Head circumference

  • The head growth of an infant is rapid: in the first 6 months the circumference increases by between 8 and 9 cm.

  • By the first year there is an increase of 33% in the overall size of the head.

  • The size of the skull is closely related to the size of the brain.

Measurement

  • Use a paper disposable tape-measure for this measurement as linen tape-measures stretch and produce inaccurate results (Fig 1.3).

  • Measure the infant’s head around the point of greatest circumference—this is usually slightly above the eyebrows and pinna of the ears and around the occipital prominence at the back of the skull.


Fig 1.3 Circumferential measurements.

Fig 1.3 Circumferential measurements.

Surface area

  • This measurement is important for the prescription of some drugs.

  • Once the child’s height and weight are known you can calculate the surface area using the body surface area nomogram.

Further reading

Hockenberry MJ, Wilson D (2011). Wong’s Nursing Care of Infants and Children, 9th edn. Mosby, St Louis, MO.Find this resource:

Physical development

Factors affecting growth and development

  • Genetic/chromosomal factors.

  • Racial factors.

  • Endocrine system.

  • Drugs.

  • Illness: children grow more slowly during periods of illness, but after recovery there may be increased growth to catch up.

  • Nutrition: poorly nourished children grow more slowly and do not reach full potential size; malnutrition can have a permanent effect on some parts of the brain and nervous system.

  • Environment: the ability to practise skills, e.g. crawling, walking.

Measuring development

Development is measured using developmental scales. There are four major areas:

  • Physical: growth, vision, hearing, locomotion, coordination.

  • Cognitive: language and understanding.

  • Psychosocial: adapting to the society and culture to which the child belongs.

  • Emotional: control of feelings and emotions.

Differences in rate

There may be individual differences in the rate and timing of developmental progress.

Developmental assessment

The health visitor usually carries out these assessments, but they could be carried out by a general practitioner or paediatrician. They include the evaluation of:

  • locomotion or gross motor development (referring to large muscle skills)

  • fine motor or manipulation skills (referring to small muscle skills)

  • hearing and speech

  • vision

  • social development, e.g. feeding, dressing, and social behaviour.

In order to assess deviations from the normal, it is first necessary to know about normal development. The development of a child between the ages of 0 and 18 months is very complex. These are the major milestones and their approximate age of appearance:

  • Smiles

1–2 months

  • Laughs

6 months

  • Sits:

    • with support

6 months

    • without support

8–9 months

  • Crawls

8–9 months

  • Stands/walks

12 months

  • Pincer grip

12 months

  • Delicate pincer

18 months

  • Walks backwards

18 months.

All aspects of development are interlinked, and skills are acquired sequentially. An example of this is the sequence of development of motor skills, which is often described as cephalocaudal, i.e. head (cephalo) to toe via the spine (caudal): initially head control is developed before the baby is able to sit independently; this is followed by crawling, and finally control of the lower limbs for standing and walking.

Further reading

Hockenberry MJ, Wilson D (2011). Wong’s Nursing Care of Infants and Children, 9th edn. Mosby, St Louis, MO.Find this resource:

Sharma A, Cockerill H (2014). Mary Sheridan’s From Birth to Five Years, 4th edn. Abingdon: Routledge.Find this resource:

Fundamental aspects of children’s and young people’s nursing Child Development Institute website: www.childdevelopmentinfo.com/development/

Developmental milestones

Newborn

  • In ventral suspension the head droops below the plane of the body (Fig 1.4).

  • When the baby is pulled to sit, there is marked head lag (Fig 1.5).


Fig 1.4 Ventral suspension—newborn.

Fig 1.4 Ventral suspension—newborn.

Aged 1 month

Posture and large movement

  • When the baby is pulled to sit, the head lags until the body is vertical when the head is held momentarily erect before falling forward.

  • When held sitting the back is one complete curve (Fig 1.6).

  • In ventral suspension, the head is in line with the body and the hips are semi-extended (Fig 1.7).


Fig 1.7 Ventral suspension—1 month.

Fig 1.7 Ventral suspension—1 month.

Vision and fine movement

  • Pupils react to light.

  • Shuts eyes tightly when light is shone in them.

  • Fixes and follows.

  • Watches mother’s nearby face when she feeds or talks to him.

Hearing and speech

  • Startled by sudden noise.

  • Stops whimpering and (usually) turns towards sound of nearby soothing voice.

  • Cries lustily when hungry or uncomfortable.

  • Guttural noises when content.

Social behaviour and play

  • Sucks well.

  • Sleeps most of the time when not being fed or handled.

  • Expression still vague—more alert later, progressing to social smile and responsive vocalizations at 5–6 weeks.

3 months

Posture and large movement

  • Supine, prefers to lie with head in midline, limb movements smoother.

  • When pulled to sit, little or no head lag (Fig 1.8).

  • In ventral suspension, head held well above line of body (Fig 1.9).

  • When prone, lifts head and upper chest, uses forearms for support, buttocks flat.


Fig 1.9 Ventral suspension—3 months.

Fig 1.9 Ventral suspension—3 months.

Vision and fine movement

  • Visually alert, turns head deliberately to look around.

  • Watches movements of own hands and demonstrates finger play.

  • Recognizes feeding bottle and makes eager movements as it approaches.

  • Defensive blink present.

  • Holds rattle for a few seconds but doesn’t look at it at the same time.

Hearing and speech

  • Sudden loud noise still causes distress.

  • Definite quietening or smiling in response to mother’s voice.

  • Vocalizes happily when spoken to, can also vocalize when playing alone.

  • Cries when uncomfortable or angry.

Social behaviour and play

  • Intense gaze at mother’s face when being fed.

  • Reacts to familiar situations by showing excitement.

  • Enjoys bathing.

  • Responds with obvious pleasure when played with.

6 months

Posture and large movement

  • When supine, raises head to look at feet, lifts legs into vertical and grasps feet (Fig 1.10).

  • When hands are held, braces shoulders and pulls self to sit (Fig 1.11).

  • Held sitting, head firmly erect, back straight. Can sit alone momentarily.

  • Held standing, bears weight on feet and bounces up and down.

  • When placed prone, lifts head and chest well up, supporting himself on extended arms (Fig 1.12).


Fig 1.11 Hands held, pulls self to sit—6 months.

Fig 1.11 Hands held, pulls self to sit—6 months.

Vision and fine movement

  • Visually insatiable, moves head and eyes eagerly.

  • Immediate fixation on interesting small objects at 30 cm.

  • Uses whole hand to palmar grasp and passes object from one hand to the other.

  • When toys fall outside visual field does not follow them.

Hearing and speech

  • Vocalizes tunefully to self and others.

  • Using single or double syllables—adah, goo, aroo.

  • Laughs and chuckles.

  • Screams with annoyance.

  • Demonstrates different responses to mother’s tone of voice.

Social behaviour and play

  • Reaches out and grasps small toys.

  • Plays with feet and hands.

  • Puts hands around bottle and pats it.

  • Shakes rattle deliberately to make sound.

  • Friendly with strangers but shows some anxiety if approached too quickly.

1 year

Posture and large movement

  • Crawls on hands and knees, shuffles on buttocks or bear walks.

  • Usually able to stand alone, may walk.

Vision and fine movement

  • Looks in correct place for toys dropped out of sight.

  • Recognizes familiar people at 7 m distance.

Hearing and speech

  • Turns immediately to own name.

  • Comprehends simple instructions associated with gesture, e.g. ‘come to mummy’.

Social behaviour and play

  • Drinks from a cup.

  • Waves ‘bye-bye’, plays ‘pat-a-cake’.

  • Helps with dressing, e.g. holding out arm for sleeve.

Further reading

Sheridan M, Sharma A, Cockerill H (2007). From Birth to Five Years: Children’s Developmental Progress. Routledge, New York,Find this resource:

Psychological theories of attachment

Attachment theory overlaps with behavioural, biological, and interpersonal theories and cognitive development, and aims to:

  • Describe the character of the lasting relationships between a person and significant others (often the carers, in the case of a child).

  • Explain those relationships in terms of behaviours, emotions, and cognition.

Attachment styles

Secure attachment

This is seen in the way the child responds to their carer—with sensitivity, empathy, and affection. There is often a degree of perception, insightfulness, nurturing, and consideration for the other person, which can result in altruistic behaviours. If children see their carer as responsive, supporting, and available, they are cooperative, easily comforted, and eager to explore new situations.

Insecure attachments

These develop in response to inconsistencies, uncertainty, and abuse or neglect by the carer(s):

  • Anxious–ambivalent: the child appears hostile and dependent when upset, as seen in separation anxiety—there are often reactions of protest, despair, and detachment when the parent leaves the child, but avoidance of the parent by the child when they return.

  • Anxious–avoidant: distrust and a lack of confidence in getting a response from carers results in the child becoming distant, not seeking support if upset.

  • Disorganized–disorientated: the child demonstrates a mixture of avoidance, anger, and behavioural issues.

John Bowlby (1969) proposed a model for early parent–child interactions that influence development of the infant’s understanding of others, and connections to them. Genetically preprogrammed and instinctive, this development also depends on the degree of attention and care given by the significant carer, serving as a guide for the child’s social expectations, perceptions, and behavioural interactions, not only in childhood but also in adolescence and adulthood. This results in a reciprocal, complex relationship. Fundamental to the child’s psychological well-being, the strength and quality of the emotional attachment of the carers/parents to each other affects the emotional and behavioural ability of the child. Likewise, the behaviour of the child will also affect the parents.

Further reading

Fundamental aspects of children’s and young people’s nursing International Attachment Network http://www.ian-attachment.org.uk/

Cognitive development

The question of how children learn has been an area of development that has been debated at great length, but what we do know is that within the first few years of a child’s life, including the time in utero, they will learn more than at any other period of existence. The concept of cognition is a vast subject covering memory, attention, language, social cognition, reasoning, and problem-solving.

Cognitive development refers to how a child perceives, thinks, and gains an understanding of the world through interaction and is influenced by genetic and learned factors. It is the process by which developing individuals becomes acquainted with the world in which they live. Children ultimately have the ability to reason abstractly, to think logically, and organize intellectual functions or performances into higher-order structures. Cognitive development consists of age-related changes that occur in mental activities.

Nature versus nurture debate

The nature (genetics) versus nurture (environment) debate is one of the most contested arguments in relation to age-related developmental changes. The debate wrestles with the question of ‘What is the best possible explanation for how development takes place?’ The ideal position is that all human activities are a product of both nature and nurture.

Influential learning theorists

Piaget’s theory of cognitive development

Jean Piaget (1896–1980) developed the most comprehensive theory of cognitive development. Piaget defined four areas of intelligence and child brain development—they include a biological approach to intelligence; the cognitive succession of stages; knowledge; and intellectual competence. The child is viewed as an organism adapting to the environment, and cognition progressing through a series of hierarchical stages. These stages are described as universal across all cultures and invariant, meaning that all children pass through the same stages in the same sequence, unless there are underlying problems. In the process of learning, the child is viewed as an isolated individual who adapts the world around him/herself through processes of:

  • schemas

  • assimilation

  • accommodation

  • equilibrium.

The stages of intellectual development formulated by Piaget appear to be related to major developments in brain growth (Table 1.1).

Table 1.1 Piaget’s four stages of cognitive development

Stage

Approximate age

Sensor motor

Birth to 2 years

Preoperational

2–7 years

Concrete operational

7–11 years

Formal operational

11 years plus

Lev Vygotsky’s theory of cognitive development

Vygotsky (1896–1934) believed that the child is born into a complex cultural world of social relationships. Vygotsky proposed two aspects of development:

  • Natural line of organic growth and maturation.

  • Cultural improvement of psychological function.

He proposed the zone of proximal development, which is the distance between the actual developmental level as determined by independent problem-solving, and the level of potential development as determined through problem-solving under adult guidance, or in collaboration with a capable peer.

Bruner’s theory

Bruner (1966) describes three modes of representing the world: enactive, iconic, and symbolic. He proposed the idea of encoding information, stored in the forms of codes generated visually or symbolically, such as language. His theory stresses the role of education and the adult.

Information-processing theories

The information-processing approach to cognitive development is based on an analogy between the computer and the human mind. This represents the view that the mind is like a system that manipulates symbols according to a set of rules.

Further reading

Bukatko D, Daehler MW (2004). Child Development: A Thematic Approach, 5th edn. Houghton Mifflin, New York.Find this resource:

Gross R (2005). Psychology: The Science of the Mind and Behaviour, 5th edn. Hodder Arnold, London.Find this resource:

Language development

Many theories have attempted to explain language development. It is known that children learning any language progress through similar periods of development (Table 1.2). They begin by learning the elements of the sound of their own language, progressing through the stages of one- and then two-word utterances to begin using words in combinations integrating appropriate grammatical forms. By the age of 3 years they are producing short sentences intelligible to most adults, and finally they progress to using sentences recognizable as matching adult forms. Theorists have argued that language is learned just like any other behaviour and that by repeating back infant vocalizations adults positively reinforce the development of speech. Some believe language to be an innate ability and that children are born with a genetic mechanism for the acquisition of language, called a ‘language acquisition device’ (LAD). It has also been proposed that critical periods exist that determine the universality and invariant order for the process of language development. However, we cannot ignore the importance of social influences on language development, interactions between the parent and child establish the communicative function of vocalization, and throughout development adults both correct and reinforce speech through everyday communications and play. Three features are said to distinguish human language:

  • It has semanticity: it represents thoughts, objects, and events through specific and abstract symbols.

  • It is productive: we can be creative with it.

  • It has displacement: we can communicate about things distant in space and time.

Table 1.2 Language development

Age

Normal language development

Normal speech development

Intelligibility

Infant

Cooing

Non-cry vocalic sounds

Babbling

Consonant–vowel syllables with intonation patterns

1 year

Appearance of first 2–3 words

Omits most final and some initial consonants

Usually no more than 25% intelligible to familiar listener

Imitates sounds of animals

Substitutes consonants m, w, p, b, k, g, n, t, d, and h for more difficult sounds

2 years

Uses 2- to 3-word phrases

Uses above consonants with vowels but inconsistently and with substitution

50–65% of spoken language can be understood

  • Has a vocabulary of 250–300 words

  • Can put together simple 2- or 3-word phrases

Word usage and comprehension develops but comprehension lags behind expressive ability

Uses I, me, you

Can understand much adult communication directed to them

3 years

Says 4- to 5-word sentences, with a vocabulary of about 900 words. Uses who, what, where. Uses plurals, pronouns and prepositions.

Says b, t, d, k, and g but r and l may be unclear. W is either omitted or substituted. Often repeats self

75% of communications are intelligible

4–5 years

Vocabulary has increased to about 1500–2100 words. Sentences are complete and most grammar correct

Says f and v. May still have some distortion of r, l, s, z, sh, ch, y, and th

All speech can be understood although some words may not be perfectly enunciated

5–6 years

Vocabulary of 3000 words

May still distort s, z, ch, sh and j

In order to successfully master language we have to learn phonology (the sounds words are made up from), semantics (individual words and their meanings), syntax (combinations of words), and pragmatics (how to use language in a social setting). Language is about learning the words and rules (the recipe)—it is essentially a creative skill.

Further reading

Benson J, Marshall M (2009). Language, Memory and Cognition in Infancy and Early Childhood. Elsevier, Oxford.Find this resource:

Owens RE (2011). Language Development: An Introduction. Pearson, London.Find this resource:

Fundamental aspects of children’s and young people’s nursing Child Development Institute. Language Development In Children. www.childdevelopmentinfo.com/development/language_development.shtml

Social development

Human beings are social animals. In every society children must learn the rules, behaviours, and values in order to function within that group. Early interaction establishes building blocks for acquired socialization skills. This is called socialization; it is achieved by observational learning and direct teaching. A society’s rules and standards of behaviour are called social norms: they are not usually written down, yet they govern our behaviour and our expectations of the behaviour of others. Children tend to learn them as facts. Social norms are developed and perpetuated because they give society stability.

The individual is required to:

  • recognize self, develop self-concept and personality.

  • enter relationships with parents, family, peers, and others.

  • go beyond people’s behaviour to their intentions and perceived expectations.

