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CHAPTER 1

Growth and Development


in Children

N
ursing care of children requires extensive knowledge of growth
and development so that every child can receive care tailored
to his or her age (both chronological, which is age in years, and
developmental, which is age based on assessment) and matched to in-
dividual and family needs. The nurse can use the information in this
chapter to implement nursing care for the child, in either acute care or
community settings.
The Institute of Medicine (2003) competen-
cies for nursing were used to identify quality QSEN APPLICATION
and safety parameters for these areas: Patient-
The intention of the Quality
Centered Care, Teamwork and Collaboration, and Safety Education for
Evidence-Based Practice, Quality Improvement, Nurses (QSEN) project is
Safety, and Informatics. In this chapter, along “to meet the challenge of
with knowledge about growth and development preparing future nurses
who will have the knowl-
and the use of growth charts, QSEN competen- edge, skills and attitudes
cies ensure delivery of the best nursing care. necessary to continuously
Growth and development comprise a con- improve the quality and
stant process. Growth refers to the continuous safety of the health-care
systems in which they work”
adjustment in the physiological size of the child.
(http://www.qsen.org/
Growth is an increase in the size of the child’s about_qsen.php).
body, including height, weight, and growth of
bones and internal organs. The use of growth
charts is a standard part of a nursing assessment and allows the health-
care provider to plot the child’s pattern of growth. The percentile curves
on the growth chart illustrate the distribution of body measurements
in children: height, weight gain, and head circumference over time
(Figs. 1–1 to 1–3). Growth charts from the National Center for Health
Statistics (NCHS) are found at http://www.cdc.gov/nchs/about/major/
nhanes/growthcharts/charts.htm
Development is the ongoing process of adapting throughout the life
span (Ward & Hisley, 2009). It is an evolving acquisition of skills and

Growth and Development in Children 1


F I G U R E 1 - 1 : Weighing the
infant. From Ward, S. & Hisley, S.,
(2009). Maternal child nursing care:
Optimizing outcomes for mothers,
children and families. Philadelphia:
F. A. Davis.

F I G U R E 1 - 2 : Measuring the
infant’s body length. From Ward, S.
& Hisley, S., (2009). Maternal child
nursing care: Optimizing outcomes
for mothers, children and families.
Philadelphia: F. A. Davis.

F I G U R E 1 - 3 : Measuring the
head circumference. From Ward, S.
& Hisley, S., (2009). Maternal child
nursing care: Optimizing outcomes for
mothers, children and families.
Philadelphia: F. A. Davis.

BEST PRACTICES 1–1


When parents express concern about their child’s growth, the nurse can explain
that a growth chart is a tool that contributes to forming an overall impression of
their child’s growth. A series of accurate measurements is taken (weight, height,
head circumference, and body mass index) to establish an observed pattern of
growth. The child is weighed and measured at each health-care visit, and the
data are plotted on the growth chart to track the child’s progress and compare
it with expected norms. (See Chapter 3 for anthropomorphic measurements.)

2 Pediatric Nursing Care


functioning. The astute nurse assesses the child’s development as an
ongoing component of care. The Denver II Screening Test is a reliable
tool used by the nurse practitioner. It assesses personal-social, fine
motor-adaptive, gross motor, and language skills (Frankenburg, Dobbs,
Archer, Shapiro, & Bresnick, 1992). Early detection and appropriate care
measures, such as the incorporation of play, games, social interaction,
and mental stimulation, can be key to maintaining or restoring the
child’s development (Fig. 1–4).

Aspects of Growth and Development


Several other important aspects of growth and development are as follows:
Cognitive: having adequate mental functions such as the ability to
think, reason, and remember
Fine motor: having control of the small muscles to perform such
tasks as holding a spoon or picking up a piece of cereal between
the thumb and finger (pincer grasp)

F I G U R E 1 - 4 : A and B, At 3 months of age, an infant can lift her head and


chest while on her belly (top) and roll on her side (bottom). From Ward, S. &
Hisley, S., (2009). Maternal child nursing care: Optimizing outcomes for mothers,
children and families. Philadelphia: F. A. Davis.

Growth and Development in Children 3


Gross motor: having control of the large
DEVELOPMENTAL muscles to perform such tasks as control-
DELAY ling the head, sitting up, and walking
Language: using spoken or written words or
Developmental milestones symbols by being able to talk and be under-
are age-specific skills and
tasks that most children
stood, as well as understanding what other
can accomplish at a certain people say
age. Every child is unique; Sensory: using the five senses: seeing, hearing,
however, the child should tasting, touching, and smelling
meet developmental mile-
Psychosocial: developing personality, judg-
stones within a certain time-
frame. A delay in growth ment, and temperament (Venes, 2013) and
and development occurs having the ability to interact with other
when the child has not people, including playing and building
reached expected mile- relationships
stones by the expected
time period. A delay can
Spiritual: having an awareness about a spiri-
happen in many areas: tual presence beyond oneself
physical, motor (fine and
gross), speech and language, Basic Principles
emotional, behavioral,
moral, psychosocial, or As children grow and develop, they progress in
cognitive. In addition, a a predictable and orderly sequence through the
delay in one area can
various stages within a certain time frame. Re-
affect growth and devel-
opment in other areas. gardless of the rate of growth and development,
For example, a child with some basic principles apply:
a speech and language Cephalocaudal is maturation that progresses
delay may also have a from the head to the toes. For example,
social or emotional delay.
A delay can be influenced
in physical development, the infant’s
by one or more factors, head grows first in comparison with the
such as environment, rest of the body. Developmentally, the
health, genetics, family, infant gains control of her head and neck,
society, lack of education,
rolls over, crawls, sits up, stands, and
nutrition, culture, or mal-
treatment. The nurse then walks.
completes an accurate Proximodistal is the direction of maturation
nursing assessment at each from the midline to the periphery. For
child care visit and during example, the torso of the body develops
hospitalization, to track
the child’s developmental
before the arms and legs. Development
progress. The nurse also proceeds to the hands and feet first and
reports any suspected then to the fingers and toes (Ward &
delays to the primary Hisley, 2009).
health-care provider.

4 Pediatric Nursing Care


The term growth spurts describes the peri-
ods, in infancy and puberty, of marked DEVELOPMENTAL
acceleration in the slow and steady LAG
process of growth (Venes, 2013).
A developmental lag
happens when the child is
temporarily behind in growth
EVIDENCE FOR PRACTICE 1–1 and developmental mile-
stones. Sometimes during
NICU RESEARCH an acute illness, hospitaliza-
tion or stressful situations
Concern exists that an adverse neonatal intensive result in a slowing down in
care unit (NICU) environment compounds morbid- the child’s development.
ity in preterm infants. An evidence-based, inter- However, the pause in
vention review study was conducted to discover development is short, and
whether developmental care promoted develop- the child soon returns to
ment and prevented morbidity in preterm infants. normal developmental
The Neonatal Review Group search strategy was progress. The nurse can
used, and extensive computerized searches were instruct the parents to give
the child developmentally
conducted from a variety of databases. After per-
appropriate toys and
tinent articles were determined, a list of the articles games to help the child
was sent to two experts to identify omissions or return to the expected
additional unpublished studies. Articles that met developmental level in a
all predetermined criteria for relevance, as well relatively short time.
as suitable quality, by both reviewers were in-
cluded in the analysis. Several articles showed
that developmental care interventions such as
noise and light reduction, minimal handling, and
longer rest periods may help preterm infants CLASSIFICATION
cope better in the NICU environment. However,
other articles presented conflicting evidence, “so A newborn’s growth and
before a clear direction for practice can be sup- development are based on
ported, evidence demonstrating more consistent classification. Newborns are
effects of developmental care interventions on classified by prematurity or
important short- and long-term clinical outcomes postmaturity, gestational
age, birth weight, intrauter-
is needed” (Symington & Pinelli, 2006).
ine growth restriction (IUGR),
small for gestational age
(SGA) size, or large for
gestational age (LGA) size:
BEST PRACTICES 1–2
The premature newborn:
The nurse must be knowledgeable about normal newborns born at
37 weeks’ gestation
growth and developmental aspects to customize
or before
nursing care to each child. The nurse finds good
The normal newborn:
information about growth and development in re- newborns born after
liable resources such as books, journals, and online 37 weeks’ and before
resources that can sharpen assessment skills for a 42 weeks’ gestation
better understanding of normal patterns, as well The postmature newborn:
as variations in growth and development. newborns born at
or after 42 weeks’
gestation

Growth and Development in Children 5


Developmental Tasks
MNEMONIC and Milestones According
to Age Groups
A medical
mnemonic used to A review of the developmental tasks and mile-
help remember develop- stones according to age groups is important for
mental tasks: cubes
the practicing nurse. The nurse uses develop-
Age × 3 = number of cubes
mental information to provide care based on both
a child is able to stack
to make a tower the chronological age and the developmental age
1 year: three cubes of the child (Table 1–1 and Fig. 1–5).
2 years: six cubes
3 years: nine cubes

Table 1–1 Developmental Tasks and Milestones According


to Age Groups
AGE AND PHYSICAL SENSORY AND
GROWTH FINE MOTOR GROSS MOTOR LANGUAGE

• Newborn refers • Hands predomi- • Reflexes present • Touch the


to the stage nately closed • Absence of head first sense to
immediately after • Strong grasp control, but can develop
birth until 1 month reflex momentarily • Can recognize
• Infant’s physical hold the head mother by her
growth entails in midline smell
doubling weight • Head lag when • Has taste
by 6 months and the newborn is preference for
tripling it by pulled from a sweets
1 year lying to a sitting • Hearing well
position developed, and
• Assumes flexed becomes quiet
position when hears a
• When supine, as- familiar voice
sumes tonic neck • Limited visual
flex position acuity 20/100,
• Kicks legs and fascinated with
waves arms faces, follows
• Rounded back moving objects,
when sitting likes contrasting
• Rolls over colors (black
accidently and white)
• Cries and smiles
during sleep

• Infant refers to the • Holds hands open • Improved head • Moves toward
period from 1 month • Grasp reflex control, turns sound
to 12 months absent and lifts head • Thoroughly ex-
• Infant’s physical • Plays with toes from side to side plores and expe-
growth entails • Can pull at clothes when prone; riences objects
gaining 1.5 pounds and blanket, bats some head con- • Points to simple
(680 g)/month and at object trol when upright objects