The ultimate aim of socialization is to give children the ability to discipline themselves, to compromise between what they want and what society demands of them. Socialization is a lifelong process; there is a need to learn new norms at each stage of the lifespan. Children will have to cope with learning new rules at playgroup, school, groups, university, and employment.

To understand social development, it must be remembered that:

  • it is closely connected to psychological and cognitive development.

  • children are part of a large network of people and activities.

  • it is influenced by the child’s relationship with their mother, and to other important relationships the child has when growing up.

Theories of social development

An understanding of child development (Table 1.3) is essential in allowing us to understand the cognitive, emotional, physical, social, and educational growth from child to adolescent. A number of theories have been proposed to assist in our understanding of social development of children. Bowlby (1969) proposed the earliest attachment theories focusing on child and caregiver relationships. Bandura’s (1977) social learning theory details modelling behaviour based on observation to serve as a guide for action. Vygotsky’s (1896–1934) social–cultural theory suggests that parents, caregivers, peers, and the culture are responsible for development. Piaget (1932) argued that children’s relationships with adults are structured along a vertical dimension, meaning that relationships are unequal or asymmetrical. In contrast, he viewed children’s relationships with other children as more balanced or symmetrical and egalitarian, and structured on a horizontal plane.

Table 1.3 Summary of social development (adapted from Keenan 2002)

Age

Milestones

0–6 months

By 6 months of age infants are aware of other infants, and are interested in them

6–12 months

Infants show an interest in their peers

12–24 months

Engage in parallel play, use language, development of self-understanding, first evidence of behaviours such as empathy, engagement in rules of social exchange, child operates according to desire

3 years

Engage in cooperative play, behaviours are based upon desire, dominant hierarchies evolve in peer groups

4 years

Engage in associative play, emergence of socio-cognitive conflict

6 years

Desire to spend more time with peers, shared interests, coordinated successful play

7–9 years

The goal of friendship is peer acceptance

Early adolescence

Friendship is centred on self-disclosure and intimacy, peer group is organized around crowds and cliques, first appearance of adolescent egocentrism

Late adolescence

Friends increasingly provide emotional support, adolescent egocentrism declines

Identity

The differentiation of self begins in infancy and continues throughout childhood, where there are changes in the development of the self concept and the relationship of self to others. Through childhood, self-descriptions become more complex, and by adolescence they forge a more coherent view of self which integrates various characteristics.

Theorists consider biological factors, social learning theory, and cognitive-developmental factors, gender schemas, and social-cognitive theories important to the development of identity. Furthermore, there are several theories relating to the inherent processes of acquiring a sex role or sex-role identification.

Ethnicity

Ethnic identity is an awareness of one’s own ethnicity and it is closely linked to, and parallels, developing an understanding of ethnicity in others. By the age of 4–5 years children seem to be able to identify fundamental differences, and by 8–9 years children understand that ethnicity is constant.

Relationships

Once the infant has formed a rudimentary concept of self and established particular habits, the next stage is the utilization of these skills to form relationships. Relationships are based on interactions, but require the integration of self with others. Types of relationships include parental relationships, family relationships, sibling relationships, peer/friendship relationships, acquaintance relationships, and love/sexual relationships.

Further reading

Schaffer R (2003). Social Development. Blackwell, London.Find this resource:

Keenan T (2002). Introduction to Child Development. Sage, London.Find this resource:

Immunization schedule

To achieve herd immunity in a population it is vital to ensure that children are appropriately immunized against preventable diseases. Inaccurate press coverage relating to the purported adverse effects of certain vaccines has frightened some parents, resulting in less than optimum uptake of immunizations. This not only puts individual children in jeopardy but potentially exposes larger groups of not yet immunized children to unnecessary risk. It is therefore an integral part of the assessment process for a nurse to ascertain and record the immunization status of every child admitted. Remedial immunization must be available for children who have not received the recommended schedule of vaccination.

Routine childhood immunization schedule

All children starting the immunization programme at 2 months of age will follow the schedule shown in Fig 1.13.

Nurses advising and promoting immunization are professionally accountable for providing evidence-based information as defined by the Nursing and Midwifery Council.1 This is particularly important as Department of Health guidelines on immunization change at regular intervals and nurses must ensure that they keep themselves informed of the latest evidence and recommended schedule. All nurses administering vaccinations must have received specific training in immunization, including the recognition and treatment of anaphylaxis.

Reference

1. NMC (2015). The Code: Professional Standards of Practice and Behaviour for Nurses and Midwives. Nursing and Midwifery Council, London. Fundamental aspects of children’s and young people’s nursing http://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/revised-new-nmc-code.pdfFind this resource:

Further reading

Fundamental aspects of children’s and young people’s nursing Public Health England. Routine Childhood Immunisations From July 2014. https://www.gov.uk/government/publications/routine-childhood-immunisations-from-july-2014

Models of health promotion

Various theoretical frameworks of health promotion have been developed and these models provide structure to help direct and manage practice.

The Tannahill model has been selected to demonstrate different ways of promoting health in relation to preventing obesity in childhood. Historically malnutrition has been the main focus of practice but today, in our comparatively affluent society, obesity is becoming a major concern.

Tannahill model of health promotion

A Venn diagram demonstrates the different relationships between the various health-promotion activities described by Tannahill’s model (Fig 1.14). Domains 1, 5, and 6 are the main areas of activity, because health promotion is about prevention, education, and protection. To be successful they need to be combined: domain 4 is central to all activities and would be the most likely to effect change (see Table 1.4).


Fig 1.14 The Tannahill model of health promotion.

Fig 1.14 The Tannahill model of health promotion.

Table 1.4 Tannahill’s seven domains

Domain

Examples in practice

Obesity

1

Preventive services

Developmental surveillance, immunization

Monitor growth in children

2

Preventive health education

Educating to influence lifestyle

Education about physical activity, change eating patterns, e.g. promote family mealtimes

3

Preventive health protection

Legislation to make all enclosed public places and workplaces in England smoke-free.

National school fruit scheme; 4–6-year-olds receive a free piece of fruit each day

4

Health education for preventive health protection

Central to all practice—involves all aspects of health promotion

All examples + 5-a-day campaign—recommends at least 5 portions of fruit and vegetables a day

5

Positive health education

Positive reinforcement of health promoting behaviour, e.g. exercise to develop fitness, health-related life skills

National curriculum: personal health social education—information about healthy food, exercise

6

Positive health protection

Promotion of no-smoking environments/provision of user-friendly leisure facilities

Healthier school meals—Jamie Oliver campaign

7

Health education aimed at positive health protection

Raising awareness of health issues amongst general population and policymakers

Lobbying for healthier school tuck-shops; educating parents

Further reading

Downie RS, Tannahill C (1996). Health Promotion: Models and Values, 2nd edn. Oxford University Press, Oxford.Find this resource:

Fundamental aspects of children’s and young people’s nursing Department of Health (2009). Healthy Child Programme. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_107563

Promoting child health

Health promotion is key to improving child health as a substantial part of child ill health is preventable. The main thrust of nursing children, young people, and their families is in fact health promotion. It must be seen in the broadest of definitions and should embrace influencing social policy and local policy right through to immunizing children. Nursing children involves primary, secondary, and tertiary health promotion or a combination of all three. Table 1.5 shows the five main approaches to promoting health.

  • Health promotion = health education + healthy public policy.

  • Health promotion = empowering people to take control of their own health.

  • Nursing children = empowering children and their families to achieve the best outcomes possible for their individual situations.

Table 1.5 Approaches to promoting health

Approach

Objective

  1. 1. Medical or preventive

To prevent disease

  1. 2. Behaviour change

To facilitate individuals/groups to make healthy choices

  1. 3. Educational/information giving

To provide individuals/groups with information about how to be healthy

  1. 4. Empowerment/client centred

To enable individuals/groups to take control of their own health

  1. 5. Social change/radical/political

To develop/adapt policies/environments that support healthy choices

There is now more emphasis on public health because it is recognized that some daily activities have a huge influence on health, ranging from the narrow confines of personal nutrition to the wider impact of social policy around nutrition. Public health focuses on disease prevention, monitoring, and management. A recent DH report, the Healthy Child Programme2, recommends a programme of preventive measures to support parenting and healthy choices for children.

Hall and Elliman3 is a review of child health in Britain. This report, plus other government policies, suggests that nutrition is a crucially important aspect of child health—the prevention of obesity being a prime target at present, due to its increasing prevalence. Good nutrition will also maintain dental health, skin integrity, hydration, and pain-free elimination. A new problem related to diet is the development of type 2 diabetes in children in the UK.

References

2. Fundamental aspects of children’s and young people’s nursing Department of Health (2009). Healthy Child Programme. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_107563

3. Hall DMB, Elliman D (2006). Health for All Children, revised 4th edn. Oxford University Press, Oxford.Find this resource:

Patient and parent information and education

The provision of adequate information is an essential prerequisite to the formation and development of a trusting relationship between practitioner, child, and family. It is therefore extremely important that all information provided should be clear, factual, and aimed at empowering and enabling the family in relation to their understanding, consent, and participation. This may include the creative use of verbal communication; non-verbal communication; abstract communication; aids such as leaflets, books, and posters; or interactive methods such as videos, CDs, DVDs, and computers with Internet access.

All information provided needs to be good quality, based on up-to-date evidence, and adapted to take account of the age, development, and level of understanding of all involved.

This requires knowledge and skills on the part of practitioners, not only in relation to their understanding of child development and interpersonal communication strategies, but also their ability to assess and evaluate information needs and understanding. It must never be assumed that parents lack knowledge in relation to their child or their child’s condition. With increasing access to the Internet, children and their parents now have improved access to information, which can, in many cases, lead to an expert knowledge and understanding on their part. It is important that practitioners do not perceive this as a threat to their own expertise. Rather, it should be viewed as a basis on which to develop communication strategies based on partnership, mutual trust, and respect. In this way further exploration and explanation of specific issues can be provided and appropriate skills acquired by all, with guidance given towards reliable sources of good-quality information.

Factors to note when providing information include the following:

  • Information should be appropriate in its presentation and linked to the age, ability, and level of understanding of those involved.

  • Verbal information should be clear and factual and spoken at a normal pace.

  • Technical terms or jargon should be avoided and explanations should be simple and uncomplicated.

  • Adequate time should be allocated; include time for questions and discussion.

  • Not all information will be understood at first; back-up material, such as leaflets, videos, or books, should be provided for reinforcement and further explanation.

Further reading

Matthews J (2006). Communicating with children and their families. In: Glasper A, Richardson J (eds) A Textbook of Children’s and Young People’s Nursing, pp. 121–36. Elsevier, London.Find this resource:

Fundamental aspects of children’s and young people’s nursing Deafness and Hearing Impairment website: www.deafnessatbirth.org.uk

Working with diverse communities

As the population of the UK is heterogeneous, practitioners working with diverse populations must investigate their own philosophical assumptions about diversity if they are to work within an ethos of justice, equality, and access. In the past, many nurses have worked with givens, often in an ethnocentric way, rather than theorizing about the factors that have influenced their approach with patients and clients somehow ‘different’ from themselves. This pragmatic, non-reflective style may not be sensitive to the needs of those considered ‘outsiders’.

British society has generally benefited from raised living standards, leisure, health, and education. However, there are many socially excluded groups who are prevented, either overtly or covertly, from all the benefits of British society that many enjoy and take for granted.

When we come into contact with a person perceived as different from ourselves, we socially construct this person as ‘other’. This reconstruction occurs because, often hidden, stereotypes and prejudices come into play, and this can affect our behaviour, compassion, and commitment to relating to them, and them to us.

Requirements to promote inclusion, tolerance, and acceptance of ‘difference’ include the following:

  • Open and critical debate about the concepts of belonging, ‘active citizenship’, diversity, community, and exclusion/inclusion.

  • A philosophical debate regarding how practitioners perceive health work and how this influences the encounters they share with patients and carers, by exploring the ethics and the truth of what they believe are ‘givens’.

  • The ability, willingness, and skills to problem-solve, challenge, engage with, and transform situations and services, recognizing power imbalances within society.

  • Being aware of concept of ‘rights’, ‘responsibilities’, and how to hear ‘hidden voices’.

  • Advocating not only for individuals but working strategically and politically to oppose disadvantage.

Practitioners need to explore the dynamics of the exclusionary practices that affect many aspects of daily life and ultimately affect people’s health and well-being. This is vital if we as a society wish to raise awareness and stimulate debate to overcome apathy and deep-seated suspicion of others, and to receive the support of the diverse communities that we serve.

Further reading

Davis J, Hoult H, Jones M, et al. (2005). Working with socially excluded groups. In: Robotham A, Frost M (eds) Health Visiting: Specialist Community Public Health Nursing, 2nd edn, pp. 123–48. Elsevier, Edinburgh.Find this resource:

Price B (2005). Practice, philosophy, culture and care. Multicultural Nursing, 1(1), 21–6.Find this resource:

Fundamental aspects of children’s and young people’s nursing www.rcn.org.uk/resources/transcultural/childhealth/index.php

Transcultural nursing

The 2002 census estimated that the size of the ethnic minority population in the United Kingdom was 4.5 million or 7.6% of the population. This figure is increasing, and nurses working with children need to ensure that care for children and families from diverse cultural backgrounds is of equal quality to that provided for non-minority groups.

Coping with childhood illness can become very traumatic for children and families when there are cultural differences. The Code4 states that nurses must not discriminate in any way and must meet people’s language and communication needs. This can be helped by the nurse encompassing transcultural principles such as:

  • showing respect by always being approachable.

  • getting to know different cultures and their needs.

  • being comfortable asking children, young people, and their families about differing needs.

  • accepting that it is not possible to understand all cultures but recognizing the need to search for information and knowing where to gain information.

Considerations

  • A holistic approach to care delivery requires that you take into account lifestyle dimensions while considering:

  • You also need to take account of your own culture.

  • The quality of the assessment interview will influence the effectiveness of care.

  • A cultural assessment tool can assist you in developing awareness of the cultural needs of the child and the family.

  • availability of interpreters

  • gender-sensitive issues

  • provision of culturally appropriate information and education

  • multicultural play

  • naming systems

  • nutrition practices

  • parenting styles

  • perceptions and reactions

  • privacy/socializing

  • religious preferences.

Within nursing there is a need to strive to provide care that is fair for all, and to balance this with individualistic holistic care. When respecting the uniqueness of children and young people in our care, we often focus on trying not to make them feel different. Being comfortable with difference is at the heart of transcultural care, and nurses who value diversity by respecting differences help ensure care is culturally appropriate for each child or young person, and their family.

There are many complexities surrounding interpersonal communication and although an interpreter will help the situation, the possibility of misunderstanding is greater when communicating across a cultural boundary.

Reference

4. NMC (2015). The Code: Professional Standards of Practice and Behaviour for Nurses and Midwives. Nursing and Midwifery Council, London. Fundamental aspects of children’s and young people’s nursing http://www.nmc.org.uk/standards/code/read-the-code-online/#fourthFind this resource:

Further reading

Papadopoulos I (2006). Transcultural Health and Social Care: Development of Culturally Competent Practitioners. Churchill Livingstone, Edinburgh.Find this resource:

Religious aspects of food

For some people, food has a spiritual significance. Certain foods may be prohibited and these rules form a vital part of people’s everyday life (Table 1.6).

Table 1.6 Religious restrictions on food

Food

Muslim

Jewish

Sikh

Hindu

Rastafarian

Lamb

Halal

Kosher

Yes

Some

Some

Pork

No

No

Rarely

Rarely

No

Beef

Halal

Kosher

No

No

Some

Chicken

Halal

Kosher

Some

Some

Some

Cheese

Some

Not with meat

Some

Some

Yes

Milk/yoghurt

Some

Not with meat

Yes

Some

Yes

Eggs

Yes

No blood spots

Yes

Some

Yes

Fish

Halal

With fins, scales, and backbone

Some

With fins and scales

Yes

Cocoa, tea and coffee

Yes

Yes

Yes

Yes

Yes

Fast periods

Ramadan

Yom Kippur

No

No

No

Alcohol

No

Yes

No

No

No

Religious restrictions may affect the diets of Hindus, Sikhs, Muslims, Jews, and Rastafarians.