6 Pediatric Nursing Care


Table 1–1 Developmental Tasks and Milestones According
to Age Groups—cont’d
AGE AND PHYSICAL SENSORY AND
GROWTH FINE MOTOR GROSS MOTOR LANGUAGE

increasing in height • Clutches own • In sitting position • Says “mama”


by 1 inch (2.5 cm)/ hands, inspects (tripod), back is and “dada,”
month for the first and plays with straight and and progresses
6 months and hands balances head to single words
then slowing down • Grasps objects well; sits alone and simple
with both hands by 8 months phrases
(palmar grasp) • Rolls from back • Responds to
• Shakes rattle and to side and then own name
holds bottle from abdomen • Exhibits
• Eventually able to back stranger anxiety
to put objects • Creeps on hands • Five senses
in container and knees becoming well
and bang them • Pulls self to developed
together standing posi-
• Carries objects tion and then
to mouth stands alone
• Transfers objects • Changes from
from hand to prone to sitting
hand position
• Reaches and • Begins to walk
bangs toys on holding hand
table and then inde-
• Likes mirror pendently; takes
images first step

• Toddler refers to • Holds a pencil or • Stands without • Well-developed


the stage from a large crayon support vision
12 months to • Copies a circle • Walks independ- • Can identify
approximately and cross by age ently (pulls toys geometric
3 years 3 years while walking) objects
• Toddler’s physical • Knows colors • Runs with wide • Intense interest
growth slows • Feeds self with a stance in picture books
down and toddler spoon and drinks • Jumps in place and listens to
gains 4–6 pounds from a cup with both feet stories
(1.8–2.7 kg) and • Builds tower of • Climbs • Distinguishes
increases in height three to four • Throws a ball; food prefer-
by 3 inches (7.5 cm) cubes; eventually eventually kicks ences based on
during this period builds tower of the ball senses
seven to eight • Rides a tricycle • Says single
cubes by 3 years words and sim-
• Screws and un- • Begins to stand ple phrases; at
screws lids on one foot 15 months
• Turns pages in a momentarily knows 15 words;
book one page at • Can walk up and 20 words by
a time down stairs with 2 years
• Turns door knobs alternate feet • Follows simple
• Removes shoes • Blows kisses instructions
and socks; learns
to undress self

Continued

Growth and Development in Children 7


Table 1–1 Developmental Tasks and Milestones According
to Age Groups—cont’d
AGE AND PHYSICAL SENSORY AND
GROWTH FINE MOTOR GROSS MOTOR LANGUAGE

• Preschooler (early • Moves around in • Dresses self • Has well-


childhood) ranges a more balanced • Throws and developed
from 3–6 years old fashion catches ball senses and
• Preschooler’s • Builds tower of and can pedal a preferences are
physical growth is nine to 10 cubes tricycle based on the
steady but slow; • Draws stick figure • Kicks ball use of senses
average weight with six parts forward • Learns home
gain for preschooler • Uses scissors to • Stands on one address and
is 4.5–6.5 pounds cut outline of a foot for 5 to phone number
(2–3 kg), with an picture 10 seconds • Recognizes
increase in height • Copies and • Skips and hops most letters;
by 2.5–3.5 traces geometric on one foot vocabulary has
(6.2–8.7 cm) patterns • Walks down increased from
per year • Ties shoelaces steps with 1,500–2,000
• Uses fork, spoon, alternate feet words; eventu-
and knife (with • Jumps from the ally speaks
supervision) bottom of a step in complete
• Colors, prints • Balances on sentences
letters alternate feet • Sings songs
• Mostly independ- with eyes closed
ent toileting and
dressing

• School-age refers • Good eye-hand • Gradual increase • 20/20 Visual


to child who is coordination in dexterity and acuity
6 to 12 years old • Balance improves becomes limber • Color discrimi-
• School-age child’s • Can sew, draw, • Improves coordi- nation fully
physical growth is make arts and nation, balance, developed
about 4–6 pounds crafts, build and rhythm • Mature sense of
(1.8–2.7 kg), with models, play • Climbs, bikes, smell
an increase in video games skips, jumps • Enjoys using the
height by 2 inches • Prints and writes rope, and swings telephone and
(5 cm) per year • Likes activities • Learns to swim, collecting objects
that promote dance, do • Vocabulary
dexterity such as somersaults, expands to
playing a musical and skate 8000–15,000
instrument • Likes competi- words; engages
tion and games in long conver-
sations on a
variety of topics

• Adolescent refers • Manipulates com- • Begins to de- • Increased


to child about plicated objects velop endurance concentration
12 years old, and • High skill level • Increases speed so can follow
the period lasts playing video and coordination complicated
until the beginning games and using • Focuses skills on instructions
of adulthood the computer an interest area

8 Pediatric Nursing Care


Table 1–1 Developmental Tasks and Milestones According
to Age Groups—cont’d
AGE AND PHYSICAL SENSORY AND
GROWTH FINE MOTOR GROSS MOTOR LANGUAGE

• Adolescent’s • Good finger dex- • Senses tied into


physical growth terity for writing body image
entails girls’ gaining and other intricate • Develops adult
15–55 pounds tasks preferences
(6.8–25 kg) and • Precise hand-eye based on senses
growing in height coordination • Continues to
2–8 inches develop and re-
(5–20 cm); boys fine vocabulary
gain 15–66 pounds up to 50,000
(6.8–30 kg) and words
grow in height • Improved
4–12 inches communication
(10–30 cm) during skills; converses
this period with increasingly
abstract thought
and analysis

From Ward & Hisley, 2009.

F I G U R E 1 - 5 : One of the first fine motor skills to develop is the ability to


pinch, picking up small objects like food. From Ward, S. & Hisley, S., (2009).
Maternal child nursing care: Optimizing outcomes for mothers, children and families.
Philadelphia: F. A. Davis.

Growth and Development in Children 9


What Else Influences Growth
MNEMONIC and Development?
A medical How Play Influences Growth
mnemonic used to and Development
help remember develop-
Play has a crucial role in children’s optimal growth
mental tasks: by year
and development. Play also is an important part
1 year:
Walk
of learning for children from infancy through
Single words adolescence (Packer-Isenberg & Quisenberry,
2 years: 2010). Children progress from the beginning
Climb two steps levels of play to more sophisticated levels of
Two-word sentences
play as they grow and change.
“Parallel” requires two
things Common types of play include the following:
3 years: • Unoccupied play (infant): The child is fairly
Tricycle stationary and performs random movements
Repeats three digits with no apparent purpose.
4 years:
Copies a square (four sides)
• Solitary play (infant): The child plays alone,
without noticing others around her.
Shape copying: Shapes
are in alphabetical order: • Onlooker play (infant and toddler): The child
circle (3 years), cross (4 years), observes others play around her but does
square (5 years), and triangle not join in; she may or may not alter her
(6 years). The shapes are own play based on what she observes.
also in order clockwise
around a PlayStation pad,
• Parallel play (toddler): The child plays with
starting at the 3 o’clock the same toys as another child but is not yet
position and 3 years actively engaging with her in play.
(Mnemonics for develop- • Associative play (preschooler): The child
mental milestones, 2010).
becomes interested in another child and
plays with her. This is the first time that
the child engages in social interaction while
OFFERING SUPPORT she plays.
• Cooperative play (school-age child): The
Not all situations are alike, child’s play becomes more formal. When
obviously, and the nurse will children play, they assume designated roles,
want to tailor the interaction
have rules, and learn to rely on one another
to the situation. The follow-
ing are sample interactions for the play to continue (Fig 1–6).
that the nurse may find
helpful to get started: Key Factors Influencing Growth and
1. Tell me more about Development
the concerns you have Because children live in an ever changing
regarding your child’s and multifaceted environment, key factors
development.
2. When did you become
also influence their growth and development
concerned about your (Table 1–2).
child’s development?
3. Can you give me specific
examples that help
explain your concerns?
Continued

10 Pediatric Nursing Care


OFFERING
SUPPORT—cont’d
The nurse can provide
information and written
material about specific
developmental milestones
that apply to the child.
The nurse can encourage
parents to observe and
document the child’s exact
developmental achieve-
ments. The parents’ notes
can then be used as a
springboard for discussion
at the next health-care visit.
If the primary health-care
provider suspects a prob-
lem, the nurse can assist
F I G U R E 1 - 6 : Child Life Specialist plays with a the family by explaining the
child. From Ward, S. & Hisley, S., (2009). Maternal necessity for further assess-
child nursing care: Optimizing outcomes for mothers, ment and testing. The nurse
children and families. Philadelphia: F. A. Davis. can also help the family
access proper community
resources such as an occu-
pational, speech, or physical
therapist (Fig. 1–7).

F I G U R E 1 - 7 : The nurse provides community


resources to parents. From Ward, S. & Hisley, S.,
(2009). Maternal child nursing care: Optimizing out-
comes for mothers, children and families. Philadelphia:
F. A. Davis.

Growth and Development in Children 11


Table 1–2 Factors Influencing Growth and Development
Communication Hygiene

Community Immunizations

Culture Language

Day care New sibling

Dental care Nutrition

Discipline Parenting

Family structure Play

Gender Safety

Genetics Schooling

Grandparents Sleep and rest

Health status Socioeconomic status

BEST PRACTICES 1–3


The nurse identifies key factors influencing growth and development and pro-
vides appropriate educational material directly related to the needs of the child
and family. Based on astute assessment skills, the nurse is able to identify
additional factors that may be influencing growth and development.

Applicable Theorists
THE IMPORTANCE
OF PLAY Theories can help the nurse provide care based
on the changes that occur across the life span
During hospitalization, the between birth and adolescence. Applying infor-
nurse understands the im- mation from applicable theorists is an impor-
portance of incorporating
play into the child’s plan of
tant aspect of care because it helps the nurse
care. The nurse must take understand the child as she grows and develops,
time to play with the child as well as how the child matures emotionally,
or contact the Child Life mentally, socially, spirituality, morally, and
Specialist, who will initiate
cognitively. Understanding how the family
appropriate play measures.
functions and develops is also important.

12 Pediatric Nursing Care


Mary Ainsworth’s Attachment Theory
Mary Ainsworth was a developmental psychol- TIP
ogist. She is known for her work in the area of
emotional attachment with “the strange situa- Important theories help the
nurse understand the
tion” and her development of the Attachment “why’” behind children’s
Theory. developmental tasks and
• Phase I (birth to 2 months): preattach- stages and allow the nurse
ment phase. The infant responds to every- to tailor care for each child.
one in his or her environment without
discrimination.
• Phase II (8 to 12 weeks): attachment-in-the making phase. The in-
fant responds to the most significant caregivers in his or her life.
• Phase III (6 to 7 months): clear-cut attachment. The infant re-
sponds visibly to the caregiver by crawling toward, reaching for,
or cooing at the caregiver.
• Phase IV (about 3 years): goal-corrected partnership. The young
child begins to develop a mutual understanding of attachment
with the caregiver.