Some religions may not only have dietary customs but also strict rules about how foods should be prepared:

  • Halal meat: meat that has been slaughtered and prepared in accordance with the Muslim faith.

  • Kosher meat: meat that has been slaughtered and prepared in accordance with the Jewish faith.5

Both faiths believe that eating meat that has not been slaughtered in their religious way is wrong.

Vegetarians do not eat meat and vegans do not eat any meat or dairy products at all.

Culture

Any definition of culture must contain three basic ideas:

  • There are typical patterns of emotional, social, and intellectual behaviours.

  • They derive from a shared set of beliefs and values, including religious ones.

  • These patterns are adaptive to the environment.6

Some of these cultural differences will include skin care, bathing and toileting, diet, discipline, and the life-stage rituals of birth, marriage, and death.

Culture can thus be extremely important for many of the different people living in the UK and throughout the world.

In the UK, various laws have been passed which will give everyone, irrespective of their cultural background, the same opportunities as anyone else in society. This will give children an equal chance to achieve, to learn, socialize, and practise cultural activities chosen by their families. These laws are:

  • Race Relations Act (Amendment) (2000)

  • Sex Discrimination Act (1995)

  • Equal Pay Act (1970)

  • United Nations Convention on the Rights of the Child (1998)

  • Human Rights Act (1998)

  • Children Acts (1989 and 2004).

Every employer must ensure that their employment policies abide by governmental legislation regarding employment rights, religious rights, and cultural rights for every employee as an individual in their own right. In hospitals such policies must be available to read, and be taught to and understood by all staff working there.

References

5. Deen D, Hark L (2007). Complete Guide to Nutrition in Primary Care. Blackwell, Oxford.Find this resource:

6. Watts S, Norton D (2004). Culture, ethnicity, race: what’s the difference? Paediatric Nursing, 16(8), 37–42.Find this resource:

Cultural issues and the dying child

Judaism

The medical professional is held in high regard. There is very little mystique about medicine within the Jewish community. Questions from relatives tend to be direct and practical.

  • Cremation is forbidden in Orthodox Judaism.

  • The family may wish to recite psalms and prayers (the Kaddish).

  • The body should be handled as little as possible and buried within 24 h, delayed only by the Sabbath.

  • The Sabbath begins at sunset on Friday and ends on Saturday evening.

  • It may be difficult to contact the family and other members of the Jewish community during the Sabbath as they do not answer the phone or travel (specifically Orthodox Jews).

  • Close the eyes after death and wrap the child in a clean sheet or shroud.

  • The family will contact a Jewish undertaker and synagogue.

Islam

Muslims believe that whatever takes place is the will of Allah.

  • The family may wish to place the dying child facing towards Mecca (south-east in the UK).

  • Relatives will whisper prayers in the dying child’s ear.

  • Family members will recite prayers around the bed.

  • Organ donation is acceptable on religious grounds, but not popular.

  • Post-mortems are only acceptable if demanded by the coroner (body belongs to Allah, and should not be cut).

  • The child’s body should not be touched by non-Muslims.

  • The Muslim funeral takes place within 24 h of death.

  • Muslim procedure requires that the body is straightened immediately. Turn the head to the right shoulder (this allows the body to be buried with the face towards Mecca).

  • Wrap the child’s body in a clean white sheet.

  • Do not wash the body, or cut the hair or nails.

Christianity

Church of England

  • No specific requirements.

  • Cremation and burial are equally acceptable.

  • Post-mortems and organ donation are acceptable.

Roman Catholicism

  • Practising Catholics may wish for a priest to perform the sacrament of the sick.

  • Relatives may keep a vigil by the bedside and say the Rosary.

  • If a young baby has not been baptized, the family may request this to be done.

Pentecostal/Methodist

The family may wish to say prayers and sing hymns. Afro-Caribbean families are often more demonstrative than the average white family and can feel inhibited and restricted in UK hospitals.

  • Post-mortems are only agreed to on request of the coroner.

  • There may be many visitors.

  • Wrap the child in a clean white sheet.

  • Burial is more common than cremation.

  • The body may be brought home for viewing prior to the funeral.

Sikhs

  • Post-mortems are only acceptable if legally unavoidable. No objections to organ transplantation.

  • Close the eyes and mouth and straighten limbs.

  • The body is washed and white clothes put on before cremation. Cover the body in a white sheet or shroud.

  • Do not cut the hair or remove any religious objects from the body.

Hindus

  • The family may wish to lay the child on the floor; a link with Mother Earth.

  • Post-mortems and organ transplants are acceptable on religious grounds.

  • Funerals are arranged within 24 h. All adults are cremated but generally children under 5 are buried.

  • Close the child’s eyes and straighten limbs.

  • Do not wash the body (relatives will do this).

  • Do not remove any religious objects from the body, including sacred threads.7

Reference

7. Shuba R (2007). Psychosocial issues in end of life care. Journal of Psychosocial Nursing and Mental Health Services, 45(8), 24–9.Find this resource:

Family nursing

Conceptual clarification

Represents a paradigm shift from family-centred care to family nursing focus.

There is ongoing debate within the profession as to what constitutes ‘family nursing’ and little understanding of nursing interventions that might begin to address family needs. The extent to which we have developed family nursing in paediatric practice is debatable.

Family nursing can be perceived as:

  • a philosophy of care

  • an ethos of care

  • an approach to care.

The family

  • Definitions are diverse and often unclear. It is a dynamic concept that is culturally influenced.

  • Understanding of family systems is fundamental to understanding family nursing.

Family systems

  • Parts of a family are related to each other.

  • One part of the family cannot be understood in isolation from the rest of the system.

  • Family functioning is more than just the sum of the parts.

  • A family’s structure and organization are important in determining the behaviour of family members.

  • Changes (e.g. change in overall health status) in one family member create changes in other family members, which in turn create a new change in the original member.

  • Family health has been reported to be a significant factor in a child’s recovery from illness and/or adjustment to disability.

Family assessment

In order to practise family nursing, it is necessary first to conduct a comprehensive family assessment. Four intrinsic elements in family nursing assessments include:

  • having a human caring presence

  • acknowledging multiple perceptions

  • respecting diversity

  • valuing each person in the context of family.

Each of the above is consistent with family nursing systems, in that all members are involved in the assessment process.

Child health nurses need to critically appraise various family nursing assessment tools available for possible adoption in their practice context.

Family nursing interventions

Family systems nursing targets the cognitive, behavioural, and affective domains of family functioning. Interventions that meet these three domains of family functioning may assist the family in finding new solutions to their problems arising from such changes in health status.

Typical interventions

  • Behaviour modification

  • Contracting

  • Case managing/coordinating

  • Collaborative strategies

  • Empowering/participating

  • Family advice

  • Environmental modification

  • Family crisis intervention

  • Networks/self-help groups

  • Information and technical expertise

  • Role modelling

  • Role supplementation

  • Teaching strategies.

The above list is by no means exhaustive and points to synonyms, related roles, and prerequisites for family nursing.

Further reading

Friedman MM, Bowden RV, Jones EG (2003). Family Nursing: Research, Theory and Practice, 5th edn. Prentice Hall, Upper Saddle River, NJ.Find this resource:

Communicating with the child and family

Definition

Communication is a two-way multifaceted process, consisting of verbal and non-verbal strategies. Communication takes place on an informal and formal basis, throughout which it is just as important to observe and listen as it is to talk.

General points

Purpose:

  • To gain information

  • To give information

  • To establish a therapeutic relationship

  • Social.

Set scene

  • Ensure privacy.

  • Avoid interruptions, e.g. phones, staff.

  • Organize furniture avoiding confrontational arrangement, e.g. chairs at an angle, not face to face.

  • Allow for personal space, e.g. leg room.

  • Do not position chairs in front of window; this reduces non-verbal aspect of communication, while backlight may be discomforting for those facing it.

Plan

Consider:

  • Purpose.

  • Developmental level of recipient(s).

  • Stage of child’s illness/condition.

  • Emotional state of child/family, and their readiness for communication.

  • Any barriers to communication such as learning difficulties, hearing impairment, English not being first language.

Explain to child/family the purpose of discussion; allow them preparation time if possible.

Implement

Verbal

  • Adjust vocabulary/tone to gain maximum understanding.

  • Speak clearly, express yourself unambiguously.

  • Use layman’s language, not technical jargon.

  • Give small amounts of information at a time.

  • Minimize barriers between you and the child/family.

Non-verbal

  • Open, friendly, professional approach.

  • Avoid judgemental facial expressions, body posture.

  • Use appropriate responses, e.g. facial expression, touch.

  • Encourage dialogue by eye contact, nodding, etc.

  • Use diagrams and leaflets.

  • Observe for signs of discomfort, change subject, and revisit later if possible/necessary.

  • Respond to verbal and non-verbal cues; do not rush to fill silences.

Evaluate

  • Summarize discussion or ask child/parents to do so; checks/reinforces understanding.

  • Ensure child/family do not feel pressurized to give a correct answer.

  • Give child/family an opportunity to ask questions, state concerns, etc.

Follow-up

  • Arrange further discussion if necessary, e.g. Tuesday, not 2.30 pm Tuesday; avoids potential deterioration of relationship if emergency occurs.

  • Encourage child/family to:

    • write down any concerns arising in interim

    • ask questions any time to avoid excess worry or delay.

Important point

It is just as important to know when not to ask a question as when to ask it.

Further reading

Bach S, Grant A (2011). Communication and Interpersonal Skills in Nursing, 2nd edn. Learning Matters, Exeter.Find this resource:

Hargie O, Dickson D (2004). Skilled Interpersonal Communication: Research, Theory and Practice, 4th edn. Routledge, London.Find this resource:

Fundamental aspects of children’s and young people’s nursing Bliss (organization for parents of babies requiring special care) website: www.bliss.org.uk

Dealing with parental aggression

In today’s society, having the skills to manage anger, aggression, and violent behaviour successfully is very important for a children’s nurse. However, prevention of the occurrence and escalation of these situations is more satisfying and productive for all involved. Where prevention has not been possible and aggression or violence is a reality, nurses must be able to utilize high-level interpersonal skills in order to effectively relate to the individuals involved.

It is important that you can:

  • define and differentiate between anger, aggression, and violence

  • understand the possible causes of anger, aggression, and violence

  • identify what signs to look for

  • understand how to respond

  • develop the skills required to prevent and deal with situations as they occur.

Factors that can lead to families becoming angry and aggressive can include:

  • staff shortages and increased workload that lead to a reduction in the time you can spend with families

  • unrealistic expectations of the family

  • poor planning and prolonged waiting times

  • poor communication

  • lack of appropriate information

  • inadequate resources

  • inappropriate discharge planning.

In relation to this, an important aspect is the ability of the children’s nurse to become self-aware. Self-awareness will enable you to learn about your own behaviour and reactions. This, in turn, will lead to an understanding of how your own behaviour is perceived by others and how, in certain circumstances, if your responses are deemed to be inappropriate, this may contribute to increasing the frustration and anger experienced by the family. Along with the development of self-awareness, you must strive to incorporate some of the basic principles of communication. Communication involves content and context factors, and situations may escalate if one person misinterprets or misunderstands what the other person has said or done.

It is also essential that you learn to become tuned in and perceptive to the possible predisposing factors and emotions that can lead to a person becoming frustrated, angry, or aggressive. These may include:

  • fear—for the welfare of the child or of the environment

  • stress and anxiety

  • feelings of loss of control

  • blaming themselves and feelings of guilt for their child’s illness

  • perceived inappropriate waiting times

  • insufficient information.

By developing this understanding, the skills and strategies aimed at calming the situation and preventing escalation can be more successfully applied. These include:

  • effective listening

  • remaining calm and actively engaging with the family

  • demonstrating empathy and understanding of the situation

  • being responsive but remaining in control

  • being aware of the environment and personal safety.

Further reading

Arnold E, Underman Boggs K (2003). Interpersonal Relationships: Communication Skills for Nurses, 4th edn. W.B. Saunders, St Louis, MO.Find this resource:

Hollinworth H, Clark C, Harland R, et al. (2005). Understanding the arousal of anger: a patient-centred approach. Nursing Standard, 19(37), 41–7.Find this resource:

Working with families

Introduction

Families contribute greatly to the care and well-being of the child, but to do so effectively they must be considered part of the healthcare team. The nature of interaction between the family and professionals will impact upon team functioning. Developing positive relationships is a complex and demanding task which, to be successful, requires respect for each other’s knowledge, skills, and expertise.

Paternalism

  • Professionals, with the best intentions, decide what is best and expect compliance.

  • Power lies with professionals.

  • Assumptions are made which may be incorrect.

  • The family has a limited, controlled, contribution to care.

  • The family may feel frustrated at their perceived lack of input.

  • The family may be relieved that they do not have to make decisions.

Collaboration

  • Partnership, where power is shared with child/family, increases family choices.

  • Decision-making meets a family’s need to be included in care delivery and increases the prospect of compliance.

  • There is a danger that the family may feel overwhelmed and abandoned by professionals.

Empowerment

  • The family is educated and informed regarding condition, treatment, and care.

  • They are encouraged to participate in care delivery.

  • Support is provided in a non-judgemental way.

  • The family feels prepared for their role in care delivery.

  • Family wishes are taken into account when care is planned.

Important points

Team working:

  • Role clarity is crucial.

  • Be consistent: confusion/resentment arises when the family is part of the team one minute and then disregarded the next.

  • The family should not be pressured into carrying out care they feel unprepared or unable to do.

  • In a true collaboration, child/family decisions are accepted even if they differ from yours.

Communication

  • Acknowledge that often the child/family know what is best for them.

  • Be truthful at all times.

  • Give the family time to assimilate information and make decisions.

  • Speak to family members as individuals, as well as part of a group.

  • Remember to respect confidentiality of all family members.

Working with siblings

Siblings of all ages are affected by having an ill brother or sister, especially if the illness is chronic.

Young children

Parents report that they feel that babies, toddlers, and preschool siblings miss out on the normal cuddles and prolonged contact that they would have from mum, as she is constantly caring for her ill child. One parent’s solution to this was to ensure that another carer attended to her sick child for a full day once a week so she could give undivided attention to her other son on his special day. Other relatives or care team members may be available to give parents time to devote to siblings.

Older children

As children get older, parents report that they are often angry, frustrated, ashamed, attention seeking, and naughty. Children <10 years of age may not understand what is happening with their sibling. They may feel they are at risk of getting the disease or that they have caused the illness in some way. They may feel embarrassed and confused as they see their sibling is different from others. Parents need to acknowledge the feelings that their well child has, and discuss with the child how difficult it is to live with a poorly sibling, allowing them to feel free about discussing their feelings.

Adolescents

Adolescents may struggle with their own need for independence and may feel guilty about not wanting to be available for care-giving. They need to be reassured that their life does not revolve around caring for their sibling and that they should be attentive to their own needs. Most children of any age like to feel useful, but the burden of care should not be on their shoulders.

Interventions

In a study looking at psychosocial support for siblings of children with cancer, Murray8 reported that the most helpful interventions were emotional and instrumental support, followed by informational and appraisal support. It was noted that the greatest difficulty siblings remembered was being left out and not being able to share their feelings.

Support

Respite, especially in children’s hospices, is a valuable asset to allow siblings more access to family activities, as the care team takes over some of the parents’ care roles.

Support groups, e.g. Sibs, are available to provide centres where children of all ages can meet, socialize, and discuss concerns. They provide short breaks and holidays, enabling siblings to meet others in a similar situation.

Reference

8. Murray JS (2002). A qualitative exploration of psychosocial support for siblings of children with cancer. Journal of Pediatric Nursing, 17, 327–37.Find this resource:

Further reading

Fundamental aspects of children’s and young people’s nursing Sibs (for brothers and sisters of disabled children and adults) website: www.sibs.org.uk

Types of communication

  • Communication is a transfer of information and the flow of communication will be hindered if the non-verbal cues and the spoken message are incongruous (Table 1.7).

  • Effective communication requires good active listening skills.

  • In verbal communication, 7% of what we pick up relates to the content; 38% is vocal cues such as voice, style, and volume; and body language, including facial expression, makes up 55%.

Table 1.7 Challenges and solutions in communication

Challenge

Solutions

Ensuring consistency through multiprofessional working

Everyone uses the same words for body parts

Information is documented

Liaise with different agencies, e.g. youth worker

Access appropriate training

Involving children/young people and their families in decision-making

Consult and listen to their views about their care, how they want to be cared for, and change practice accordingly

Recognize where verbal communication is not possible

Engage with children/young people using their preferred method of communication, e.g. Makaton, drawing

Ensuring family involvement, where appropriate, but also recognize child/young person’s independence

Offering child/young person choice regarding whether their family is present

Be sensitive to the family’s contribution

Recognizing what child/young person considers embarrassing

Remove stigma through honest and frank dialogue

Use jargon sparingly and explain meaning

Use humour where appropriate

Developing mutual trust where information is freely exchanged

Establish boundaries regarding confidentiality. Create suitable environments, which create privacy

Identifying and establishing cultural expectations

Access knowledge and resources (Internet, community) regarding cultural issues

Ask child/young person and their family about their cultural needs

Relating treatment and care to lifestyle choices

Listen and establish the child/young person’s lifestyle and support them by accessing appropriate resources.

Keep informed about national initiatives, e.g. sexual awareness, obesity

Establishing understanding

Ask pertinent questions

Obtain child/young person’s and family’s perceptions of what is happening

Verbal communication

  • Voice and tone convey different messages, including pleasure, anger, frustration, and understanding.

  • Using an interpreter if the recipient does not have English as a first language aids understanding.

  • Accent, dialect, jargon, and language can detract from the message.

  • Tone and intonation of voice can reflect one’s emotion or attitude.

Non-verbal types of communication

  • Be aware of physical aspects:

    • Facial expressions, such as raised eyebrows, frown, smile, and yawn all convey information.

    • Eye contact: stare, direct focus, or blinking may indicate emotion and listening, but be aware of cultural differences.

    • Gestures such as hand movements are most commonly used when expressing a message and tactile information demonstrates emotional expression.

    • Remember to be sensitive towards personal space.

  • Creative communication, also known as aesthetic communication, includes creative expression such as play and music.

  • Symbolic communication makes use of religious, cultural, and cult symbols, which may include clothing, jewellery, and behaviour.

  • Environment and smell, including furniture arrangement, use of space and decor, enhance or detract from the communication process.

  • Movement can suggest a message, such as rushing past a patient, or children may communicate their emotions through movement such as rocking. Silence can convey comfort, tension, confusion, lack of understanding, fear, or reflection.

Communication systems

  • Makaton, sign language, and Braille are universally recognized as formal types of communication.

  • Picture books, photographs, drawings, shapes, and models are used successfully to convey messages.

  • Written information, including email, Internet, text, poetry and prose, are examples of communication that are used widely nowadays.

  • Storytelling, including patient’s stories, can share experiences and feelings, and give feedback.

Multimedia, electronic voices, and audio devices can offer alternative approaches to communication.

Effects of hospitalization

Children’s and young people’s nurses now adopt a range of initiatives to minimize the potentially harmful effects of hospital admission.

From Victorian times through to the 1960s and beyond, some hospitals only allowed parents to visit once a week or even less often. Until the advent of antibiotics, bed rest for ill children was long and continuous, and the screams and incessant crying bouts that accompanied each weekly visit convinced the nursing staff that parents were generally a hindrance rather than a help.

The recognition that psychological trauma might be perpetrated on children during their hospital stay owes much to the work of psychiatrist John Bowlby and his colleague James Robertson. Their work was to play a crucial role in improving the conditions under which children were cared for in hospital. As a result of this Sir Harry Platt launched ‘The Welfare of Children in Hospital’ in 1959 which fundamentally changed practice. However, much of the credit for changing the way children are cared for in hospital and the introduction of open and unrestricted visiting must be attributed to the National Association for the Welfare of Children in Hospital (NAWCH), now Action for Sick Children (ASC).

The important process of bonding and attachment is put at risk by any form of separation between mother and infant, leading Bowlby to pronounce: ‘Motherlove in infancy and childhood is as important for mental health as are vitamins and proteins for physical health’. (Bowlby later acknowledged that ‘mother’ could also imply another main carer and today it is commonplace for fathers or other significant family members to stay in hospital to support the child as well as, or instead of, the child’s mother. The ideal is to provide care at or closer to home to minimize the potential negative effects of hospitalization.)

Stages of maternal deprivation

Protest

This stage can last from a few hours to a few days. The child has a strong conscious need of the mother and the loud crying exhibited is based on the expectation, built on previous experience, that the mother will respond to the child’s cries. During this stage of the maternal deprivation sequence, the child will cry noisily and look eagerly towards any sound that might be the mother.

Despair

This stage succeeds protest and can best be compared to clinical depression. It is a sign of increasing hopelessness and despondency. The child becomes less active and vocal, and in the past this was interpreted by the nursing staff as a sign that the child was settling into the ward.

Denial/detachment

In this final stage of maternal deprivation the child represses the longing for the mother and begins to lose attachment. They appear, at least superficially, to have settled into the hospital routine and will respond positively, if shallowly, to kind adults who take an interest in them. Importantly, they will react badly to the mother’s brief reappearances, e.g. during the weekly visiting periods, giving rise to the fallacy that parents actually made matters worse. There is no wonder that generations of children’s nurses dreaded ‘Sunday afternoon visiting’.

Further reading

DH (2003). Getting the Right Start: National Service Framework for Children. Standard for Hospital Services. Department of Health, London.Find this resource:

Making the environment child/young person oriented

Children and young people require age-appropriate care when experiencing hospitalization. NHS modernization promotes the right of children and young people to be treated as individuals. The National Service Framework (2003) highlights the need for safe and suitable services that are designed around the needs of children and their families (including siblings). They should be staffed by suitably trained and skilled people. Any hospital department where services are provided for children and families needs to provide an environment of care which recognizes and responds to the following:

  • Children are different from adults, so they need distinct and tailored services.

  • Children’s physiology differs from that of adults and changes as they grow and develop.

  • Children suffer from a different range of diseases and disorders from those commonly seen in adults. This includes a higher proportion of rare and often complex congenital and inherited disorders.

  • Children’s mental capacity and level of understanding, e.g. about their bodies, illness, and death, may differ from that of most adults, and changes as they develop.

  • Children’s legal status, e.g. with respect to consent to treatment, differs from that of adults, and changes, in the eyes of the courts, at certain key points in chronological age, and with developmental and emotional factors.

  • Children are more vulnerable than most adults, and there is a greater need to safeguard their welfare.

  • Children using health services are usually accompanied by a parent or other responsible adult. This person may have distinct legal rights with respect to the child, for instance over consent to treatment. They will also have their own needs, e.g. for explanation and reassurance.

  • Children are strongly affected by the context in which they live. Usually the most important element of this context is the family, followed by friends, school, neighbourhood and community.

  • Children will become adults; and there is a growing understanding of the effects of childhood experiences, including illness, on their adult life.

A carefully designed hospital environment can help a child cope with the sense of loss experienced in their absence from home. An environment that encourages and displays play will aid its beneficial process:

  • Equipment used for treatment should be covered with colourful sheeting to alleviate fears.

  • Bright colours and pictures will project a friendly atmosphere where play is easily accessible.

  • Messy play is used to relieve anxiety.

  • Role play is facilitated to act out experiences with the help of puppets, dolls, and dressing up.

  • Visits from pets enable links with home.

  • Brightly coloured materials are used to make tabards for uniforms.

  • Posters and toys can be used to reflect and accommodate cultural diversity, including various languages and dolls of different ethnic mix.

Young people are a group quite distinct from children, and attention should be paid to their particular needs:

  • Hospital school provides a routine for the older child, and can also be delivered to the school-age bed-bound patient.

  • A teenage room can provide an escape from younger children.

  • A dedicated adolescent unit with specially trained staff is the ideal.

  • Patients’ beds can be grouped according to age, as resources and patient condition allow.

Children’s nurses work in the family, delivering the ethos of family-centred care with an environment that:

  • encourages normal family routine

  • recognizes the parent as the expert in their child

  • provides resident parenting.

Play is an integral part of family-centred care. Collaborate with the hospital play specialist or play leader to maintain a child-focused environment.

A dedicated environment for children and young people can be achieved by practical measures, supported by a philosophy of care to strengthen its delivery.

Further reading

DH (2003). Getting the Right Start: National Service Framework for Children. Standard for Hospital Services. Department of Health, London.Find this resource:

Preparing children and young people for hospital

Emotional factors may be an even greater source of concern than the child’s physical condition during a hospital admission.

There are five key potential threats to a child on admission to hospital:

  • Fear of the unknown

  • Fear of physical harm and pain

  • Loss of control and identity

  • Uncertainty about what is expected of them

  • Separation from security and family routine.

The way in which children interact with the world and how they understand and interpret what they see and hear is influenced enormously by their age and stage of development. A number of different strategies have been developed to help children and their families cope with hospital admission.

Family preparation for day- and in-patient surgery may be important in reducing the psychological effects of hospitalization. This has led to the development of paediatric pre-admission programmes throughout the UK which aim to protect children from the stresses of hospital admission.

Preadmission preparation programmes (cited as good practice in the National Service Framework) offer the child and family the opportunity to visit the hospital and familiarize themselves with the environment and personnel. At the same time, practical issues can be discussed and the child and family informed about anticipated specific events.

Invitations to programmes are often sent out in the mail with all the other information prior to admission. These programmes often consist of a PowerPoint or video/DVD presentation followed by a visit to the ward/unit to which the child will be admitted. Additionally, the children may have the opportunity of visiting the anaesthetic room with their carers, where they can see first hand where they will receive their anaesthetic and, importantly, know that their parent or carer will be allowed to go with them on the day.

The role of the skilled play specialist is another essential element of pre-admission preparation, but not to the exclusion of the skilled children’s nurse. A major benefit of these programmes is that they facilitate interaction between hospital staff and parents, who are encouraged to ask programme workers about their child’s admission.

Children learn through play, and time set aside to hospital-type play gives the child an ideal opportunity to find out about their hospital experience. In doing so, their fears may be allayed and their abilities to cope enhanced.

Further reading

DH (2003). Getting the Right Start: National Service Framework for Children. Standard for Hospital Services. Department of Health, London.Find this resource:

Admission to hospital

The aim of the contemporary NHS is to deliver hospital services to meet the needs of children, young people, and their parents in a suitable, child-friendly, child-centred environment by appropriately trained and skilled staff.

Admission to hospital may be an anxiety-provoking experience for both child and parents alike. The role of parents in the care of their child in hospital cannot be overstated and has been advocated in many policy documents.

Admission to hospital may be planned, as in the case of a child attending for investigations or for elective surgery. This can be undertaken through pre-admission programmes, the provision of written information, visits to the ward/unit, and preoperative assessment clinics. However, for many infants, children, and young people their attendance to hospital will be unplanned.

A child with limited life experiences may well have preconceived ideas about hospital from friends, relatives, and the media. The aim of the admission process is not only to identify the alterations to the physical status of the child but, more importantly, to inform the child of all expected outcomes in order to allay fear and stress.

Children should only be admitted to children’s wards, and young people should be offered a choice of accommodation. The concept of family-centred care and partnership needs to be embraced as a key principle when admitting a child to hospital. Parents know their child better than we ever can, and the need to involve the parents serves to enhance their locus of control, thus having a more positive outcome for the child.

This may be achieved by the following:

  • Introductions to the ward team and fellow patients.

  • Identifying what the child and family wish to know and allowing them time to question.

  • Drawing on any previous experience of hospitalization.

  • Orientation to the ward and hospital, outlining facilities available; this should be supported by written information.

  • Considering the child’s developmental stage at all stages of the hospitalization episode.

  • Clarifying the child’s and family’s understanding of the reason for hospitalization.

  • Including other family members (if present).

  • Identifying the impact of hospitalization on the child and family, and helping them to comprehend their reaction (e.g. reaction of siblings, behaviour of the sick child).

  • Identifying normal routines and integrating them into the care plan; non-medical needs such as play and school work should not be overlooked.

  • Negotiating care with parents; establishing the role of parents in care.

  • Establishing preferred names.

  • Identifying who has parental responsibility.

  • Recognizing the terms the child and family may use for the pain or illness.

  • Applying identification band and allergy band (if used) to child, having confirmed correct details with parent and child first.

  • Including child and parent, performing nursing admission history and documenting.

  • Recording vital signs as a baseline; this normally includes temperature, pulse rate, respiratory rate, blood pressure, weight, height, oxygen saturation level.

  • Collecting any specimens as required and managing as required.

  • Supporting child and family during physical examination by medical colleagues, or other investigations such as venepuncture, ensuring adequate preparation prior to any procedure.

  • In the case of an emergency admission, prioritizing care on physical need, with a nurse assigned to support the parents during this stage.

  • Documenting admission process and findings before establishing nursing diagnosis and beginning to plan care with the child and parents.

  • Asking the child and family to reiterate information, to identify their understanding of it.

Children with learning disabilities

Children with learning disabilities and their families may need additional support when the child is admitted to hospital. Strategies may include:

  • emphasis on the value of emotional support for the child and family.

  • ensuring that staff are prepared for the child’s admission.

  • clarifying staff and carer roles and strategies to support the child’s behaviour.

  • providing private space as appropriate.

Further reading

DH (2003). Getting the Right Start: National Service Framework for Children. Standard for Hospital Services. Department of Health, London.Find this resource:

Jackson Brown F, Guvenir J (2009). The experiences of children with learning disabilities, their carers and staff during hospital admission. British Journal of Learning Disabilities, 37(2), 110–15.Find this resource:

Partnership model of nursing

Principles

Partnership nursing is based on recognition of, and respect for, the child/young person and family’s rights and preferences, as well as their knowledge about, and expertise in, (their own) care and treatment. It involves the following:

  • Ongoing provision of information, teaching, and support to enable them to be involved in decision-making, care, and treatment to the extent that they wish to be.

  • Negotiation of choices and care responsibilities, balancing the child/young person and family’s needs and preferences with available resources and professional views of what is needed.

Partnership is an approach to child- and family-centred care; it differs from family involvement in that there is no assumption that the child and family will be involved.

Practice

Assess

  • Ask the child; ask the parents/carer.

  • Invite the child/parent to observe and measure.

  • Confirm your impressions and conclusions with the child and parents, especially their view of priorities.

Plan

  • Agree goals with the child and parents.

  • Discuss possible actions and assist them in making choices.

  • Agree plan for what needs to be done, who will do it, when, and how.

  • Plan for regular shared review of the plan, care responsibilities, and teaching and support needs.

Implement

  • Perform direct care as planned (child, parents, nurse).

  • Facilitate learning and information sharing.

  • Provide support and supervision.

  • Monitor progress and re-assess as planned (child, parents, nurse).

  • With consent, refer to other professionals and coordinate care.

Evaluate

  • Invite the child and parents to observe and measure outcomes and report their experience of care.

  • Review and reflect on the care process from the child and family perspective and from the professional nursing perspective.

Outcomes

Evaluation and audit of the partnership model for nursing children and young people address the following questions:

  • Did the child/young person and family feel that their views and preferences were heard and their knowledge and experience respected?

  • Were they involved in decisions, care, and treatment to the extent they wished to be?

  • Did they feel adequately informed and supported in making decisions and carrying out care/treatment?

Further reading

Casey A (2010). Assessing planning care in partnership. In: Glasper EA, Richardson J (eds) A Textbook of Children’s Nursing, 2nd edn, pp. 87–100. Churchill Livingstone, London.Find this resource:

How to write a care plan

What is a care plan?

  • A nursing care plan is a written structured plan of action for patient care based on a holistic assessment of patient requirements, the identification of specific problems, and the development of a plan of action for their resolution.

  • Care plans are designed to provide the organizing frame for the planning, provision, and evaluation of nursing care, and they operate as a vehicle for communication and a record of care given.

  • The NMC views record-keeping as an essential aspect of nursing care and not a distraction from its provision. It is a professional requirement for nurses to construct and maintain accurate care plans.