E. R. Duvall’s Family Stages


E. R. Duvall’s theory is about family development and explains the
systematic and patterned changing characteristics of families as they
move through various stages in the life cycle. The theory is based on the
oldest child who marks each stage.
• Marriage: The couple establishes themselves as a pair and pre-
pares for parenting. This is the emergence of a new family.
• Family With Infants: The couple begins to adjust to their new
role as parents with integration of infants into the family.
• Family With Preschool Children: The oldest child enters early
childhood, and the family begins to socialize the child(ren) by
helping her or them adjust to school and cope with separation
from home.
• Family With School-Age Children: The family adjusts as the
children develop friendships outside the family.
• Family With Adolescents: The oldest child begins to obtain in-
dependence and balance freedom with responsibility. The parents
begin to refocus on their marriage.
• Family Launching Young Adult: The oldest child leaves home.
The family focus centers on the development of the children and
helping them gain their independence. The parents continue to
focus on their marriage.
• Middle-Age Family: The parents continue to focus on reinvesting
in the couple’s relationship while the children continue to establish
their own lives.
• Aging Family: The family copes with the process of and changes
involved in retirement and aging.

Growth and Development in Children 13


Erik Erikson’s Psychosocial Stages
Erik Erikson organized his psychosocial theory into eight stages that ex-
tend from birth to death. Each stage of the theory is concerned with the
individual’s becoming competent and feeling a sense of mastery before
moving on to the next stage. Each stage also has the threat of conflict.
Based on these dichotomies, the individual can experience potential
growth or failure.
• Infancy: Trust Versus Mistrust (birth to 1 year): The baby
learns trust by having basic needs met (feeding).
• Early childhood: Autonomy Versus Shame and Doubt (1 to
3 years): The child learns personal control and a sense of inde-
pendence without shame (toilet training).
• Preschool: Initiative Versus Guilt (3 to 6 years): The child de-
velops the resourcefulness to achieve and learn without remorse
(exploring the environment).
• School age: Industry Versus Inferiority (6 to 12 years): The
child develops a sense of confidence through mastery of tasks
(games).
• Adolescence: Identity Versus Role Confusion (12 to 18 years):
The adolescent acquires a clear sense of self during new and
sometimes conflicting experiences (social relationships).
• Young adulthood: Intimacy Versus Isolation (19 to 40 years):
The young adult forms intimate, loving relationships with others
(relationships with other people).
• Middle adulthood: Generativity Versus Stagnation (40 to
65 years): The middle adult concentrates on nurturing others and
creating a positive change that benefits other people (parenting).
• Maturity: Ego Integrity Versus Despair (65 to death): The
older adult reflects on his or her life and feels a sense of fulfillment
(reflection).

James Fowler’s Stages of Faith


James Fowler developed a theory about the stages of faith or spiritual
development across the life span.
• Stage 0: Undifferentiated (infancy): The child is influenced by
examples of the visible faith in caregivers. This stage is the foun-
dation for developing a spiritual faith.
• Stage 1: Intuitive-Projective (2 to 6 or 7 years): Based on magical
thinking, the child’s beliefs are unquestioning. This is the stage of
first self-awareness.
• Stage 2: Mythical-Literal (6 to 12 years): The child learns faith-
filled stories and takes them literally. This stage creates the need
for a personal relationship with a spiritual source.
• Stage 3: Synthetic-Convention (12 years): The youth begins to
personalize his or her beliefs. This stage prepares the youth for
experiences that extend beyond the family.

14 Pediatric Nursing Care


• Stage 4: Individuation-Reflexive (late adolescence through
adulthood): The individual begins to take responsibility for his or
her personal beliefs. This stage provides genuine movement toward
individual personal beliefs, regardless of what others believe.
• Stage 5: Conjunctive Faith (midlife): The individual reclaims
and reworks his or her past to emerge into a deeper self. With the
realization that life is half over, the individual becomes interested
in cultivating other people and in generating identity and meaning.
• Stage 6: Universalizing Faith (older adult): This stage is rarely
achieved in which the individual views the community as univer-
sal. The individual has relationships with others at any of the
other stages and from any other faith tradition.

Sigmund Freud’s Psychosexual Stages of Development


Sigmund Freud’s psychosexual stages of development have three aspects:
the id, identified as the pleasure principle; the ego, identified as reality prin-
ciple, and the superego, related to the conscience, that internalizes punish-
ments and warnings, as well as rewards and positive feedback, as the child
is presented with life experiences. There are also five psychosexual stages:
• Oral (birth to 1 year): The oral stage begins at birth, and the oral
cavity is the primary focus of the libido. Sucking and biting are
favorite activities of the infant at this stage.
• Anal (1 to 3 years): The anal stage occurs with toilet training, and
the child becomes aware of the erogenous zones in the genital
area. The child becomes interested in the retention or expulsion
of feces. Potty training occurs during this period.
• Phallic (3 to 6 years): The phallic stage happens when the child
becomes more interested in his or her genitals and in the genitals
of other people. Masturbation is common during this period.
• Latency (6 to 12 years): In the latency stage, the child’s energy is
focused on his or her genitals. The child becomes interested in
best-friend relationships, but the sexual impulse is suppressed as
a result of a marked interest in learning.
• Genital (12 to 18 years): The genital stage represents the child’s
renewed energy that is focused on his or her genitals. The adoles-
cent develops a sex drive, and that has a specific focus on the
pleasure of sexual intercourse.

Lawrence Kohlberg’s Moral Development


Lawrence Kohlberg’s theory of moral development describes the basis
for ethical behavior across the life span in six stages:
Preconventional Morality
The person’s morality is determined by rules and laws, along with con-
sequences of actions that guide his or her behavior.
• Obedience and punishment: The person obeys the rules to
avoid being punished.

Growth and Development in Children 15


• Individualism and exchange: The person thinks that it is ac-
ceptable to commit wrongdoing if something good comes from it.
Conventional Morality
The person’s morality is determined by being a good person with the in-
tent of pleasing others.
• Good interpersonal relationships: The person’s moral decisions
are based on the goodness of motivation and on what other people
expect.
• Maintaining the social order: The person’s good moral decisions
are based on decisions that preserve the needs of society.
Postconventional Morality
• Social contract and individual rights: The person’s thinking is
characterized by questioning the social order versus individual
personal rights.
• Universal principles: The person’s judgment incorporates a
deep awareness of justice.

Jean Piaget’s Stages of Cognitive Development


Jean Piaget designed a theory that described four stages of cognitive de-
velopment related to how an individual gains the ability to understand
and assimilate information into new understanding.
Sensorimotor (Birth to 2 Years)
The baby learns to coordinate actions and begins to develop object
permanence.
• Use of reflexes (birth to 1 month): The normal newborn reflexes
are present: rooting, sucking, Moro, tonic neck, grasping, stepping,
and Babinski.
• Primary circular reactions (1 to 4 months): The baby’s reflex
activity is repeated and creates pleasure.
• Secondary circular reactions (4 to 8 months): The baby’s actions
become intentional.
• Coordination of secondary schemes (8 to 12 months): The
baby uses actions to reach goals.
• Tertiary circular reactions (12 to 18 months): The baby explores
and tries new things.
• Mental combinations (18 to 24 months): The baby uses
language, and replication is common; object permanence is
well developed.
Preoperational (2 to 7 Years)
The child uses language to facilitate thought; magical thinking is present,
and logical thinking is not mature.
• Preconceptual (2 to 4 years): The child is egocentric.
• Intuitive (4 to 7 years): The child is less egocentric, with increased
awareness of thoughts and an ability to see another’s perspective.
Concrete Operational (7 to 11 Years)
The child’s thought is logical. Children at this age are able to classify,
and their understanding is literal.

16 Pediatric Nursing Care


Formal Operational (11 to 15 Years)
The older child’s thinking is abstract and logical, with the ability to
analyze and construct theories.

Anticipatory Guidance
In any health-care setting such as the hospital or community, the nurse
applies the principle of anticipatory guidance, which prepares parents
for the child’s next developmental phase.
3 Months
A 3-month-old infant follows a moving object or person with his or her
eyes, grasps a rattle, spontaneously smiles, makes babbling or cooing
sounds, and has variations in cry that express feelings such as attention
seeking, anger, hunger, tiredness, and pain. Anticipatory Guidance
for this age includes teaching parents about crib and car seat safety,
“Back to Sleep,” and Abusive Head Trauma. Providing the childhood
immunization schedule is also important. In addition, include information
about expected developmental milestones. Teach parents about cuddling
and holding the infant frequently and providing comfort using a soothing
voice. Tell the parents about the importance of a regular schedule
(for feeding, play, bath, nap, and bed time) and about age-appropriate
and safe toys (soft and big toys that are safe for the mouth).
6 Months
A 6-month-old infant is growing rapidly, doubling birth weight. The in-
fant smiles easily, verbalizes a variety of sounds and searches for the
source of sounds, enjoys music and rhythm, learns easily, and begins to
remember. Anticipatory Guidance for this age includes teaching par-
ents about the importance of well-baby checkups, baby-proofing the
home, reading books (with big pictures or noises) to the baby, talking,
singing, and interacting with the infant frequently, as well as providing
age-appropriate and safe toys (big, soft, and colorful to touch and hold).
9 Months
A 9-month-old infant recognizes and looks for familiar people, becomes
shy with strangers, cries when parents leave the room, bangs two cubes
together, puts objects in and out of a container, lets objects go voluntar-
ily, uses simple gestures such as shaking the head for “no,” and uses ex-
clamations such as “oh-oh!” Anticipatory Guidance for this age
includes teaching parents to play simple games with the infant such as
“all gone,” “so big,” and “peek-a-boo.” Additionally, tell parents to respond
readily to cries and needs, provide a safe environment in which the child
can move around and play, provide age-appropriate and safe toys (toys
that push and pull and make noise or are interactive), and learn basic
first aid and cardiopulmonary resuscitation (CPR).
12 Months
A 12-month-old infant triples his or her birth weight. At 1 year of age,
the child has good eye-hand coordination and basic problem-solving
skills. The child understands names of familiar objects, shows interest