Structure of a care plan

  • The structure of a care plan is dependent on the nursing model on which it is based, and as there are many models, there is also a wide range of formats for a nursing care plan. Whichever nursing model the care plan is based on, it should involve all four elements of the nursing process, i.e. the assessment, planning, implementation, and evaluation of nursing care.

  • The nursing care plan must be factual and accurate. It should be seen as a structured tool for documenting holistic care, including a balanced assessment of patient need.

  • The care plan should contain sufficient detail for a nurse to care for the patient without further information.

Writing a care plan

  • Following the nursing assessment, the nurse must identify the patient’s needs and document accordingly.

  • A plan must be written for each identified need, consisting of a nursing diagnosis (what the problem/need is), expected outcome(s) and/or goals, nursing interventions and rationales required to meet the outcome, and a time at which the plan should be reviewed.

  • The intended goal may not be a return to full health but should be appropriate to the patient and the individual circumstances.

  • There may be more than one goal for each diagnosis, and each goal should have a set of interventions/rationales required for its achievement.

  • The nurse caring for the patient should follow each care plan, which should be assessed and evaluated following every intervention or change in the patient’s condition.

  • Care plans should remain contemporary—they must be reviewed regularly and rewritten or changed to accurately reflect the patient’s current needs (Fig 1.15).

Further reading

NMC (2015). Keep clear and accurate records relevant to your practice. In: The Code: Professional Standards of Practice and Behaviour for Nurses and Midwives. Nursing and Midwifery Council, London. Fundamental aspects of children’s and young people’s nursing http://www.nmc.org.uk/standards/code/read-the-code-online/#fourth

Evaluation of care

In order to measure the effectiveness of the care that is delivered, and to justify the contribution that we as nurses make to the patient experience, evaluation of that care is essential to identify whether the goals or outcomes of that care has been achieved.

Evaluation involves:

  • Comparison of the outcome with the original goal or outcome statement.

  • If the goal or outcome is not achieved, then reassessment and reformulation of the nursing outcomes or goals for the child.

The evaluation of care cannot take place if there is no statement or tool to measure it against. For example, how can you evaluate the effectiveness of analgesia that you administered to a child if you have no nursing outcome statement with which to compare it?

Evaluation skills are similar to assessment skills, and are intrinsically linked. By continually evaluating the care delivered to the child, predictions and effectiveness of interventions will become known to both the nurse and the child, thus affording the child choice in their future care.

Evaluation of care is an ongoing process and it is an essential component of the nursing process. This may be referred to as formative evaluation, with summative evaluation taking place once the nurse is no longer involved in the care of the child. In evaluating the care given and its effectiveness, the nurse must also critically examine the implementation of the care given, to identify if it was delivered by the most effective means and what it was like for the child and family. Any difficulties encountered in carrying out the plan of care should be documented, as should any changes to the plan of care. Nursing records serve to protect the patient and should contain an accurate account of the treatment given and the care planned and delivered.

Although it is the final part of the nursing process, it is a continual activity, and best practice should advocate the involvement of the child and family so that assumptions will not be made about the effects of care; thus making evaluation objective and empowering the child and parent.

Further reading

NMC (2015). Keep clear and accurate records relevant to your practice. In: The Code: Professional Standards of Practice and Behaviour for Nurses and Midwives. Nursing and Midwifery Council, London. Fundamental aspects of children’s and young people’s nursing http://www.nmc.org.uk/standards/code/read-the-code-online/#fourthFind this resource:

Parental participation in care

Parental participation in care is an essential aspect of partnership with parents and family-centred care. Care is planned and delivered in negotiation with parents, who enjoy an equal partnership with healthcare professionals in the care of the child.

Power in decision-making and care-giving is usually invested in the family, but in the hospital the nurse holds the balance of power. Parents may not see themselves as equal partners in care. The success of parental participation is dependent on a number of variables, but particularly on the willingness of nurses and parents to work together.

Although contemporary child care philosophy encourages parents to accompany their hospitalized children and to be actively involved in their care, this role sometimes causes stress for both parents and nurses:

  • Parents because of increased demands made upon them, or because they feel deskilled in their parental role.

  • Nurses because of changes to their traditional caring roles, leaving them feeling threatened by parental participation in care.

Barriers to parental participation

  • Role stress

  • Nurses’ attitudes, judgements, and beliefs

  • Parental attitudes

  • Poor communication skills

  • Poor negotiation skills

  • Poor documentation.

  • Poor information exchange

  • Lack of commitment on either side

  • Lack of clarity of the concept

  • Lack of equal partnership

  • Lack of parental control

Implications for practice

  • Education to promote the concept

  • Commitment to the concept

  • Recognition of the barriers and strategies to overcome them

  • Development of negotiation and communication skills

  • Development of self-awareness.

  • Development of documentation to support practice

  • Equal partnership

  • Clear guidelines about expectations on both sides

  • Respect, empowerment, and empathy

Parents are likely to know their child better than anyone and may already be experts in their care; they will need to make informed decisions and choices about what happens to their child; they are likely to be one of the best communicators with, and advocates for, the child when they are unwell or vulnerable; they are the best people to ‘normalize’ the experience of coming into hospital for the child.

Further reading

Royal College of Paediatrics and Child Health (2010). Not Just a Phase: A Guide to the Participation of Children and Young People in Health Services. Royal College of Paediatrics and Child Health, London.Find this resource:

Moving and handling of children

The Manual Handling Operations Regulations 1992 (amended in 2002) define manual handling as: ‘any transporting or supporting of a load (including the lifting, putting down, pushing, pulling, carrying or moving thereof) by hand or bodily force’.

The UK Health and Safety Executive have identified that manual handling is a major cause of back injury. Because of the high incidence of back injuries in the health services, many Trusts have a ‘no lifting’ policy, but what about the nurse who needs to lift distressed babies and toddlers? If you undertake this task, you must comply with good handling techniques (Fig 1.16) and avoid all high-risk activities.


Fig 1.16 Techniques in lifting children.

Fig 1.16 Techniques in lifting children.

Before any manoeuvre, a manual handling assessment should be undertaken, to reduce the risk of handling to the lowest level, with TASK, LOAD, INDIVIDUAL and ENVIRONMENT being considered.

Lifting children will never be completely safe, but working with the following weight guidelines (Fig 1.17 and Table 1.8) will cut the risk and reduce the need for a more detailed assessment. These guidelines are for infrequent operations, <30 lifts an hour, and therefore compatible with your day- to-day work. The two positions are close to or away from the body.


Fig 1.17 Weight guidelines for lifting children.

Fig 1.17 Weight guidelines for lifting children.

Table 1.8 Interpreting ‘safe’ weights into age groups of children

Average age of child

Weight

Comments

Birth–1 month

3 kg

Before lifting a child make a quick assessment. If a child is lifted between zones, e.g. from floor to waist, the smallest weight should be the guide weight. If the weight involves any twisting, such as getting a child out of a car, the weight needs reducing further

4–6 months

7 kg

11–13 months

10 kg

22–25 months

13 kg

3 years

15–16 kg

5.5–6 years

20 kg

8 years

25 kg

Manoeuvres requiring special consideration

There are many instances when you will have to consider the risk carefully; the following are just a few examples:

  • Lifting children with disability such as cerebral palsy, when the child’s movements may be unpredictable.

  • Lifting and moving a child of any age with a plaster cast.

  • Lifting children who are attached to equipment; in most of these instances the child cannot be held close to the waist.

There are also special considerations if you are lifting when pregnant.

Further reading

Health and Safety Executive (2004). Manual Handling: Manual Handling Operations Regulations 1992 (as amended). Guidance on Regulations, 3rd edn. HSE Books, London.Find this resource:

Fundamental aspects of children’s and young people’s nursing Health and Safety Executive. Moving and Handling in Health and Social Care. www.hse.gov.uk/healthservices/moving-handling.htm

Therapeutic holding and restrictive physical intervention

Definition

Therapeutic holding

Therapeutic holding is a practice performed by skilled nurses or practitioners to support a child or young person through a therapeutic intervention, preventing harm or further discomfort, such as splinting or holding or using limited force. It is performed with consent from someone in a position to give this, e.g. the child or the child’s parent or guardian. It can also be known as supportive holding or clinical holding.

Restrictive physical intervention

Restrictive physical intervention is a practice performed by skilled nurses or practitioners who need to use a greater degree of force to prevent a child or young person from hurting themselves, others, or property, preventing serious harm. It may be performed without the consent of the individual being restricted or from someone in a position to give this. If in doubt, seek legal advice. It can also be known as containing or restraint.

Differences

The difference between restrictive physical intervention and therapeutic holding is the degree of force used, the outcome, and consent. It is imperative that the degree of force used to restrain or hold, should be such that it does the child no further harm (non-maleficence). Both are performed in the best interest of the child or young person (beneficence).

Risk

When considering the need to hold or restrict a child there will always be risks involved, not only for the child but also for the nurse or practitioner performing the restrictive physical intervention or hold. All risks need to be identified and reduced to the lowest level possible.

  • There needs to be recognition of the rights of the child and knowledge of ethical and legal implications, consent, and mental capacity.

  • There should be recognition that de-escalation as a method of risk assessment is useful to prevent the need to hold in the first place.

  • Consideration must be given to the restraint or holding technique used, and the impact this will have on the child’s physical and mental well-being.

Accountability

Nurses are accountable and must be able to justify their actions, now and in the future. All nurses have a duty to provide the best possible care to the child or young person, remember: ‘Children of today will be adults of tomorrow, able to question practice from the past.’

Nursing management

The RCN (2010) clearly addresses the need for good practice when restricting or holding children and has produced guidelines. They suggest that consideration is needed to ensure the practice is performed:

  • within an ethos of caring.

  • with the support of a written policy relevant to each practice area and identifying the risks, roles, techniques, and the need to document actions.

  • by nurses and practitioners educated in the principles of restrictive physical intervention and holding techniques.

  • in an atmosphere where staff will be heard if they disagree with the need to hold.

  • where appropriate with the agreement beforehand of the child, parent or guardian, and nurses and practitioners.

  • where appropriate, with the involvement and presence of the parent or guardian.

  • as a last resort, after considering the use of distraction, analgesia, and sedation.

  • by nurses and practitioners with the knowledge of how to reduce the need to hold in the future for those requiring ongoing treatment.

Further reading

Jeffery K (2008). Supportive holding of children during therapeutic interventions. In: Kelsey J, McEwing G (eds) Clinical Skills in Child Health Practice, pp. 49–58. Churchill Livingstone Elsevier, London.Find this resource:

Jeffery K (2010). Supportive holding or restraint: terminology and practice. Paediatric Nursing, 22(6), 24–8.Find this resource:

Jeffery K, Deaves J (2007). Translating policy and guidelines into practice: an education–practice synergy. Journal of Children’s and Young People’s Nursing, 1(2), 93–7.Find this resource:

NMC (2015). The Code: Professional Standards of Practice and Behaviour for Nurses and Midwives. Nursing and Midwifery Council, London. Fundamental aspects of children’s and young people’s nursing http://www.nmc.org.uk/standards/code/read-the-code-online/#fourthFind this resource:

RCN (2010). Restrictive Physical Intervention and Therapeutic Holding for Children and Young People: Guidance for Nursing Staff. Royal College of Nursing, London.Find this resource:

Principles of physical assessment

The principles of paediatric physical assessment involve more than observation, palpation, percussion, and auscultation. It should be remembered that even though the examination of the child is relatively painless, interventions such as the introduction of an oroscope into the ear, the palpation of the abdomen, or a cold stethoscope on the chest might all be very stressful to the child. Consideration should always be given to the child’s psychological needs.

General guidance for performing paediatric physical examination

  • Perform the examination in an appropriate non-threatening area that provides privacy.

  • Place all strange and potentially frightening equipment out of sight.

  • Have some appropriate toys and games available to comfort or distract the child; consider involving a play specialist if appropriate.

  • Provide time for play and becoming acquainted.

  • When appropriate, involve the child and parents in the examination process.

  • Provide an explanation to the child and parent about the examination procedure.

  • Use a quiet, calm, and confident voice.

  • Begin the examination in a non-threatening manner.

  • Examine the child in a secure and comfortable position.

  • Proceed to examine the child in an organized sequence.

  • Leave painful and unpleasant procedures until last.

  • In emergencies, examine Airway, Breathing, and Circulation first.

  • Reassure the child and family throughout the examination.

  • Discuss the findings of the examination with the child and family at the end of the examination.

  • Thank the child and family for their cooperation during the examination.

Examining the child

Usually the child is examined from head to toe by dividing the body into specific areas, so as to reduce the likelihood of omitting sections of the examination. When examining children, the order in which these sections are examined frequently changes to take into account the child’s developmental needs.

When examining the child, remember the following four principles:

  • Rapport: develop a rapport with the child in order to gain their confidence.

  • Observation: gain information from informal observation while taking their history.

  • Undress the child: the child should be undressed down to the underwear to maximize the likelihood of finding physical signs; however, care should be taken to maintain the child’s dignity. Wherever possible ask the child or parent/carer to do this.

  • Be systematic: follow the order of:

    • observation

    • palpation

    • percussion

    • auscultation.

Further reading

Cook K, Montgomery H (2010). Assessment. In: Trigg E, Mohammed TA (eds) Practices in Children’s Nursing: Guidelines for Hospital and Community, 3rd edn, pp. 67–80. Churchill Livingstone, London.Find this resource:

Assessing a child’s temperature

Indications

  • To determine the child’s temperature as a baseline for comparison with future measurements (see Table 1.9).

  • To monitor fluctuations in temperature.

Table 1.9 Normal core temperature by age

<6 months

37.5°C

7 months–1 year

37.5–37.7°C

2–5 years

37.0–37.2°C

>6 years

36.6–36.8°C

Methods of assessment

Axilla

An electronic digital thermometer or disposable chemical dot thermometer is placed in the clean, dry armpit for 3 min.

  • Advantages: safe and non-invasive and the preferred method for babies and small children (<5 years) if the rectal method is not suitable.

  • Disadvantages: relatively inaccurate and unreliable, readings being up to 0.92°C lower than the rectal reading, commonly listed as the least accurate method. The time required to obtain an accurate reading can pose a problem with young, active children.

Tympanic membrane

An electronic tympanic membrane thermometer is placed in the ear canal for 2–10 s.

  • Advantages: very quick, safe, and non-invasive. This method is preferred by children.

  • Disadvantages: some doubt exists as to reliability and accuracy. Least accurate for babies and young children and in detecting high fever. It cannot be used where the probe does not fit the ear canal, where ear problems exist, where accuracy is important, or within 20 min of a change in ambient temperature. High fevers need to be confirmed by another method.

Oral

An electronic digital thermometer or disposable chemical dot thermometer is placed in the sublingual pocket at the base of the tongue for 2 min.

  • Advantages: provides the second most accurate and reliable readings; readings are commonly only 0.3–0.6°C lower than rectal measurements.

  • Disadvantages: caution should be exercised with non-compliant children, those <5 years, or those with a history of seizures, to avoid the hazards of biting the thermometer.

Rectal

A glass/mercury thermometer or electronic digital thermometer is inserted 2–4 cm into the rectum.

  • Advantages: most accurate and reliable reflection of core temperature and the preferred means of assessing moderately or critically ill children and babies <1 year.

  • Disadvantages: invasive, potentially perceived as abusive. Risks include lower bowel perforation, breakage of glass thermometer and exposure to toxic mercury, cross-infection, and reactionary diarrhoea (in babies).

Further reading

Aylott M (2008). Assessment of temperature, pulse and respiration. In: Kelsey J, McEwing G (eds) Clinical Skills in Child Health Practice, pp. 70–95. Churchill Livingstone. London.Find this resource:

Cook K, Montgomery H (2010). Assessment. In: Trigg E, Mohammed TA (eds) Practices in Children’s Nursing: Guidelines for Hospital and Community, 3rd edn, pp. 67–80. Churchill Livingstone. London.Find this resource:

Gormley-Fleming E (2010). Assessment and vital signs: a comprehensive review. In: Glasper A, Aylott M, Battrick C (eds) Developing Practical Skills for Nursing Children and Young People, pp. 109–47. Hodder Arnold, London.Find this resource:

RCN (2011). Standards for Assessing, Measuring and Monitoring Vital Signs in Infants, Children and Young People. Royal College of Nursing, London.Find this resource:

Assessing a child’s heart rate

Indications

  • To determine the child’s heart rate as a baseline for comparison with future measurements (see Table 1.10).