Growth and Development in Children 17


in picture books, pays attention to conversation, responds to his or her
name, and dances (bounces) to music and attempts to sing. Indicating
what he or she wants with gestures other than crying and drinking from
a cup independently are also important developmental milestones. An-
ticipatory Guidance for this age includes teaching parents to be con-
sistent with the child’s schedule (feeding, play, bath, nap, and bed time),
saying no in a firm and consistent tone of voice, showing the child what
is safe and unsafe, and providing a special toy or blanket. Parents need
to learn that it is acceptable to allow the child to play alone under the
watchful eye of a caregiver. Tell the parent to read stories and teach
simple songs to the child.
Toddler (1 to 3 Years)
Temper tantrums are a major developmental milestone for the toddler,
who exerts much energy to gain independence. The toddler talks in short,
simple sentences and uses the word, “no.” At this age, the child can listen
and understand short explanations, name dozens of things that she sees
on a regular basis (e.g., items around the house), and understand the con-
cept of “more” (asks for “more cookie”). Toddlers like to sing songs or
say simple rhymes. The child moves from resisting sharing toys to some-
times playing and sharing with others. Examples of play include throwing
and catching a big ball, sorting objects that match, and playing imitation
or action games. Anticipatory Guidance for this age includes teaching
parents about safety and the importance of consistent discipline. Teach
the parents to remain calm and comforting during temper tantrums. Par-
ents can learn to use simple instructions to teach the child about dressing
and self-care measures. To promote independence, parents can show the
toddler how to put toys away. Tell parents to include experiences during
the day in which the child can help and feel like a “big boy or girl.” During
this growth period, parents can help the child learn new words by reading
books and carrying on conversations. Instruct parents to provide positive
reinforcement and use good role modeling.
Early Childhood (3 to 6 Years)
At this age, the child talks, can be understood by others, and follows sim-
ple directions. As a part of his or her vocabulary, the child asks and an-
swers questions containing the concepts of who, what, where, and when.
The child also likes rhymes and silly words. Good gross motor skills
(climbs up and down a slide) and fine motor skills (constructs simple puz-
zles) are present. Dressing, counting, printing his or her own name, and
playing with others are also important developmental milestones. Even
though the child is still egocentric, he or she has more internal control
over impulses, emotions, and behaviors. Anticipatory Guidance for this
age includes teaching parents about setting safe and secure limits, such
as having the child play in a fenced yard, bathing and swimming under
supervision, and keeping toxic materials out of the child’s reach. Tell par-
ents that the child needs to learn how to share and recognize the feelings
of others. Playing in small groups can enhance this type of learning. Par-
ents need to pay attention when the child is talking and to teach the child

18 Pediatric Nursing Care


about rules. Allowing independent dress (including simple self-care meas-
ures) and helping with easy chores and with planning promote maturity
and responsibility when making choices. Instruct parents that discipline
can be done with gentle restraint, distraction, or “time outs.” Tell parents
to praise good behavior and give plenty of smiles and hugs.
School Age (6 to 12 Years)
The school-age child focuses on following rules and working independ-
ently for short periods of time. “Best friends” is an important concept of
this age group. This age child knows that his or her actions have both
causes and effects (e.g., understands right and wrong, fair and unfair).
Concepts such as in, out, under, on, off, front, and back are understood. As
a part of his or her vocabulary, the child asks and answers “why” ques-
tions. He or she knows the time of day and left from right. The child has
the ability to tolerate frustration better than before and to follow through
with simple directions. Gross motor skills (riding a bicycle) and fine motor
skills (tying shoelaces) are well developed. Anticipatory Guidance for
this age includes teaching parents about listening and emphasizing the
concepts of right and wrong. Parents need to establish rules for watching
television and video gaming. Encouraging physical activities, reading,
playing board games, and participating in experiences outside the home
are fundamental to growth and development. Implementing safety rules
for the home, such as conducting fire drills and locking up poisons,
matches, electrical tools, and firearms, is crucial to health promotion. So
is reinforcing safety rules when the child is away from the home, includ-
ing playground safety, “stranger danger,” wearing seatbelts, swimming
rules, crossing the street, bicycling (with a helmet), playing sports, and
applying sunscreen—essentially anything that will prevent injury to the
child is essential. Teach the parents that praising the child’s efforts is vital.
Adolescence (12 to 18 Years)
During adolescence, boys and girls develop primary and secondary sex
characteristics that mark the onset of puberty. The adolescent investi-
gates sexual preferences. Conflict begins as the adolescent begins to
question personal philosophy, morality, and social issues. At this time,
the adolescent knows it is possible for several views of morality to exist
and takes a stand for individual values. The adolescent can think ab-
stractly, use deductive reasoning, make plans for the future, and set
long-term goals. Gross motor skills (engaging in team sports) and fine
motor (intricate artistic) skills are highly developed. The adolescent has
good language skills and can communicate alternative points of view.
Anticipatory Guidance for this age includes teaching parents how
to help the adolescent make good decisions related to personal safety
and health. In partnership with the adolescent, parents can provide
experiences that support responsibility (curfew and chores), as well as
reinforcing that behavior has consequences. Topics for discussion in-
clude driving, exposures to crowd illness (meningitis), alcohol and
drugs, sex, peer pressure, social media (and possible dangers; predators
and pornography), depression or anxiety, eating disorders, and firearms.

Growth and Development in Children 19


Supporting the adolescent’s quest for independence and keeping him
or her healthy and safe are tricky. Telling parents to seek professional
help when the adolescent’s behavior is dangerous or is out of control
is important.

NURSING CARE PLAN: GROWTH AND DEVELOPMENT

PRIORITY NURSING DIAGNOSIS


Delayed growth and development, related to chronic illness
GOAL
Child achieving optimal growth and developmental milestones
NURSING OUTCOMES CLASSIFICATION
• Growth (0110): Normal increase in bone size and body weight during
growth years
• Child Development: Middle Childhood (0108): Milestones of physical,
cognitive, and psychosocial progression from 6 through 11 years of age
(specify other age groups as appropriate)
• Play Participation (0116): Use of activities by a child from 1 year through
11 years of age to promote enjoyment, entertainment, and development
NURSING INTERVENTIONS
1. Build a trusting, supportive relationship with the child and caregivers by
spending time, actively listening to concerns, and offering age-appropriate
information and encouragement.
Rationale: Trusting relationship facilitates implementation of develop-
mental interventions.
2. Measure the child’s height and weight (specify frequency), and record it
on a continuous flow sheet.
Rationale: A flow sheet provides a continuous record of the child’s
growth over time.
3. Monitor attainment of age-appropriate developmental milestones.
Rationale: Provides information about the child’s developmental needs.
4. Collaborate with the child, caregivers, and dietitian, as needed, to provide
healthy, high-calorie, and high-protein meals, snacks, and drinks that the
child enjoys.
Rationale: Collaboration ensures that the diet will be appealing to the
child and provide the necessary nutrients for growth and development.
5. Encourage caregivers to view the child as “a child with an illness,” rather
than “an ill child.”
Rationale: Encouraging normalcy within the bounds of what is physically
possible assists the child to reach maximal growth and development.
6. Assist caregivers to identify the child’s special needs, and make environ-
mental adaptations to promote normalcy. Refer to community resources
as needed (specify).
Rationale: A supportive, adaptive environment may downplay the child’s
disabilities and enhance normal development.

20 Pediatric Nursing Care


NURSING CARE PLAN: GROWTH AND DEVELOPMENT—cont’d

7. Refer caregivers to appropriate support groups (specify).


Rationale: The support of other families and children may provide addi-
tional information and ideas to foster growth and development.
8. Encourage caregivers to hold the same expectations and use the same
parenting techniques for the child as they would for other children in the
family, as appropriate.
Rationale: Consistent caregiver expectations and parenting techniques
help the child view himself or herself as a normal child.
9. Provide anticipatory guidance to caregivers about age-appropriate
developmental tasks and milestones for the child.
Rationale: Provides information for goal-setting in development
enhancement.
10. Encourage caregivers to provide age-appropriate activities and normal
childhood experiences for the child whenever possible (specify, e.g.,
school, scouting, camp).
Rationale: Participation in usual activities and experiences for age facilitates
the child’s physical, emotional, and social development.
11. Assist the caregivers to provide for and encourage the child’s interaction
with other children.
Rationale: Interaction with peers promotes the child’s social development.
12. Collaborate with care provider to enlist the assistance of a Child Devel-
opment Specialist when the child is hospitalized.
Rationale: Provides professional developmental support specifically for
the hospitalized child.
13. Provide age-appropriate explanations to the child about the illness,
treatments, and procedures.
Rationale: Provides information at a developmentally appropriate level.
14. Encourage and facilitate the child’s participation in activities of daily
living and self-care during hospitalization.
Rationale: Participation enhances motor development and self-esteem.
15. Provide age-appropriate materials and play activities for the hospitalized
child (specify).
Rationale: Play enhances motor and psychological development.
16. Assist the caregivers to arrange for the child’s continuation of school
work during hospitalization, as appropriate.
Rationale: Prevents the child from falling behind in school during illness.
17. Assist the child and caregivers to set a preferred daily schedule for activ-
ities while hospitalized.
Rationale: A regular schedule promotes normalcy and participation
enhances the child’s self-esteem.
18. Provide developmentally appropriate incentives and rewards for the
child’s accomplishments (specify for child).
Rationale: Incentives and rewards bolster the child’s self-esteem and
encourage further development.
19. Encourage caregivers to obtain needed rest and respite from child care.
Make referrals as needed.
Rationale: Fatigue and stress during chronic illness may interfere with Continued
optimum caregiving for the child.
From Ward & Hisley, (2010).

Growth and Development in Children 21


SPEAKING OUT

The nurse can advocate for the child and his or her family by encouraging parents to:
• Monitor their child’s growth and developmental progress on a regular basis, and
report any concerns to the primary health-care provider.
• Become knowledgeable about expected growth and developmental milestones.
• Access community agencies that have resources and programs for promoting child-
hood growth and development: schools, faith communities, and organizations such as
Girls and Boys Clubs.
• Discuss their child’s progress with other adults who have contact with the child: coaches,
group leaders, and teachers.
• Involve a Child Life Specialist in the care of the child during hospitalization.

BEST PRACTICES 1–4

Understanding and applying growth and developmental principles are crucial


to providing safe and competent nursing care to children. The nurse must also
use this knowledge to communicate with the family and provide community
resources to parents.