  • To assess the stability of the cardiovascular system.

  • As part of routine monitoring.

  • As part of assessing pain.

  • To monitor fluctuations in the heart rate.

Table 1.10 Normal heart rates

Awake (bpm)

Asleep (bpm)

Newborn

100–180

80–160

<3 months

100–220

80–180

3 months–2 years

80–150

70–120

3–10 years

70–110

60–100

10 years–adult

55–90

50–90

Methods of assessment

Infant

  • Use a stethoscope to hear the sound of the heart beating—’apex beat’.

  • Place the stethoscope head on the baby’s chest, between the left nipple and the sternum, and establish the characteristic ‘lub-dub’ sound of the heartbeat.

  • The number of complexes heard over a full minute gives the heart rate.

  • If the rate is very rapid (>120 bpm), you may be able to count every other complex and double it to establish the actual rate.

  • You may be able to palpate a pulse in an artery (such as brachial or femoral) to verify the rate and observe the amplitude of the heartbeat.

Child

  • Assess the heart rate by palpating the arterial pulse at any of a number of sites, including the radial, brachial, femoral, carotid, and temporal arteries.

  • Consider the most appropriate site to be used with regard to privacy, dignity, and comfort.

  • The radial artery pulse is the most common site and tends to cause the least discomfort; however, in shock it is likely to be one of the first pulses to become impalpable.

  • Place the pads of your first and second fingers over the pulse point and establish the pulse.

  • Count the number of pulses over 1 full minute, giving the heart rate.

  • Also note the characteristics of the pulse.

Pulse characteristics

When assessing the heart rate by either method, it is important to note the characteristics of the heartbeat.

  • The amplitude of the beat gives a reflection of the pulse strength and elasticity of the artery wall and may be described as full or bounding, weak or faint.

  • The rhythm may be noted as regular or irregular; and an irregular beat as ‘regularly-irregular’ or ‘irregularly-irregular’. In these cases, an apex beat should also be observed for comparison.

  • When recording the heart rate, it is also important to relate the observation to the activity level of the child and what rate might reasonably be expected.

Further reading

Aylott M (2008). Assessment of temperature, pulse and respiration. In: Kelsey J, McEwing G (eds) Clinical Skills in Child Health Practice, pp. 70–95. Churchill Livingstone. London.Find this resource:

Cook K, Montgomery H (2010). Assessment. In: Trigg E, Mohammed TA (eds) Practices in Children’s Nursing: Guidelines for Hospital and Community, 3rd edn, pp. 67–80. Churchill Livingstone. London.Find this resource:

Gormley-Fleming E (2010). Assessment and vital signs: a comprehensive review. In: Glasper A, Aylott M, Battrick C (eds) Developing Practical Skills for Nursing Children and Young People, pp. 109–47. Hodder Arnold, London.Find this resource:

RCN (2011). Standards for Assessing, Measuring and Monitoring Vital Signs in Infants, Children and Young People. Royal College of Nursing, London.Find this resource:

Assessing a child’s respiratory rate

Indications

  • To determine the child’s respiratory rate as a baseline for comparison with future measurements (see Table 1.11).

  • To monitor fluctuations in the respiratory rate.

  • To assess and monitor the infant’s and child’s condition.

  • To evaluate the child’s response to respiratory medications or treatments.

  • Respiratory failure is the primary cause of collapse in children.

Table 1.11 Normal respiratory rates (breaths/min)

Newborn

30–60

6 months

30–45

1–2 years

25–35

3–6 years

20–30

7–12 years

20–25

Adolescent

14–20

Method of assessment

  • Carry out this observation surreptitiously, to avoid the child being aware of the process and, either consciously or subconsciously, altering their breathing pattern.

  • Count the number of complete inhale/exhale combinations over the course of a minute, observing the chest or abdominal movements and sounds as indicators.

  • In babies and young children, it is important to count for a full minute as it is normal for the rate and pattern of breathing to change from one moment to the next, including pauses of up to 10 s.

Respiration characteristics

When assessing the child’s respiratory rate, observe:

  • The depth of respirations: gives an indication of the adequacy of the tidal volume.

  • The quality of respiration: this can be indicated by use of muscles, breath sounds, and other body responses.

A baby normally uses its abdominal muscles and a school-age child its costal muscles, to breathe. Respiratory distress should be suspected in a baby who is breathing costally or a child breathing abdominally.

Normal respiration is quiet, but unusual sounds such as wheezing, crackling, grunting, crowing, or stridor may indicate respiratory distress.

If breathing is difficult, there may be evidence of accessory muscle use, including use of the intercostal muscles, shoulders rising on inspiration, or head-bobbing. Other signs such as tracheal tug, nasal flaring, restlessness, unusual posturing, intercostal, subcostal, or sternal recession, and peripheral or central cyanosis must all be taken as evidence of respiratory distress.

Further reading

Aylott M (2008). Assessment of temperature, pulse and respiration. In: Kelsey J, McEwing G (eds) Clinical Skills in Child Health Practice, pp.70–95. Churchill Livingstone. London.Find this resource:

Cook K, Montgomery H (2010). Assessment. In: Trigg E, Mohammed TA (eds) Practices in Children’s Nursing: Guidelines for Hospital and Community, 3rd edn, pp. 67–80. Churchill Livingstone. London.Find this resource:

Gormley-Fleming E (2010). Assessment and vital signs: a comprehensive review. In: Glasper A, Aylott M, Battrick C (eds) Developing Practical Skills for Nursing Children and Young People, pp. 109–47. Hodder Arnold, London.Find this resource:

RCN (2011). Standards for Assessing, Measuring and Monitoring Vital Signs in Infants, Children and Young People. Royal College of Nursing, London.Find this resource:

Assessing a child’s blood pressure

Indications

  • To determine the infant’s and child’s blood pressure as a baseline for comparison with future measurements (see Table 1.12).

  • To monitor fluctuations in the blood pressure.

  • To assess the infant’s and child’s cardiovascular system.

  • To assist in the diagnosis of disease (e.g. renal; cardiac).

Table 1.12 Normal blood pressure values

Systolic pressure (mmHg)

Diastolic pressure (mmHg)

Newborn

60–85

20–60

6 months

75–105

40–70

2 years

75–110

45–80

7 years

75–115

45–80

Adolescent

100–145

60–95

Methods of assessment

The blood pressure may be measured either directly or indirectly:

  • Direct measurement is by far the more accurate method and involves placing a tiny pressure transducer into an artery, calibrating it, and reading the pressures on an electronic monitor.

  • Indirect measurement can be carried out by either auscultation or oscillometry.

Auscultation

This method involves the use of an aneroid sphygmomanometer and stethoscope.

  • Place the sphygmomanometer at the level of the child’s heart and place the appropriately sized cuff snugly around the upper arm.

  • Support the arm in a slightly flexed position and inflate the cuff rapidly while palpating the brachial pulse.

  • When the pulse can no longer be detected, inflate the cuff by a further 20 mmHg and apply the stethoscope head gently over the brachial artery.

  • Deflate the cuff at a rate of 5 mmHg/s while listening for Korotkoff’s sounds (Table 1.13).

  • When the first ‘sharp thud’ is heard, this marks the systolic pressure.

  • As the cuff is deflated further, the sound changes from a ‘softer thud’ to a ‘softer blowing’ sound, which marks the diastolic pressure.

  • Deflate the cuff rapidly and remove.

Table 1.13 Korotkoff’s sounds

Phase 1

Phase 2

Phase 3

Phase 4

Phase 5

Sharp thud

Blowing/swishing sound

Softer thud

Softer blowing/swishing sound

Silence

Systolic

Diastolic

This method is very difficult to use reliably on infants and young children, especially if they are not cooperative.

Oscillometry

This involves the use of an electronic blood pressure machine to measure the pressures and can be advantageous for use on babies and young children.

The cuff can be applied to either the upper arm or lower leg. However, there are limitations to its use; movement of the limb adversely affects accuracy and reliability, and the cuff inflation pressure may be excessive and painful.

Factors to consider

  • A child’s blood pressure varies with age, is closely related to height and weight, and there is normal variability between children of the same age and build.

  • Excitement, anxiety, discomfort, pain, and the process of measurement itself may all result in a rise in actual blood pressure.

  • For these reasons, clinical decisions should never be based on a single blood pressure recording.

  • Measurement should be carried out when the child is relaxed and has been sitting or lying quietly for at least 2 min.

  • Korotkoff’s sounds may not be reliably heard in children <5 years of age.

  • When measured in the legs, the blood pressure may be slightly higher than when measured in the arms.

  • The widest possible cuff that can be applied to the limb should be used and the inflation bladder should be at least two-thirds of the circumference of the limb. An undersized cuff will result in a false high reading; an oversized cuff will give a false low reading. The cuff should be removed from the limb between use to prevent problems associated with ischaemia and neuropathy. Mercury sphygmomanometers are no longer considered acceptable for use due to the hazard that toxic mercury presents.

  • NB it is sometimes difficult to get a blood pressure reading and in an emergency situation an assessment of capillary refill time is recommended.

Further reading

Brennan EP (2008). Assessment of blood pressure. In: Kelsey J, McEwing G (eds) Clinical Skills in Child Health Practice, pp. 88–95. Churchill Livingstone, London.Find this resource:

RCN (2011). Standards for Assessing, Measuring and Monitoring Vital Signs in Infants, Children and Young People. Royal College of Nursing, London.Find this resource:

Observation of the sick child

The European Resuscitation Council recommends using the Airway, Breathing, and Circulation (ABC) approach. This is a structured approach which is easy to remember, and the child should be constantly re-assessed using this system.

Airway and breathing

The rate and rhythm should be noted (Table 1.14). Observe for:

  • signs of recession

  • inspiratory or expiratory noises

  • grunting

  • use of accessory muscles

  • nasal flaring

  • chest symmetry when auscultating the chest

  • a silent chest is a worrying sign

  • SaO2 should be >98% in air. Use of supplemental O2 will affect the reading

  • child’s ability to talk: severe breathlessness will affect this.

Table 1.14 Respiratory rate by age at rest (breaths/min)

Newborn

30–60

6 months

30–45

1–2 years

25–35

3–6 years

20–30

7–12 years

20–25

Circulation

  • Note heart rate (see Fundamental aspects of children’s and young people’s nursing Table 1.11, p. 55) and pulse volume.

  • Capillary refill should be <2 s and should be done on the sternum. A patient who is shocked or has hypothermia will give a false capillary refill time.

  • If the capillary refill time is >2 s, give a fluid bolus of 20 mL/kg. Normal saline is the first bolus of choice. Repeat the fluid bolus until the capillary refill is <2 s.

Blood pressure

  • Hypotension is a preterminal sign. Children maintain their blood pressure for a long period and respiratory arrest commonly follows a fall in blood pressure (Table 1.15).

  • The correct cuff size should be used for an accurate reading. The biggest size to fit the arm should be used—too small will result in a falsely raised reading. If the child is screaming, in pain, or fitting, this may also result in a falsely raised blood pressure.

Table 1.15 Normal blood pressure values

Systolic pressure (mmHg)

Diastolic pressure (mmHg)

Newborn

60–85

20–60

6 months

75–105

40–70

2 years

75–110

45–80

7 years

75–115

45–80

Adolescent

100–145

60–95

Disability

  • A rapid assessment can be made using:

    • A:  Alert

    • V:  Responsive to voice

    • P:  Responsive to pain

    • U: Unresponsive.

  • If a child has a score of P/U, consider intubation to maintain a secure airway.

  • After the initial assessment, use the Glasgow Coma Scale (GCS) with the appropriate age scale. There are two age scales: <4 years of age and >4 years of age.

  • All observations should be recorded in black ink and initialled by the professional recording them. It is important to look at the trend when recording observations and not isolated observations. The trend will show an improvement or decline in condition. Record observations as frequently as appropriate.

Further reading

Aylott M (2008). Assessment of temperature, pulse and respiration. In: Kelsey J, McEwing G (eds) Clinical Skills in Child Health Practice, pp. 70–95. Churchill Livingstone. London.Find this resource:

Brennan EP (2008). Assessment of blood pressure. In: Kelsey J, McEwing G (eds) Clinical Skills in Child Health Practice, pp. 88–95. Churchill Livingstone, London.Find this resource:

Kelsey J, McEwing G (2010). Respiratory illness in children. In: Glasper A, Richardson J (eds), A Textbook of Children’s and Young People’s Nursing, 2nd edn, pp. 385–404. Churchill Livingstone, London.Find this resource:

Smith J, Martin C (2010). Caring for a child with a neurological disorder. In: Glasper A, Richardson J (eds), A Textbook of Children’s and Young People’s Nursing, 2nd edn, pp. 473–500. Churchill Livingstone, London.Find this resource:

Recognition of the sick child

Recognition of the sick child can be difficult and clues can be missed, as infants/children are unable to describe their symptoms. The European Resuscitation Council recommends using the ABC approach.

Airway and breathing

  • Respiratory rate: a raised rate may indicate lung or airway disease or metabolic acidosis.

  • Recession: may be intercostal, subcostal, or sternal.

  • Inspiratory/expiratory noises: stridor or wheeze.

  • Grunting: a sign of severe respiratory distress; an attempt to prevent airway collapse by generating a positive end expiratory pressure.

  • Accessory muscle use: in infants this may cause head bobbing.

  • Nasal flaring.

A child who is in respiratory distress for a long period will become exhausted and the signs of increased effort will decrease. ► Exhaustion is a preterminal sign and requires prompt attention.

Auscultation of the chest will indicate the amount of air being inspired and expired. Chest movement should be symmetrical and regular. ► A silent chest is extremely concerning.

Effects of respiratory distress on other organs

  • Heart rate: initially produces tachycardia; prolonged hypoxia leads to bradycardia, a preterminal sign.

  • Skin colour: initially pale; cyanosis is a preterminal sign.

  • Mental status: hypoxia causes agitation and drowsiness.

Circulation

  • Heart rate: increases in shock.

  • Pulse volume: absent peripheral or weak central pulses are a sign of advanced shock.

  • Capillary refill: should be < 2 s.

  • Blood pressure: children maintain their blood pressure for long periods; hypotension is a preterminal sign.

When assessing a sick child, ABC takes priority and should be repeated until normal parameters are reached.

Disability

Conscious levels can be assessed rapidly using:

  • A:  Alert

  • V:  Responsive to voice only

  • P:  Responsive to pain only

  • U: Unconscious.

Level P/U equates to a Glasgow Score of <8. If a child is at this level, intubation should be considered to protect the airway.

Preoperative care

Effective and appropriate physical and psychological preparation of the child and the psychological preparation of their family are necessary to ensure the safety of the child and reduce the anxiety they experience.

Psychological preparation and support

  • Must be age appropriate.

  • If surgery electively planned, then ideally preparation should start prior to admission via a pre-admission programme visit, where staff can explain and discuss what will happen with both the child and their parents.

  • Explanations about hospitals/operations before admission using age-appropriate books and audiovisual aids, available from local libraries.

  • Parents should receive both verbal and written information.

Physical preparation

  • Explain procedure to child and parents.

  • Ensure doctor has explained procedure to parents and child and that consent form has been completed correctly and signed.

  • Record baseline observations: temperature, pulse, respirations, and blood pressure.

  • Obtain and record current weight and height.

  • Ensure identity wrist band with name, age, date of birth, ward, and weight is in place and legible.

  • Ensure allergies are recorded clearly in notes and apply a second armband identifying the allergies.

  • Identify and clearly record any loose teeth.

  • Ensure specific preoperative investigations have been obtained and results recorded in notes, e.g. chest X-ray, urinalysis, blood samples.

  • Ensure child has had a bath and is wearing appropriate clothing.

  • Remove any nail varnish.

  • Remove all jewellery, give to parents for safe keeping.

  • Tie long hair back with a non-metallic bauble.

  • Ensure child has been fasted for the specified time.

  • Ensure child’s bladder has been emptied, or infant has had a dry nappy put on, before giving premedication.

  • Administer premedication as prescribed.

  • Ensure medical staff have clearly marked operation site if necessary, e.g. leg or arm.

  • Ensure notes, nursing documentation, and radiographs are available.

  • Complete theatre checklist according to trust policy.

  • Accompany child and parents to theatre with porter.

  • Check child into theatre with theatre staff and advise regarding specific issues such as allergies or loose teeth.

Further reading

RCN (2005). Peri-operative Fasting in Adults and Children. A National Guideline Developed by the Royal College of Nursing. Royal College of Nursing, London.Find this resource:

Paediatric early warning tools

Clinical deterioration resulting in near or actual cardiopulmonary arrest in hospitalized children is common; usually the outcome is poor and may be preventable. Timely identification and referral of children may be facilitated by the application of scoring criteria. Paediatric early warning tools are being used in many children’s units and emergency departments to assist in the detection of vulnerable children.

Paediatric Early Warning Score (PEWS) is a simple scoring system to determine the severity of illness in children. The PEWS incorporates the use of physiological vital signs that are measured routinely by healthcare professionals. A PEWS is recorded when a nurse is worried about a child or the vital signs fall into a preset area on the vital signs chart. PEWS can improve patient outcomes by detecting and acting upon early signs of deterioration in a child’s condition.

PEWS achieves this by:

  • identifying trends in the child’s observations.

  • ensuring that the child’s condition is reviewed when necessary and appropriate treatment initiated.

  • encouraging contemporaneous and relevant documentation of the child’s condition.

An early warning score is a set of simple algorithms relating to the findings of physiological parameters. These parameters are given numbers depending on the range of severity within which they fall, the total number added at the end of the observations taken is the score given.

A PEWS is to be calculated when vital signs fall into a shaded area on vital signs chart or a nurse is ‘worried’ about a patient. The vital signs include temperature, heart rate, blood pressure, respiratory rate, and conscious level (AVPU)

If the total PEWS reaches an initial trigger point, the activation protocol should be initiated. There is a referral algorithm alerting the nurse to the course of action that should be taken. This scoring system provides nurses with a tool to evaluate subtle signs that may predict the possible deterioration of a child’s condition. PEWS can:

  • ensure a full set of observations are recorded and repeated as required.

  • document trends in the child’s improvement or deterioration.

  • aid recognition of sick/deteriorating children.

  • encourage the nurse to call for medical advice earlier.

  • empower nurses to be more confident when discussing their clinical assessments.

  • decrease the incidence of respiratory/cardiac arrest and emergency admissions into PICU.

The use of PEWS should not prevent notification in the following situations:

  • When clinical deterioration occurs with other criteria other than that assessed by the PEWS.

  • Where sound clinical judgement suggests that the child’s condition is deteriorating.

  • When an experienced nurse is worried about the child from ‘intuition’ or ‘gut feeling’.

Almost every hospital in the UK uses different PEWS charts and calculates PEWS in different ways, but the NHS Institute is performing some collaborative work in an attempt to develop universal charts.

Further reading

NICE (2007). Acutely Ill Patients In Hospital (CG50). National Institute for Health and Clinical Excellence, London.Find this resource:

NPSA (2007). Safer Care for the Acutely Ill Patient: Learning from Serious Incidents. National Patient Safety Agency, London.Find this resource:

Fundamental aspects of children’s and young people’s nursing Adshead N, Thomson R. The Implementation of a Paediatric Early Warning Tool for Use Within the Emergency Department and on Acute Paediatric Wards. www.rcn.org.uk/__data/assets/pdf_file/0004/232690/paediatric_early_warning_tool_for_ED.pdf

Fundamental aspects of children’s and young people’s nursing NHS Institute. PEWSC harts. www.institute.nhs.uk/safer_care/paediatric_safer_care /pews_charts.html

Assessment of pain in children

It can be difficult to measure pain precisely and accurately in children. Many pain measurement tools and scores have been developed for use with children; however, development of verbal skills and cognitive ability can show wide variation in children, which must be taken into account.

The assessment of pain must be appropriate for the child’s stage of development, the severity of the child’s illness, the surgical or medical procedure, and the medical environment. It is also vital that the nurse is completely familiar with the use of the selected pain assessment scale.

Whichever scoring system is used, pain assessment should be repeated regularly, appropriate interventions should be prescribed, and their effectiveness should be recorded.

Selecting a pain assessment tool: points to consider

  • Condition of child: a very sick child may be too ill to comprehend instructions regarding the use of a pain scale.

  • Age of child: behavioural measure or self-report measure.

  • Time available to teach child to use selected tool.

  • Interventions that may be necessary: pain assessment must be linked to interventions with the aim of ensuring that the child experiences no pain or only mild pain.

  • Culture: can influence an individual’s perception and response to pain.

  • History-taking: vital on admission to record child’s usual reaction and normal responses to pain at home, e.g. behaviour, words used to describe pain. Include information in nursing care plan.

  • Cognitively impaired children: parents or carers are a valuable resource to assist with communication and the interpretation of behavioural signs.

  • Parent involvement: parents can be involved in identifying a pain assessment scale appropriate for their child.

  • Type of pain: acute, chronic, or recurrent.

Pain scales usually incorporate one or more of the following:

  • Self-reported assessment

  • Physiological assessment

  • Behavioural assessment.

Self-reported assessment

  • Examples of self-report assessment scales include visual analogue scales, verbal rating scales, and facial expression scales.

  • As pain is a subjective experience, self-reporting techniques are acknowledged as the most accurate indicators of pain.

  • Self-report is usually possible by 4 years of age, but will depend on the cognitive and emotional maturity of the child.

  • At 4–5 years of age children can differentiate ‘more’, ‘less’, or ‘the same’.

  • Indicating severity using a faces pain scale can work well, but in the choice of faces is best to have the first face appearing ‘neutral’ rather than ‘happy’. Some children are unable to relate the faces to their own pain experiences, while others tend to choose those at the extremes of the scale.

  • Between 7 and 10 years of age children develop skills with measurement, classification, and putting things in order.

  • Visual analogue scales can be used to describe pain intensity, location, and quality.

Physiological assessment

  • Changes in physiological parameters associated with pain include heart rate, respiratory rate, blood pressure, intracranial pressure, cerebral blood flow, pallor/sweating, skin colour, muscle spasm, vomiting, dilated pupils, and oxygen saturation.

  • Care must be taken because not all of the variability the signs show may be related specifically to pain. These signs are sensitive to pain intensity but they can also respond to other stress or an underlying physical condition. Therefore one sign alone may not be an accurate indicator of pain and pain measurement should be multidimensional.

Behavioural assessment

  • For children <3 years, a tool that includes observation of behaviour can be effective in scoring pain accurately.

  • Observations of behaviour include facial expression, body position, mobility, crying, sleep pattern, skin colour, and vital sign measurement.

  • Caution should be used against relying solely on behavioural responses with neonates because they may be physically incapable of crying or body movement, and their stillness may not indicate that they are pain free.

  • Examples of scales incorporating behavioural assessment include FLACC, PIPP, and PPP. See the Royal College of Nursing website for guidelines governing current clinical practice.

Further reading

RCN (2009). The Recognition and Assessment of Acute Pain in Children. Clinical Practice Guidelines. Royal College of Nursing, London. Fundamental aspects of children’s and young people’s nursing https://www.rcn.org.uk/__data/assets/pdf_file/0004/269185/003542.pdfFind this resource:

Fundamental aspects of children’s and young people’s nursing RCN (2012). Pain in Children. www.rcn.org.uk/development/practice/clinicalguidelines/pain

Management of procedural pain

Procedure-related pain is a major source of distress to the child and family. Poorly managed pain will result in the child continuing to display high levels of distress in future procedures. To a child there is no such thing as a minor procedure. Often the extent of tissue damage correlates poorly with the severity of pain that the child experiences.

Prevention and treatment of procedural pain should be multidimensional, involving both pharmacological and non-pharmacological interventions. The number of interventions required will depend on:

  • invasiveness of the procedure

  • level of child’s anticipatory anxiety

  • child’s age and stage of cognitive development.

Pharmacological interventions

Use depends on the type of procedure.

  • EMLA® (eutectic mixture of lidocaine and prilocaine)/Ametop® (tetracaine)

  • Simple analgesics such as paracetamol and ibuprofen

  • Oral morphine or intranasal diamorphine have been used for more painful procedures

  • Non-nutritive sucking for infants

  • Entonox®

  • Anxiolytics and sedatives.

Non-pharmacological interventions

  • Parental presence

  • Hugging, holding

  • Play, reading books, television

  • Distraction, bubble blowing, singing, deep breathing

  • Mind suggestion, e.g. ‘putting on a magic glove’

  • Guided imagery and relaxation.

Management

  • Plan ahead.

  • Justify the necessity of the procedure.

  • Provide step-by-step, honest, age-appropriate information to child and parent to increase their sense of control.

  • Plan timing of procedure with drugs and activities.

  • Use books or dolls to explain the procedure.

  • Administer pain-relieving medications at appropriate time to allow full effect during the procedure and if necessary longer-lasting analgesia if pain is prolonged following procedure.

  • Maintain a calm environment.

  • Avoid delays and unnecessary distress by preparing all the equipment beforehand, and keep it covered.

  • Use a treatment room if possible and keep the child’s room/bed-space as a ‘safe area’.

  • Allow choices, e.g. which arm shall we use?

  • Give the child a role, e.g. holding the tape.

  • Encourage use of distraction and play.

  • Ensure communication with the multidisciplinary team to reduce the number of procedures, e.g. taking all blood tests at once.

  • For long procedures use time-out periods.

  • Use appropriate equipment, such as automatic lancets.

  • Limit the health professional to a number of attempts made for venepuncture.

  • Afterwards praise with an emphasis on the positive aspects of the experience; use reward stickers or certificates.

  • Always aim for a positive first experience.

Further reading

Lonnqvist PA, Morton NS (2005). Postoperative analgesia in infants and children. British Journal of Anaesthesia, 95(1), 59–68.Find this resource:

Fundamental aspects of children’s and young people’s nursing World Health Organization. WHO Guide lines on Persisting Pain in Children. http://www.who.int/medicines/areas/quality_safety/guide_perspainchild/en/

Care of the child with a raised body temperature

In children, a common cause of a raised body temperature is fever. Most clinicians define fever as an oral temperature >38°C.

The body temperature rising to a higher level during fever is a normal process. Fever is not harmful and has many immunological benefits. It is only when the body temperature exceeds 42°C that tissue damage is likely to occur. In such cases the condition is referred to hyperthermia, a serious condition not regulated by the hypothalamus, therefore requiring quite different management.

Fever often has distinct stages, and a child may fluctuate between the first two stages, hence the peaks seen on a temperature chart, before reaching the final defervescence stage.

First phase

Physiological rationale

  • The thermoregulatory centre in the hypothalamus changes its set point, therefore the body temperature will rise.

  • The sympathetic nervous system is activated to increase body heat. This includes peripheral vasoconstriction, a means to conserve and retain heat.

  • To allow body temperature to rise, more energy is required, involving activation of endocrine system. There is a 10–12% increase in energy demand with every 1°C rise in temperature. More oxygen and glucose will be required, the first through increased respirations, and the second by the liver mobilizing energy stores.

  • The liver also releases substances such as C-reactive protein (CRP), an important molecule in immune defence.

  • Shivering (muscle activity) occurs to create heat.

  • The hypothalamus initiates a change in set point in response to cytokines (polypeptides released from immune cells).

Signs and symptoms

  • ⚠ Discomfort and general misery.

  • Pallor owing to peripheral vasoconstriction. The child will feel cold and shiver and may adopt a fetal position (Fig 1.18).

  • Temperature receptors in skin inform the hypothalamus whether the set temperature has been reached. As the temperature rises haemoglobin loses its affinity for oxygen, hence the mottled, slightly cyanosed look that some children have. For every 1°C rise in temperature the pulse rate increases by ~10, and respiratory rate increases by 2.5 breaths. The child may have a slight cyanotic discolouration around the lips.

  • Sympathetic nervous system activation, therefore reduced circulation to peripheral organs such as the gut. The appetite is also suppressed.

  • Sleep is induced, a symptom seen particularly in younger children.

  • There is often mild muscular pain.

  • Most children have behavioural changes with reduced coping.

Actions

  • Parents are always the first to detect that their child is unwell and this may cause anxiety.

  • Keep the child covered with loose clothes or light covers; do not over/underdress the child. Removing clothes will make child shiver more, and will make them feel more uncomfortable. Do not use a fan to cool the child down.

  • Monitor all vital signs including body temperature. Monitor the child’s oxygen saturations if any suspicion of compromised respiratory status.

  • When the child’s appetite is suppressed, limit fluids or food, as digestion and absorption are reduced.

  • Minimizing activity is beneficial so that energy can be channelled into immunological actions.

  • If the child is very uncomfortable, a mild analgesic (e.g. paracetamol) can be offered, but evidence suggests that that their benefits are exaggerated.

  • In such situations, promoting sleep is a useful strategy.

Second phase

Physiological rationale

  • This stage is controlled predominantly by the parasympathetic nervous system. The body temperature has reached the new set point and often rises above it. The hypothalamus will now initiate heat loss mechanisms until the temperature has dropped back to the adjusted set point.

  • Heat is lost from the body through radiation (60%), convection, conduction, and evaporation (20–25%). This is aided by vasodilatation of the arterioles in the skin and through sweating.

  • The regulation of heat loss is reliant on fluid and electrolyte balance.

  • Digestion and absorption from the gut improves during this phase.

  • If the fever has been caused by sepsis or other serious infections, sympathetic activation is maintained owing to shock factors. In these circumstances it is difficult to differentiate between the phases of fever.

Signs and symptoms

  • Whereas the first stage was characterized by misery, in this stage many children feel a bit better.

  • Face red and flushed. Skin, in particular on the face and top of shoulders, will feel hot. Child will often adopt a splayed-out position (Fig 1.19).

  • Heat loss through evaporation is from the skin and lungs. The child may start to appear dehydrated, with dry lips and mucous membranes.

Action

  • Child is more alert and playful, though some children will still feel unwell.

  • If the child hasn’t already kicked off the covers, remove them. The use of tepid sponging is not recommended as a method of cooling the child. Fan therapy to help cool the environment may be helpful in promoting comfort, but should not be directly focused towards the child. Further research into the use of fan therapy is required to fully assess its benefits in the management of pyrexia.

  • Maintain hydration, offer frequent oral fluids to aid replacement of fluid lost due to the fever.

Defervescence

  • The raised set point returns to normal (36.5–37.3°C). Children are often feeling much better by this stage, and behaviour returns to normal patterns. Heat loss mechanisms continue until temperature is normal.

  • Return to the child’s normal daily routine.

Further reading

Smyth J, Roberts R (2011). Vital Signs for Nurses: An Introduction to Clinical Observations. Wiley-Blackwell, Chichester.Find this resource:

Fundamental aspects of children’s and young people’s nursing NICE (2013). Feverish Illness in Children: Assessment and Initial Management in Children Younger Than 5 Years (CG160). https://www.nice.org.uk/guidance/cg160

Normal maintenance fluid requirements and intakes for children

Calculations

The calculations in Table 1.16 are cumulative, e.g.:

Table 1.16 Fluid requirements: calculations

Body weight

Fluid requirement per 24 h (mL/kg)

Fluid requirement per hour (mL/kg)

Up to first 10 kg

100

4

10–20 kg

50

2

>20 kg

20

1

A 14 kg child would require 1000 (100 × 10) + 200 (50 × 4) = 1200 mL in 24 h.

A 25 kg child would require 1000 (100 × 10) + 500 (50 × 10) + 100 (20 × 5) = 1600 mL in 24 h.

These figures can be used when caring for hospitalized children, to assess (and check) whether their oral/enteral feeds or intravenous fluids have been correctly calculated for their weight. There are a number of reasons why maintenance fluids may be restricted (e.g. due to respiratory, cardiac, renal, or central nervous system pathologies) or requirements increased (e.g. due to a negative, cumulative fluid balance in diarrhoea and vomiting—but the replacement of these is gradual over 24–48 h, in order to safely correct fluid and electrolyte balance).