CHRONIC CONDITION

A chronic condition, such as cystic fibrosis, is a condition that has a long duration (usually
more than 3 months). It progresses slowly, shows little change over time, or has a slow
recovery progress. A chronic condition can affect a child’s physical, psychological, or
cognitive health (Ward & Hisley, 2009). The chronic condition places limitations on
the child’s daily activities and affects his or her overall ability to meet developmental
milestones. The nurse understands the terminology “realistic developmental level”
because some children do not advance beyond a certain developmental level. What-
ever the circumstances, the nurse is part of the health-care team that can direct the
family to appropriate health-care services and community resources. Additionally, the
nurse helps the family adapt to the situation by offering ongoing support.

Chapter Summary
The nurse cares for children in a variety of settings. Regardless of the
setting, the nurse uses astute assessment skills to determine the child’s
growth and developmental progress accurately. The nurse monitors
the child’s growth and can tailor care to sustain or improve the child’s
health status. Advancing or restoring the child to a realistic developmen-
tal level is a key nursing intervention. Remember, growth and develop-
mental status lays the groundwork for the child’s entire life; it affects
relationships, learning, and vocation and eventually launches them into
adulthood.
22 Pediatric Nursing Care
2 Children in the Hospital
and in the Community

Setting
Family-Centered Care 23
The Child in the Hospital 25
Caring for the Child in the Community 29
The Child with a Chronic Condition 30
The Developmentally Disabled Child 31
The Medically Fragile Child 31
The Child With a Pediatric Emergency 32
The Dying Child 34
Nursing Care Plan 37
Chapter Summary 38
CHAPTER 2

Children in the Hospital


and in the Community

C
hildren have unique health needs, and nurses work in partnership
with families to reach a shared goal of delivering health care (ANA,
2010). Working in partnerships includes respecting diverse families
of varying socioeconomic status. Caring is central to the practice of nursing
and takes place in both hospital and community settings. Fifty seven per-
cent of registered nurses work in hospitals, and 22% of registered nurses
work in physician’s offices, nursing care facilities, home health services,
or outpatient care centers. Public health agencies comprise 7% of the nurs-
ing workforce (U.S. Department of Labor Bureau of Statistics, 2008). The
nursing process (assessment, diagnosis, identification of outcomes, plan-
ning, implementation, and evaluation) uses critical thinking skills and
enables nurses to provide comprehensive holistic care that meets individ-
ual and family needs (ANA, 2010). Nursing care of children in hospital and
community settings incorporates growth and developmental principles,
provides parents with relevant information, enhances families’ coping
skills, promotes health, tends to illness, and links families to helpful com-
munity resources (Hunt, 2009). Every day, nurses strive to improve the
overall health of children in a variety of settings.

Family-Centered Care
Family-centered care, the core of pediatric nursing, recognizes that the
family is the constant in a child’s life, and care of the child includes the
entire family. Siblings and extended family members are considered a
part of the family unit, and each has a unique role based on family val-
ues, culture, and traditions. From this perspective, family-centered care
is built on partnerships between families and health-care professionals.
Both nurses and family members have responsibilities in a family-
centered care environment.

Children in the Hospital and in the Community 23


In a family-centered care environment, the
QSEN APPLICATION nurse:
• Shares ongoing information with parents or
Patient-centered care legal caregivers about the child’s condition
means recognizing the
• Provides care that promotes growth and
“patient or designee as the
source of control and full development in a safe environment
partner in providing com- • Ensures that health care is accessible and
passionate and coordinated responsive to family needs
care based on respect for • Facilitates collaboration between the family
patient’s preferences,
values, and needs.” Patient-
and the health-care team
centered care includes • Provides advanced directive information if
knowledge that: applicable
• Integrates understanding • Treats families with courtesy, dignity, and
of multiple dimensions of respect
patient-centered care: • Implements appropriate policies and
• Patient, family, and
community preferences
programs
and values • Provides understandable explanations
• Coordination and • Respects family differences
integration of care • Recognizes family strengths
• Information, communi-
• Maintains confidentiality
cation, and education
• Physical comfort and • Obtains informed consent
emotional support • Respects privacy
• Involvement of family • Provides support
and friends • Makes referrals
• Transition and continuity
• Describes how diverse
In a family-centered care environment, the
cultural, ethnic, and social family:
backgrounds function as • Provides complete and accurate information
sources of patient, family, about the child, including a medical history,
and community values
medications, allergies, communicable
• Demonstrates compre-
hensive understanding diseases, and other health issues
of the concepts of pain • Informs the health-care team when the
and suffering, including disease or condition, care measures,
physiological models of medications, laboratory work, treatment
pain and comfort
• Examines how the safety,
measures, surgical procedures, or other
quality, and cost effec- health-care issues are not understood
tiveness of health care • Participates in the decision-making process
can be improved through related to the child’s health
the active involvement of
status and care
patients and families
• Examines common barri- • Joins in partnership with the health-care
ers to active involvement team to ensure the best care in the hospital
of patients in their own and transition to the home setting
health-care processes • Treats health-care providers and others in a
• Describes strategies to
empower patients or
courteous manner
families in all aspects of • Arranges for payment of health-care
the health-care process expenses
Continued

24 Pediatric Nursing Care


The Child in the Hospital
QSEN APPLICATION
The child becomes hospitalized when she is ill —cont’d
or injured and requires more in-depth care than
can be provided by a primary health-care • Explores ethical and legal
provider in the clinic or office. Often, the child implications of patient-
centered care
is admitted to a pediatric hospital, in which • Describes the limits and
physicians, nurses, and other hospital staff mem- boundaries of therapeutic
bers such as child life specialists are specifically patient-centered care
trained to work with children who require gen- • Discusses principles of
effective communication
eral care, critical care, surgery, diagnostic test-
• Describes basic principles
ing, and treatments or other health-care services of consensus building
(Ward & Hisley, 2009) (Fig. 2–1). and conflict resolution
During hospitalization, the nurse notes the • Examines nursing roles in
following signs of separation anxiety in children: assuring coordination,
integration, and continuity
• Protest of care
• In infants, protest is observed when the
In this chapter, along
infant cries, screams, clings to parents with information about
when they attempt to leave, searches children in the hospital and
for parents when they are gone, and community, QSEN compe-
visibly rejects contact with the nurse or tencies ensure delivery of
the best nursing care.
others. From Quality and Safety
• In toddlers, protest is observed when the Education Safety for Nurses
toddler physically tries to force parents to (2011). Retrieved from
stay when they are attempting to leave http://www.qsen.org/ksas_
prelicensure.php#patient-
and tells the nurse or others to “go away.”
centered_care

F I G U R E 2 - 1 : Parents at the bedside of a child in the hospital. From Ward,


S. & Hisley, S., (2009). Maternal child nursing care: Optimizing outcomes for
mothers, children and families. Philadelphia: F. A. Davis, p. 708.
Children in the Hospital and in the Community 25
EVIDENCE FOR PRACTICE 2–1
PARENT PARTICIPATION IN CARE
A systematic literature review consisting of 21 descriptive studies (between
January 1994 and June 2006) on parent participation in the care of hospital-
ized children was critiqued. Parent participation in this review was defined as
“the care giving activities performed by a parent/guardian for a child in the
hospital setting in which they share or take part in the care of their child across
the entire hospital episode.” Caregiving activities are defined as physical,
psychological, or social activities performed by parents to improve the health
and/or psychological well-being of the child, with or without collaboration or
negotiation with health-care professionals (Power & Franck, 2008, p 623).
The results of this systematic review showed that parents want to partic-
ipate in their child’s care by performing activities of daily living that they
would usually perform in the home. In addition, the attitudes and activities
of health-care professionals are both barriers and facilitators to parent par-
ticipation. One implication for practice includes the idea that parents should
be supported in their participation in their child’s care.
From Power & Franck, 2008.

The toddler hits, pinches, kicks, or bites


ALERT the nurse or others, attempts to find
parents when they are gone, and continu-
Safety is a key ously cries to exhaustion. This stage can
aspect of hospital-
ization, and the nurse is
last for days.
obligated to prevent falls. If • Despair
a fall does occur, the nurse • Infants display despair by crying and/or
first assesses the child and lethargy or by showing lack of interest in
notifies the health-care
feeding.
provider about the child’s
condition. Documentation • In children, despair is observed when the
of the fall is essential. The child becomes inactive and withdrawn
nurse gives a detailed from others. Children become sad or
account of the fall, including depressed and uninterested in the environ-
the possible cause and what
the child was doing at that
ment. Regression to earlier behavior
time. The environment must occurs, and children may be unwilling
be described, such as sur- to communicate. In an advanced stage
face of the flooring (carpet, of despair, children can refuse to drink
cement, tile), the lighting in
or eat.
the room, and any pathway
obstruction (medical equip-
ment or toys). Did the child Caring for the Child in the Hospital
fall in the bathtub or The role of the nurse when caring for the
shower? Did the child’s
hospitalized child includes the following:
clothing contribute to the
fall; was she barefoot or • Direct care provider: Providing direct
wearing a long robe? Was nursing care to children and their families
the child wearing a fall alert in times of illness, injury, and recovery
Continued

26 Pediatric Nursing Care


• Educator: Educating children and their fami-
lies about health promotion and disease pre- ALERT—
vention, as well as illness and injury care cont’d
• Collaborator: Managing the total care of
bracelet, or was there
children and their families by coordina-
a special notation posted
tion with other health-care providers on the door of the room? A
• Researcher: Contributing to the profession follow-up assessment on
of nursing by identifying the PICO(T) the child is completed as
(patient, intervention, comparison, out- needed, as well as ongoing
documentation of any injury,
come, [time]) question in evidence-based if relevant.
practice or collecting data for quantitative
or qualitative research studies
• Expanded role: Enrolling in higher educa-
tion programs, such as for Doctor of Nursing
Practice (DNP), Pediatric Nurse Practitioner TIP
(PNP), Clinical Nurse Specialist (CNS), or
Regression is a return to a
Master of Nursing Science (MNS), that train former state of develop-
the nurse to use advanced critical thinking ment such as bed-wetting,
and specialized skills in the care of children, thumb-sucking, or pacifier
with some nurses choosing to pursue a or bottle use (Venes, 2013).
doctoral degree (PhD or EdD) • Detachment
• Infants can display a
renewed interest in the
Effects of Hospitalization on the Child caregiver, in feeding,
and Family and in the environment.
Many children have not had a hospitalization • In children, detachment
experience, whereas some children have had occurs after a long
frequent hospital visits. Depending on previous separation from parents.
It is observed when
experience, the number of hospitalizations, the children show an inter-
complexity of the condition, and the family’s re- est in the environment
sponse, the level of stress related to hospitaliza- again and begin to
tion can manifest in a variety of ways. Children interact with caregivers
or strangers. At this
can exhibit signs of anxiety and fear or aloof-
stage, children are
ness and disinterest. The child’s temperament willing to form new, but
is also important to assess when providing nurs- superficial, relationships
ing care to the hospitalized child. The effect of with others.
hospitalization on the child also depends on
the length of stay, tests, procedures, medica-
tions, medical equipment, food, and interaction
with the health-care team. Lindeke, Nakai, and
SPEAKING OUT
Johnson (2006) discovered that children pro-
vided insightful information about their per- Advocate. Speaking out for
ceptions of hospitalization. These investigators better care (e.g., better
found that the most negative aspects of the health-care insurance)
includes creating new
hospital experience were pain and discomfort, partnerships, working to
and the most positive aspects were play and Continued
the relationships with hospital staff.