Remember that fluid imbalance rarely occurs without electrolyte imbalance (particular attention to plasma levels of sodium and potassium).

Resuscitation fluid requirements are separate from these normal maintenance requirements. Resuscitation fluids are required by children presenting with clinical signs of shock. The starting volume is 20 mL/kg of crystalloid fluid (intravenous/intraosseous) and this can be repeated if there is inadequate clinical response.

Further reading

Advanced Paediatric Life Support Group (2011). The Practical Approach, 5th edn. BMJ Publishing Group (Wiley Blackwell), London.Find this resource:

Fluid balance monitoring

This is an essential part of caring for a sick child, but can be hard to understand (see Tables 1.17 and 1.18).

Table 1.17 A simple formula for working out fluid requirements

Newborn infants

60 mL/kg/24 h. Increase by 10 mL/kg/24 h for 4 days

<10 kg

100 mL/kg/24 h

11–20 kg

1000 mL plus 50 mL for each kg over 10 kg

21–30 kg

1500 mL plus 25 mL for each kg over 20 kg

Table 1.18 Signs of dehydration

<5% dehydration

Thirst, decreased urine output, dry mouth

5–10% dehydration

Sunken anterior fontanelle, dry mucosa, decreased skin turgor, dark rings around the eyes, loss of body weight, tachycardia, oliguria <1 mL/kg/h, restless/irritable

10–15% dehydration

Dry mucosa, poor skin turgor with clamminess, sunken anterior fontanelle and eyes, anuria, reduced blood pressure, reduced conscious level, tachycardia, tachypnoea

Infants have a higher risk of fluid loss than older children, due to a higher metabolic rate, larger surface area, a greater percentage of total body water, and an inability to concentrate urine. This makes infants more susceptible to developing a fluid imbalance as a result of:

  • Respiratory infection

  • Diarrhoea and vomiting

  • Sepsis

  • Burn injuries.

It is therefore important to monitor all input and output. Nappies can be weighed to assess losses due to urine output and diarrhoea (1 g = 1 mL) to work out an accurate total in children unable to use the toilet/potty.

  • Urinary output of 1 mL/kg per hour is satisfactory.

  • Insensible losses must also be assessed.

  • When assessing fluid status, also assess the following:

    • abnormal blood losses

    • heart rate

    • capillary refill time

    • blood pressure (remember—a falling blood pressure is a preterminal sign)

    • conscious level by assessing AVPU

    • urea and electrolytes.

Further reading

Smyth J, Roberts R (2011). Vital Signs for Nurses: An Introduction to Clinical Observations. Wiley-Blackwell, Chichester.Find this resource:

Fundamental aspects of children’s and young people’s nursing NICE (2013). Feverish Illness in Children: Assessment and Initial Management in Children Younger Than 5 Years (CG160). https://www.nice.org.uk/guidance/cg160

Assessing dehydration

The initial assessment of the child focuses upon determining the extent of dehydration and electrolyte imbalance in addition to monitoring the effect of interventions. By taking an accurate history from the child and parents, you can gauge the success of previous interventions, in particular the nature and amount of recent oral fluid intake. The older child who continues to have diarrhoea and vomiting, but has been able to drink fluid over the previous 24 h, is less cause for concern than the younger child who has refused drinks or who is unable to tolerate oral fluids.

The assessment of the extent of dehydration in a child includes measurements of serum electrolyte levels in the blood alongside an accurate nursing assessment, which will include:

  • the child’s behaviour

  • skin colour and condition

  • capillary refill time (CRT)

  • temperature, pulse and respiration, blood pressure/PEWS assessment.

Two of the key electrolytes involved are sodium, which is present in gastric secretions and lost through vomiting, and potassium, lost through diarrhoea. The loss of these electrolytes creates a major shift of fluid from the intracellular to extracellular fluid compartments, and also alterations in the acid–base balance.

Appearance of the dehydrated infant

  • Often pale, lethargic, and listless: probably due to the effects of electrolyte imbalance and ensuing acidosis.

  • Sunken eyes due to loss of intraocular fluid.

  • Sunken fontanelle due to a reduction in cerebral spinal fluid volume.

  • Prolonged capillary refill time.

  • Skin lacks elasticity due to movement of intracellular fluid into the extracellular fluid compartment to maintain blood volume.

  • Cold extremities due to peripheral vasoconstriction.

  • Reduced urinary output, as antidiuretic hormone is produced as a response to changes in plasma osmolarity, and urinary output will be reduced in an attempt to conserve fluid.

An older child may present as irritable, restless, or weak; pale with sunken eyes; and with reduced skin elasticity.

All of the above are adaptive mechanisms that will attempt to compensate for the effects of fluid loss in the infant, child, or young person. Eventually if there is delayed or inadequate intervention, the pulse rate will rise and the blood pressure fall as hypovolaemic shock occurs.

Further reading

Fundamental aspects of children’s and young people’s nursing NICE (2009). Management of Acute Diarrhoea and Vomiting Due to Gastroenteritis in Children Under 5 (CG84). www.nice.org.uk/guidance/CG84

Fundamental aspects of children’s and young people’s nursing Rehydration Project website: www.rehydrate.org

Play and the hospitalized child

The importance of play

Play can be described as the engagement in activities for pleasure rather than for a serious or practical purpose. It is a source of enjoyment for both the player and the observer of play activity.

Play is the language of children, an essential tool through which they attain knowledge about themselves and the world around them. Play is a rich learning medium, and the ability to play develops earlier in children than the ability to communicate through language, making it a valuable communication tool for children of all ages.

For children there are no extrinsic goals in play activity. Nevertheless play makes an important contribution to normal growth and development. Play and playing are vital parts of children’s lives, and through play children learn how to learn and how to do things.

The child uses play:

  • for physical development (e.g. fine and gross motor skills, strength, and stamina)

  • for social development (e.g. social skills and social behaviours, control of aggression)

  • for moral development (e.g. learning to take turns, to win and lose, not to cheat, self-control, and consideration for others)

  • for psychological development (e.g. the development of self-awareness and self-actualization)

  • for cognitive development (Piaget linked play to cognitive development)

  • for problem-solving

  • as a communication tool (e.g. to demonstrate misconceptions about information received)

  • to normalize the environment

  • to practise adult behaviours and skills

  • for language development

  • for distraction from anxiety-provoking situations

  • to master/make sense of the environment (play helps children to understand the world in which they live and to differentiate between what is real and what is not)

  • to have fun!

Play is an important outlet for anxiety, frustration, emotional tension, and fear, and it enables the child to make sense of anxiety-provoking situations such as invasive medical procedures. In this sense, play becomes therapeutic and is emotionally enhancing for the child.

Diversionary/normal play

  • In order to enable medical/nursing staff to examine a child in the way that is least traumatic for the child, time needs to be given to build a relationship of trust through play.

  • Play can then be used for distraction, should unpleasant invasive procedures be required.

  • Ensure that the activity is developmentally age appropriate, taking into account any special needs the child may have.

  • The effect on parents is reduced stress.

Children need to be able to access play wherever they are. Play is their way of making sense of the world and coping with their feelings. Play areas provide a safe, child-friendly environment in which they are surrounded by familiar things that provide them with a link to home.

The play provided needs to be age- and ability-appropriate, taking into account special needs, and must also be appropriate for black and ethnic minority children. Staff need to take account of language and communication barriers as well as religious beliefs.

Taking time to build a relationship with parents and children can prove invaluable in gaining trust and identifying the most appropriate and effective activities.

It is important to gain as much information from parents as possible at admission with regard to the child’s special toy and any special vocabulary they may have. In addition, it is important to take into account any previous bad experiences the child may have had in hospital and any knowledge of any abuse or neglect the child has experienced.

Include parents and siblings wherever possible. This also has the benefit of creating a home-from-home environment.

Where access to the play room/teenage room is available, children/young people can be provided with an opportunity to self-select activities of their choice. When children are unable to access play independently, the necessary support needs to be provided to enable them to access play. If the child is unable to access the playroom, every effort should be made to identify the favoured activities and provide them at the bedside.

Suggested distraction tools

  • Infants: tactile soothing, cuddling, music tapes

  • Toddlers: blowing bubbles/feathers, pop-up toys and books, songs or rhymes

  • Preschool children: Where’s Wally? books/posters, songs and rhymes, puppets

  • School-age children: joke books, counting games, songs and rhymes, puppets, kaleidoscopes (with/without glitter wand), guided imagery, games consoles.

Preparation and post-procedural play

Understanding what is happening is important to help children/young people and parents relax and accept treatment.

Parents do not always prepare their child for hospital, but all children should be prepared in a way that is appropriate to their cognitive ability, taking into account any special needs and/or cultural and/or religious beliefs.

Illness, accidents, or invasive medical investigations can all bring the emotional challenge of:

  • the threat of physical harm

  • separation from one’s parents and other trusted people

  • the threat of strange and unforeseeable experiences

  • uncertainty about acceptable behaviour

  • relative loss of control and personal autonomy.

Preparation play

A range of quality play helps in preparing children/young people for procedures. This can be achieved through attending a pre-admission club, which will introduce children to the environment and equipment. They will have an opportunity to become familiar with the surroundings, including the theatre waiting room and the recovery room for those children who are to undergo surgery. The familiarization of hospital equipment and routines reduces stress and anxiety, helping the children and young people to come to terms with their condition.

Play specialists, in conjunction with the healthcare team, can develop presentation programmes for children undergoing surgical, clinical, and diagnostic procedures, to develop their understanding of what is going to happen, thus reducing fear.

Role play is particularly useful when enabling children who do not have the necessary language and/or cognitive skills to develop an understanding of the procedure and familiarize them with the equipment.

Good quality preparation play in the radiotherapy department, for example, enables children, who would otherwise need a general anaesthetic to keep still for treatment, to lie still without fear.

Post-procedural play

Post-procedural play is particularly important for children admitted as emergencies. Post-procedural play should be offered and should include:

  • praise; certificates and/or stickers will reinforce this

  • an evaluation of the coping strategies used

  • an opportunity to express feelings following the procedure

  • planning, if future admissions are necessary.

Directed and hospital role play

P

participation in play introduces normality into a strange setting.

L

lessens the impact of pain and anxiety.

A

allows the child/young person to work through feelings and fears, so that hospitalization can become a positive experience.

Y

yields results: recovery is faster and the in-patient stay is reduced.

Being in hospital can be a frightening experience. Directed play enables the child to regain some control over what is happening by acting out feelings and fears. Hospital role play involves playing with clinical equipment in order to gain familiarity and reduce fantasies about it. Gaining the child’s/young person’s confidence/trust enables medical/nursing staff to observe the patient’s reactions and to pick up and deal with fears and misconceptions. In order to achieve this, an attractive and inviting child-friendly environment is required, where children can feel confident and safe to explore and investigate the equipment and activities provided. For example, dolls that children can use to insert a central line enable them to ask questions, develop their understanding of the procedure that they will undergo, and reduce fears. Role play creates a relaxed forum where children, parents, and siblings are free to take their time and ask questions and develop their understanding in a non-judgemental environment. This activity is best carried out whenever possible by a member of the play staff in a non-clinical area, where children are in surroundings that are familiar to them and with people whom they know are safe (i.e. not going to undertake any painful procedures).

The effect on the child of skilled, directed role play is to reduce fears and anxiety. The child will then be more responsive to procedures and treatments, thus aiding the medical/nursing staff in carrying out what would otherwise be a very distressing procedure. This is particularly important where the child may have to undergo the treatment more than once. Any distress that is experienced by the child initially will be compounded with each episode, and this will make the work of those carrying out the procedure stressful and time consuming. The effect of not making time for role play results in the child potentially having a bad experience. It is extremely difficult to regain a child’s trust once this has happened, and it will take substantially more time for the play specialist to develop the child’s understanding and acceptance of the treatment or procedure that they are required to undergo.

Guided imagery

Guided imagery is a therapeutic technique that allows two people to communicate on a reality that one of them has chosen to describe through the process of imaging. It can be used with children in hospital as a form of pain management.

Before the imagery can start, it is important to carry out an assessment of the child you hope to use this technique with. You need to look at the following:

  • Age/cognitive level of child

  • What type of pain they may be experiencing, e.g. procedural, anxiety, chronic

  • Emotional state of the child

  • Expectations of the child (remember always to be realistic and do not make promises)

  • Any existing coping strategies the child may use

  • Environment

  • Staff to be involved: at least two people are needed—one to carry out the procedure and the other to guide the imagery at an appropriate point

  • Organization of procedure.

Guided imagery technique

  • Building a rapport and gaining the child’s trust.

  • ‘I know a way we could help to make this easier. Would you like to try?’

  • Child to identify what they would like to imagine (should be something fun!).

  • Start by getting the child to do some deep breathing and progressive muscle relaxation.

  • Child begins to describe imagery.

  • You begin to guide and be guided by child’s imagery.

  • Ask questions such as what can you see? What’s happening now? Is anyone there with you? Tell me what it looks like.

  • Always inform the child what is happening while they are in imagery, e.g. the tourniquet is going on now, we are going to remove the dressing now.

  • Reinforce imagery when necessary.

Always round off imagery:

  • Ask the child if they would like to finish their imagery.

  • Encourage him/her to take a big deep breath in and out slowly.

  • Think backwards from 4 to 1 (younger children count 1–4).

  • Open their eyes slowly.

  • Wiggle toes and fingers.

Ask the child how they feel and encourage them to sit still for a few moments, as they may feel a little ‘funny’.

Guided imagery response indicators

  • Eyes closed (not always at first)

  • Eye movements under closed lids

  • Slowing of breathing

  • Relaxed, absence of muscle tension

  • Speech normal–calm

  • Easy flowing description of imagery.

Points to consider

  • Guided imagery can be used with children from an age when they are able to use their imagination. It may not be suitable for children with special needs.

  • Imagery can be guided by play specialists, nurses, doctors, or parents, as long as, when it is used during a procedure, there is at least one other person to carry out the procedure.

  • Remember to review each case. It will not work for everybody. What was easy to focus on? What were the goals? How can I improve the outcome?

Further reading

Fundamental aspects of children’s and young people’s nursing Guided Imagery, Inc. website: www.guidedimageryinc.com

Fundamental aspects of children’s and young people’s nursing National Association of Health Play Specialists website: www.nahps.org.uk

Fundamental aspects of children’s and young people’s nursing Phoenix Children’s Hospital website: www.phoenixchildrens.com

Education and the ill child

Children with medical conditions have an increased likelihood of experiencing, at some time, a constellation of factors that may directly or indirectly place their education at risk. The importance of school for children with chronic diseases should not be underestimated.

If education is to be effective for children with medical conditions, education authorities, schools, and staff must make positive responses to these issues. Section 19 of the 1996 Education Act says that ‘each local education authority shall make arrangements for the provision of suitable education at school or otherwise than at school for those children of compulsory school age who, by reason of illness … may not for any period receive suitable education unless arrangements are made’. Because each case is unique, it is not possible to quantify this.

Most establishments are ill-prepared in terms of experience, professional development, knowledge, skills, and attitudes, to take up and sustain the challenge in an in-depth way.

When parents are considering their child’s education, they are mindful not only of academic and performance-related matters, but also of care, medical, and quality-of-life issues. For a family whose life is totally affected and controlled by the child’s illness, the quality of the child’s school life assumes an enormous significance.

Some children go through their entire schooling suffering the effects of their condition and experiencing difficulties. Schools should not underestimate the difference they can make to the child’s quality of life. With careful planning, appropriate activities, and sensitive teaching, the school can make a significant contribution. Teachers and support staff can be content in the knowledge that their input has the double benefit of being therapeutic and educational.

It is important that a holistic approach is adopted by all working with the family and its individual members. Sick children do not exist in isolation; they are members of a family group that functions as a unit. All members of the family are affected by the illness.

There are many other reasons why an ill and disabled child may not be able to attend school but still benefit from home tuition, such as a susceptibility to serious chest infections, difficulties over school transport, or supervision problems at school associated with distressing, unpredictable, and possibly life-threatening symptoms.

Home tuition for children with degenerative disorders, for example, is not an extension of school per se but rather is a unique service provision, a specially crafted resource to meet the needs of a child and family living under difficult, stressful, and peculiar circumstances.