Children in the Hospital and in the Community 27


Hospitalization of a child affects the family’s
SPEAKING OUT— ability to cope with the child’s condition, as well
cont’d as care for other children and maintain the
home. Having a hospitalized child affects the
influence public policy
family’s work and social obligations, and some
(on the local, state, or
federal level), taking part in families cannot meet the demands of either.
broader campaigns (e.g., Hospitalization also has a significant financial
immunizations or educa- impact on the family that often weighs heavily
tion), and being sensitive because one or more family members may miss
to family values, beliefs,
cultures, and customs.
work to stay with the child. In addition to lost
wages, the costs associated with hospitalization
are astronomical, with or without health-care
insurance.
Strategies for families coping with a hospitalized child include the
following:
1. Enlist family members, friends, and others who can offer support,
stay with the ill child, and/or help maintain the family home and
meet other obligations.
2. Garner support from faith communities or other community
agencies.
3. Contact the social worker to assess the family’s problem-solving
skills and help obtain needed resources.
4. Ask the hospital staff members or volunteers to provide sitter
services to allow the family members to leave the hospital or
take a break when necessary.
5. Provide dining, laundry, Internet connection, gathering spaces,
and other identified services needed by the family.
6. Provide temporary housing for families of hospitalized children.

BEST PRACTICES 2–1


CHILDREN APPRECIATE NURSES WHO . . .

• Engage in light-hearted conversation


• Interact with them as individuals
• Provide age-appropriate diversions
• Promote a sense of security
• Provide basic needs in a gentle manner
• Provide comfort and support
• Provide food and medicine
• Promote positive well-being
• Smile and use kind words
• Stop several times to ensure safety and well-being
• Take measures to reduce pain
From Schmidt, Bernaix, Koski, Weese, Chiappetta, & Sandrik K, (2007).

28 Pediatric Nursing Care


EVIDENCE FOR PRACTICE 2–2
THE GOOD NURSE
In a 2009 study, Hospitalized Children’s Views of the Good Nurse, five
themes highlighted important characteristics of “the good nurse”:
• Communication: “The good nurse” uses terms of endearment that make
children feel special.
• Professional competence: “The good nurse” is knowledgeable, qualified,
or educated. “The good nurse” is able to perform skills competently and
promptly, as well as make efforts to reduce unpleasant care measures.
• Safety: “The good nurse” is safety conscious and concentrates on his or
her work, has good organizational skills, and is a role model for good
health.
• Professional appearance: “The good nurse” wears a uniform that is neat,
clean, and identifies him or her as a hospital employee.
• Virtues: “The good nurse” is honest, listening, trusting, nice, helpful, gen-
tle, kind, reassuring, polite, cheerful, and friendly. Children specifically
state that they appreciate honesty about painful procedures and then
enjoy praise afterward for their bravery.
From Brady, (2009).

Caring for the Child in the Community


Whether the child has an acute short-term illness, has a complicated or
long-term condition, or is disabled or dying, nurses provide optimal care
based on accurate assessment, evidence-based information, and an un-
derstanding of individual and family needs. Nurses also assess the child’s
growth and development and then attempt to restore the child to the ap-
propriate developmental stage or maintain his or her development at
the most realistic level possible. In the community, ensuring the child’s
safety is a priority in the plan of care. Nurses must be vigilant that all
aspects of care, such as activities of daily living, medication, procedures,
feeding, play, and use of medical equipment, are all safe for the child.
Nurses also help prevent injury to the child through ongoing education
and use of anticipatory guidance. The child who is cared for in the com-
munity must have physical, emotional, social, and spiritual needs met.
Nurses use community resources to help the family members meet their
ongoing needs and develop coping strategies.
Caring for a child in the community is a collaborative approach that
includes continuity of care as a main aspect. Community-based care has
health promotion as its focus and is on the front line of prevention and
early detection. The integral role of nurse as educator can positively
affect the health and well-being of children and families. Community-
based care centers may be located in neighborhood clinics, schools,
shopping malls, or health-care centers (Ward & Hisley, 2009). If the child
has been hospitalized, community-based care consists of shifting hospital

Children in the Hospital and in the Community 29


services to agencies in the community that can meet the child’s needs
in the home setting. Often, the services needed for the child are
increased, rather than decreased (Hunt, 2009). Additionally, when the
child is cared for in the home, the child and family learn about all aspects
of the child’s care, such as how to tend to activities of daily living, oper-
ate medical equipment, administer medication, schedule health-care
visits, use adaptive devices, and find sufficient resources.
In the community, nurses give direct nursing care to the child or help
the family navigate the health-care system to find others to provide care.
Offers of ongoing support and education are important in the plan of care.
Visiting nurses, school nurses, and Faith Community Nurses can offer
ongoing support. Some important health promotion topics include nor-
mal growth and development, immunizations, nutrition, lifestyle choices,
and disease prevention, as well as water, motor
vehicle, and gun safety. Effective community-
OFFERING based nursing care also includes a thorough
SUPPORT understanding of the condition, followed by
teaching the family appropriate care measures
Not all situations are alike, for the child. Another important aspect of com-
obviously, and the nurse munity-based nursing care is family assessment,
will want to tailor interac-
tions to the situation, but
with a focus on understanding the family’s role,
the following are sample structure, and function (Hunt, 2009). Recogniz-
interaction suggestions by ing family strengths and vulnerabilities is impor-
Godshall (2003) that the tant, and nurses must have a genuine sensitivity
nurse may find helpful to
toward families’ cultural values and diversity
get started:
issues. For families, home care can be positive
• Familiarize yourself with
the child’s condition.
and rewarding or devastating and frustrating.
• Present yourself openly Receiving care in the home for a child is expen-
and honestly. sive because it includes costs related to housing,
• Show the family that you lifestyle modifications, special equipment, and
understand their burden.
special services (Ward & Hisley, 2009). Home
• Take time to listen.
• Include parents in your care may have a significant financial impact on
plan of care. the family, so nurses guide the family to find
• Treat each child as an accurate information on private and government
individual. health-care coverage.
• Allow older children to
make decisions in their
care. The Child With a Chronic
• Maintain patient and Condition
family confidentiality.
• Do not judge parents. A chronic condition is a disease lasting longer
• Help arrange for continu- than 3 months that shows little change or slow
ity of care. progression (Venes, 2009). Ward and Hisley
• Assess the family’s social
(2009) found that asthma is the leading chronic
support and resources.
• Consider the needs of condition. Other chronic conditions include
the entire family. sickle cell disease (SDS), bronchopulmonary dys-
plasia (BPD), congenital heart disease (CHD),

30 Pediatric Nursing Care


cystic fibrosis (CF), type 1 and type 2 diabetes mellitus, epilepsy, and
chronic renal failure (p 1139).
The nurse who cares for chronically ill children has specialized
knowledge and skills. However, parents of chronically ill children have
developed expertise in managing their child’s condition and want nurses
to value their participation in the child’s care (Godshall, 2003).

The Developmentally Disabled Child


A developmental disability is a lifelong condition that occurs before
18 years of age. It can be physical, mental, or a combination of mental
and physical impairment. After thorough assessment, a developmental
disability is classified as mild, moderate, severe, or profound. Develop-
mental disability limits or prevents the child’s ability to perform activities
of daily living and care for himself or herself independently (Fig. 2–2).

The Medically Fragile Child


There is a broad understanding about medically fragile children (chil-
dren with serious health conditions); however, the actual definition
varies from state to state. In Alaska, a medically fragile child is defined
as one who receives long-term care in a facility for more than 30 days
per year, who has a severe chronic condition that results in prolonged
dependency on medical care or technology to maintain health and

F I G U R E 2 - 2 : Some children
with a chronic condition require an
adaptive device to help them with
mobility. From Ward, S. & Hisley, S.,
(2009). Maternal child nursing care:
Optimizing outcomes for mothers,
children and families. Philadelphia:
F. A. Davis, p. 1135.

Children in the Hospital and in the Community 31


well-being, and who: (1) experiences periods of
SPEAKING OUT acute exacerbation or life-threatening condi-
tions, (2) needs extraordinary supervision and
The original Developmental observation, and (3) needs frequent or lifesav-
Disabilities Services and
ing administration of specialized treatments or
Facilities Construction Act
of 1970 has undergone dependency on mechanical support devices
several revisions and now (Müller, 2005).
ensures full community
inclusion and self- The Child With a Pediatric
determination of people
with developmental disabil-
Emergency
ities. An amendment to the A pediatric emergency happens when children
act in 1975 ensured advo-
cacy rights for people with
become acutely ill or injured or when the situa-
developmental disabilities tion is serious or life-threatening. Children are
to pursue legal, administra- transported to an emergency department,
tive, and other remedies where it is imperative that the delivery of care
to protect these rights
meets their unique needs. The emergency
(Legislative History and
Evolution of the Develop- department is staffed by physicians, nurses, and
mental Disabilities Act other health-care providers who specialize in
Background and Need for caring for children. An emergency department
the Legislation, 2010). can handle a wide range of medical problems,
such as gastrointestinal, respiratory, and infec-
tious conditions, as well as chronic, recurrent
illnesses such as seizures, asthma, sickle cell dis-
OFFERING ease, or cancer. Acute traumatic injuries and
SUPPORT
Not all situations are alike,
BEST PRACTICES 2–2
obviously, and the nurse will
want to tailor interactions to
NURSING DIAGNOSIS FOR THE MEDICALLY
the situation. The following
FRAGILE CHILD
are sample interactions that
the nurse may find helpful • Risk for infection related to chronic disease
to get started: • Risk for growth and developmental delays related
Examples of open-ended
to technology dependency
questions and statements:
• Compromised family coping related to prolonged
• What is your understand- disease or disability progression that exhausts
ing of your child’s
supportive capacity of significant people
condition?
• Interrupted family processes related to stress-
• Tell me about the
adjustment period to related physical illness
your child’s condition. • Risk for impaired parenting related to increased
• Tell me about your rela- care needs
tionship with your child. • Risk for powerlessness related to lifestyle of
• What do you think about dependency with inadequate coping patterns
the special needs that • Caregiver role strain related to increased care
your child has? needs
• How has your child’s
• Spiritual distress related to expressed lack of hope
condition affected your
• Chronic sorrow related to unending caregiving
family and lifestyle?
as a constant reminder of loss
Continued

From Newfield, Hinz, Tilley, Sridaromont, & Maramba, 2007.

32 Pediatric Nursing Care


critical illnesses are also treated in the emer-
gency department. The environment must be OFFERING
calming and nonthreatening to children, as well SUPPORT—cont’d
as informative and reassuring to their parents.
• Tell me how I can further
The emergency department is equipped with
assist you in the care of
appropriately sized medical equipment and has your child.
age-appropriate toys. Examples of affirmations:
The nurse in the emergency department
• Thank you for keeping
obtains a history that includes the following: your medical appoint-
• Medical history, prior surgical procedures, ments.
hospitalizations and/or medical office vis- • I really like the way you
its, previous illnesses, and immunization interact with your child.
• I can see you have mas-
status tered the important care
• Medications and herbal preparations needs of your child.
• Safety issues, language or hearing deficits, • You have a real gift for
potential for falls, developmental delays accessing community
resources needed to care
• Allergies (drug, food, and environmental)
for your child.
• Feeding history and habits, bowel and
urination patterns
• Recent fever and contact with ill persons
• Normal level of activity and changes in
activity level MNEMONIC
• Current conditions, illnesses, or other
concerns A medical
mnemonic used to help
The nurse in the emergency department remember the five Ps of
obtains a complete and thorough physical exam- arterial occlusion:
ination that includes the following: Pain
• Vital signs Pallor
• Skin assessment (rashes, perfusion, Pulselessness
bruising) Paresthesias
Paralysis
• Head assessment (eyes, ears, nose, throat,
neck tenderness, anterior fontanel)
• Hydration status (intake and output, pres-
ence of diarrhea, vomiting, or emesis)
• Eye assessment (scleral color, pupillary activity, retinal hemor-
rhages, corneal abrasions, presence of a foreign body)
• Ear assessment (tympanic membrane, redness, swelling, exudate,
presence of a foreign body)
• Mouth assessment (general appearance, mucous membranes,
new tooth eruption)
• Chest (shape, presence of retractions, rate, breath sounds, and
tachypnea)
• Cardiovascular (rhythm, murmurs, tachycardia or bradycardia or
other arrhythmias)
• Peripheral circulation assessment (pulses, skin color, and
temperature)

Children in the Hospital and in the Community 33


BEST PRACTICES 2–3
ENSURING AVAILABILITY OF NECESSARY EQUIPMENT AND SUPPLIES
IN THE EMERGENCY DEPARTMENT
• Monitoring equipment: Cardiorespiratory monitors, defibrillators, pulse
oximeters, thermometers, and blood pressure cuffs
• Airway management supplies: Oxygen equipment (mounted and portable),
oxygen delivery devices (masks, nasal cannulas, oxygen hoods [Oxyhoods],
tents) for oropharyngeal and nasopharyngeal airways, endotracheal tubes,
laryngoscope, suction catheters, bulb syringe, and chest tubes
• Vascular access supplies: Vascular access kits, intraosseous needles, arm
boards, intravenous fluid and blood warmers, and umbilical vein catheters
• Miscellaneous: Scales, infant formula and oral rehydrating solutions, over-
head warmers, restraining devices, resuscitation boards, sterile linens, and
precalculated drug or equipment lists based on weight (in kilograms)
• Specialized pediatric trays: Thoracotomy and lumbar puncture trays, urinary
catheters, and venous cutdown and surgical airway kits
• Fracture management supplies: Cervical immobilization equipment and
extremity and femur splints
• Pediatric crash cart
Data from American Academy of Pediatrics, Committee on Pediatric Emergency Medicine, and
American College of Emergency Physicians, Pediatric Committee Care of Children in the
Emergency Department: Guidelines for Preparedness, (2001).

• Abdomen (tenderness, bowel activity, con-


TIP stipation, or diarrhea)
• Genitourinary (urinary pattern, hernias, and
It is essential that the genitalia)
emergency department
have the appropriate
• Rectal (appearance, presence of blood, state-
resources (medications, ment of blood in stools or fissures)
equipment, policies, and • Musculoskeletal (movement of extremities,
education) and staff to gait, pain, dissymmetry)
provide effective emer-
• Neurological (overall activity level, level of
gency care for children.
Search for the American consciousness, responsiveness, ability to be
Academy of Pediatrics consoled, nerve function)
Joint Policy Statement—
Guidelines for Care of The Dying Child
Children in the Emergency
Department (2009) at The nurse gives palliative care and has an
www.pediatrics.org/cgi/doi/empathetic attitude when caring for the dying
10.1542/peds.2009-1807
child and his or her family. When cure is no
longer possible, providing palliative measures
becomes the highest priority. Procedures that
have no benefit and medications that may prolong life are stopped. The
nurse shifts from a curative technological approach to providing care
that enables the child to move toward death by accessing inner resources
for healing. From a healing perspective, the nurse can help the child re-
store mental, physical, and spiritual balance to attain peace at the time
of death (Ward, 2006).
34 Pediatric Nursing Care
The nurse has an openness and willingness
to discuss the difficult subject of dying. One key OFFERING SUPPORT
aspect of caring for the dying child includes
good communication, and this is often facilitated Not all situations are alike,
obviously, and the nurse
by the nurse.
will want to tailor interac-
The nurse understands the importance tions to the situation, but
of parental nurturing and attachment during the following is a sample
the child’s dying process. Helping the family interaction that the nurse
face the end of a child’s life is an important may find helpful to get
started:
nursing role. Families want to make the most
• Listen to the child and
of each moment together. The nurse facilitates
family members to
a supportive environment so parents can be understand their concerns
fully present as their child dies and then can when shifting the focus
reflect later, with a sense of peace because from cure to care and
“they did the best they could” for their dying symptom management.
• When did you realize
child. that cure was no longer
If the family decides to move the child possible?
home, the nurse who has been the primary • Tell me about your
caregiver can provide community resourses to feelings related to the
decision that has been
create a smooth transition from hospital to
made to stop lifesaving
home care. Both the child’s and the family’s treatment measures for
needs must be considered in the discharge your child.
planning process, which includes education • Tell me about your child’s
and support for both parents and other care- understanding of death.
How does this under-
givers in the home. If the family decides to standing affect your
place the child in hospice care, the nurse pro- coping abilities?
vides information about hospice care and helps • What is important to you
make the necessary arrangements. The nurse and your family during
this time?
also helps the family find resources, such as a
• What thoughts or
social worker who can explain their insurance feelings would you like
benefits. Bereavement support and counseling to express?
for families are also necessary after the death
of the child (Box 2–1 and Table 2–1).

BEST PRACTICES 2–4


HELPING THE CHILD AND FAMILY THROUGH THE FIVE STAGES
OF GRIEVING
• Denial and isolation are the initial feelings of numbness, disbelief, and shock
that happen with the realization that death is imminent.
• Anger happens after the impending death becomes a reality. The feelings
of anger, fear, and guilt are considered a normal response but can be
overwhelming.
• Bargaining happens when family members bargain with either themselves or
with God in hopes that the child’s life will be spared.

Continued

Children in the Hospital and in the Community 35


BEST PRACTICES 2–4—cont’d

• Depression happens when the illness or injury can no longer be denied or


bargained away, and profound sadness is evident.
• Acceptance happens when the family or child has made an emotional
adjustment to the illness or injury and understand that death is imminent.
During this period, there may be a renewed joy in everyday living and
finding meaning in the child’s life.
From Kubler-Ross, (1983).

BOX 2–1 Grief


The nurse understands that depression or sadness is to be expected. Grief,
loss, and bereavement are emotionally and oftentimes physically painful. There
is no rigid rule that determines when the parents, siblings, family members, and
others can expect the pain to go away and return life back to normal. Each per-
son finds a personal way of grieving and length of time for healing that is best
for him or her. However, some warning signs indicate a family member needs
professional assistance:
• Constant fear or worry about the physical wellness of other family members
• Drug and/or alcohol use
• Excessive weight gain or weight loss
• Extreme denial
• Insomnia or excessive sleeping
• Loss of concentration that interferes with the ability to function normally
• Nightmares
• Overwhelming anger
• Poor decision making (e.g., drunken driving)
• Suicidal or homicidal ideation
• Violent or aggressive acts against self or others
From Ward & Hisley, (2009).

Table 2–1 Care Measures for the Dying Child


• Create a peaceful environment to facilitate dying with dignity.
• Follow the child’s and family’s wishes for end-of-life care.
• Promote early cessation of aggressive treatments if requested.
• Limit further painful invasive procedures and unnecessary medications.
• Ensure effective communication among the total health-care team.
• Individualize nutrition and diet needs.
• Provide physical care measures such as hygiene, bathing, repositioning, and comfort care.
• Provide care measures that include relief from pain, dyspnea, and other distressing
symptoms.
• Provide emotional support to help the child and family members cope during the dying
process and bereavement period.
• Provide spiritual care, including involving a chaplain, discussing the family’s spiritual
source of strength, using prayer or meditation, following rituals, reading from a spiritual
text, playing music, offering presence, and intentionality.
• Facilitate the use of complementary care measures such as relaxation, message, aro-
matherapy, acupuncture, or other therapies performed by a licensed practitioner.

36 Pediatric Nursing Care


Table 2–1 Care Measures for the Dying Child—cont’d
• Control pain, and manage symptoms (give pain or antianxiety medications as often as
possible per the physician’s order).
• Be knowledgeable about cultural practices that may include the use of spiritual texts and
symbols, chanting, lighting a candle, and listening in silence as well, as other methods of
care as deemed appropriate by the culture.
• Provide play and/or art therapy.
• Give compassion, honesty, support, and love.
• Involve siblings and other family members (e.g., grandparents) in the child’s care.
• Talk about death if the child and family desire to do so.
• Discuss topics about grief, loss, and isolation.
• Facilitate the transition to home or hospice care.
• After the final visitation, begin care measures such as bathing and dressing the child
(include the family if desired).
• After the child’s death, provide community resources that the family may need for coping.
• After the child’s death, create a remembrance packet for the family.
• Pay attention to your (the nurse’s) personal needs and seek help if you experience
burnout, compassion fatigue syndrome, and/or moral distress.

NURSING CARE PLAN: HOSPITALIZED


CHILD ALERT

PRIORITY NURSING DIAGNOSIS There are physi-


cal signs of impend-
Anxiety related to unfamiliar environment and ing death that can include:
procedures • Alteration in respiratory
GOAL status, such as Cheyne-
Stokes respirations, with
The child will not experience unavoidable anxiety periods of apnea
during hospitalization. • Anxiety, restlessness,
and/or agitation
NURSING OUTCOMES CLASSIFICATION • Decreased urine output
• Anxiety Level (1211) Severity of manifested • Decreased, weak, or slow
pulse rate
apprehension, tension, or uneasiness arising
• Describing another world
from an unidentifiable source of peace and beauty
• Anxiety Self-Control (1402) Personal actions • Describing spiritual
to eliminate or reduce feelings of apprehen- beings and bright lights
sion, tension, or uneasiness arising from an • Drinking no fluids or only
unidentifiable source taking sips of liquids
• Drop in blood pressure
NURSING INTERVENTIONS • Frequent naps and less
1. Approach the child and parent(s) in a calm, times of wakefulness
• Lack of desire to eat
reassuring manner, and provide teaching and
favorite foods
anticipatory guidance as appropriate. • Loss of sensation (touch)
Rationale: Feelings of anxiety or apprehension • Loss of body’s ability to
in the caregiver are easily transmitted to the maintain awareness and
patient and family. Knowledge reduces fear of consciousness
the unknown. Continued

Continued

Children in the Hospital and in the Community 37


NURSING CARE PLAN: HOSPITALIZED
ALERT— CHILD—cont’d
cont’d
2. Encourage the family to stay overnight, bring
• Loss of body’s the child’s favorite toys or security objects,
ability to maintain bowel and maintain routines as appropriate.
and bladder function
Rationale: Familiarity enhances the child’s
• Loss of body’s ability to
maintain thermoregulation
feeling of safety in a strange environment.
(skin cool to touch) 3. Provide a pacifier for an infant, or rock, hold,
• Making hand gestures, or comfort an older child as needed.
reaching out or holding Rationale: Comfort measures will vary by age,
unseen objects, or culture, and individual preference.
waving to unseen beings 4. Perform any invasive or painful procedures in
• Noisy respirations with a place other than the patient’s room. Allow
accumulation of fluids in family member to be present during proce-
lungs or pharynx
dures if desired.
• Slurred speech
• Speaking to people and
Rationale: The patient’s room should become
seeing places not visible and remain a safe place where the child is able
to others to relax. Family presence is reassuring for the
• Statements spoken to child.
those who have already 5. Encourage the family, and the child, if age
died (grandparents) appropriate, to participate in care activities
such as bathing, feeding, medication admin-
istration, or help with dressing changes.
Rationale: Reduces unnecessary anxiety from
having a stranger perform tasks. An older
ALERT child will feel less anxiety if allowed some
control over how things are done.
The nurse under-
stands that a do not From Ward & Hisley, 2009, p. 708.
resuscitate (DNR) order
means only that no
lifesaving measures will be Chapter Summary
initiated in the event of
cardiac or respiratory arrest. Nurses strive to improve the overall health
This decision also can of children in a variety of settings every day.
mean removing medical
Family-centered care is the core of pediatric
equipment such as a
ventilator, cardiorespiratory nursing practice in which the nurse develops a
monitor, dialysis machine, partnership with the child, family, and other
feeding tube used for health-care providers (Pediatric Nursing Scope
artificial nutrition, and intra- and Standards of Practice, 2008). The nurse spe-
venous fluids used for hydra-
tion. Aggressive treatments
cializing in caring for children in the hospital or
such chemotherapy or community can meet their unique needs, includ-
radiation therapies are also ing children who experience chronic illness, are
terminated (Ward & Hisley, developmentally disabled, are medically fragile,
2009).
are in an emergency situation, or are dying.
Accurate assessment skills, an understanding of
the principles of growth and development,
and use of a variety of nursing diagnoses are
essential for the care of the child in the hospital
or community.
38 Pediatric Nursing Care
3 Health Assessment in
Children
Health History 40
Anthropomorphic Measurements 41
Vital Signs 45
Cultural Assessment 48
Physical Assessment 51

Assessment
Nursing Care Plan 61
Chapter Summary 63
CHAPTER 3

Health Assessment
in Children

A
thorough health assessment provides the basis for nursing care
of the child. The nurse must have a working knowledge of
growth and developmental stages for infants, toddlers, preschool-
ers, school-age children, and adolescents to eval-
uate assessment data and plan individualized
care for the child. It is important to sequence the QSEN APPLICATION
physical assessment based on the developmental
Patient-centered care
age and stage of the child. The physical assess- includes skills such as:
ment is done in the typical head-to-toe fashion.
• Eliciting patients’ values,
However, individual variation of the physical as- preferences, and ex-
sessment is expected, based on broad norms for pressed needs as part
age level, as well as health status. In the health of the clinical interview,
assessment, obtain biographical data such as the implementation of care
plan, and evaluation
child’s age, name, parent’s or parents’ name or of care
names, address, phone number, birth date, gen- • Communicating patients’
der, race, ethnic origin, people who live with the values, preferences, and
child, and other people who live in the house- expressed needs to other
members of the health-
hold. Ask who is providing the information and
care team
his or her relationship with the child. Ask about • Providing care with
the reason for seeking care at this time. sensitivity and respect
During the health assessment, it is impor- for the diversity of
tant to gain the cooperation of the child. A calm human experience
• Assessing the presence
demeanor and a gentle, unhurried approach and extent of pain and
work best. Use distraction to direct the child’s suffering
attention to something other than the assess- • Assessing levels of physical
ment. Distraction techniques that allow for as- and emotional comfort
• Eliciting expectations of
sessment include the following: listening to
patients and families for
music; watching television; playing with small, relief of pain, discomfort,
age-appropriate toys; and blowing bubbles. For or suffering
infants, singing or watching a mobile overhead Continued
may work. If the child is uncooperative, the

Health Assessment in Children 39


nurse can complete essential assessments and
QSEN then wait until the child is calm to finish the rest
APPLICATION— of the assessment (Table 3–1).
cont’d
Health History
• Initiating effective treat-
ments to relieve pain A complete health history may be obtained with
and suffering in light of input from the child, his or her parent or
patients’ values, prefer-
guardian, and medical records. To establish rap-
ences, and expressed
needs port with the family and child, the nurse takes
• Removing barriers to the time for introductions and allows the family to
presence of families and speak freely about the reason for the visit or
other designated surro- hospitalization. Therapeutic communication
gates based on patient’s
preferences
facilitates the conversation (Table 3–2).
• Assessing the level of a
patient’s decisional con-
flict and providing access
to resources
• Engaging patients or
Table 3–1 Methods to Gain the Child’s
designated surrogates in Cooperation
active partnerships that Talk to the child based on his or her developmental age.
promote health, safety
and well-being, and Start with nonthreatening areas, and save distressing
self-care management assessments until the last.
• Recognizing the bound-
aries of therapeutic Use age-appropriate distraction techniques.
relationships
• Facilitating informed Provide an explanation of the assessment based on the
patient consent for care child’s developmental level.
• Assessing one’s own level
of communication skill in Be pleasant and patient (smile).
encounters with patients
and families Set gentle but firm boundaries.
• Participating in building
consensus or resolving When speaking to the child, be at his or her eye level.
conflict in the context of
patient care Be honest.
• Communicating care
provided and needed at Expect and allow for expression of emotions.
each transition in care
In this chapter, along with Speak directly to the child.
information about health
assessment, Quality and Provide privacy.
Safety Education Safety for
Nurses (QSEN) competen- Offer support to the child and parent or parents.
cies ensure delivery of the
best nursing care. Give the child realistic choices.
From Quality and
Safety Education Safety for Complete essential assessments first, and if needed, based
Nurses (2011). Retrieved on the child’s response, wait until later to do nonessential
from http://www.qsen.org/ assessments (if possible).
ksas_prelicensure.php#
patient-centered_care Praise the child.

40 Pediatric Nursing Care


Historical data include significant family his-
tory, the mother’s pregnancy and birth history ALERT
for this child, birth weight and gestational age,
immunizations, any identified developmental For the child’s
safety, other impor-
delays or chronic conditions, past illnesses, and
tant aspects of assessment
the child’s menstrual history, if appropriate. Any include the environment:
allergies, current medications, or herbal reme- • The child is wearing the
dies should be noted. A review of systems and correct name band.
the current reason for seeking care are also • The child is wearing an
essential data. Other important data include the allergy or fall bracelet
(if applicable).
following: safety issues, such as use of car seats
• The room is uncluttered,
and seat belts; water safety measures; storage of and all medical equip-
poisons, guns, and other hazardous material; ment is out of the child’s
and exposure to smoking or second-hand smoke. reach.
Ask about bowel and bladder control and toilet • The emergency medica-
tion dosing sheet is
training. Ask the family about the child’s nutri- located in the room.
tional status and what the child typically eats • Emergency equipment
and drinks. Find out about dental care, as well (e.g., Ambu bag, medica-
as the child’s sleep and rest schedule. Activity, tion) is nearby.
• Suction and oxygen
exercise, and extracurricular activities are also
equipment works prop-
important pieces of information. It is imperative erly and is available.
to ask how much time the child is sedentary • The stethoscope, ther-
(watching television and using the computer). mometer, ophthalmo-
The nurse may ask whether the child is in day scope, otoscope, blood
pressure cuff, and sphyg-
care or school. If the child is in school, ask momanometer or elec-
about the child’s academic performance and tronic blood pressure
whether it has changed over time. Ask about machine are located in
the home environment, any environmental the room.
• The call light is available
hazards (lead or smoke), and how well the
to the parents and child
child copes with or manages stress. Adolescents (if age appropriate).
should be encouraged to know and provide in- • Side rails are raised at
formation about their health history. It is impor- all times.
tant to ask the adolescent about relationships • Intravenous lines, other
tubes, and/or monitoring
with peers, stress management, eating habits, equipment are correctly
educational experience, extracurricular activi- placed and working
ties, and employment. Information about sexual properly.
activity, exposure to tobacco smoke, access to
firearms, experience with violence, and sub-
stance use and abuse should be elicited from the
adolescent privately.

Anthropomorphic Measurements
Obtaining anthropomorphic measurements are an easy and quick way to
estimate the child’s body composition. These measurements consist of
weight, height or length, head circumference, chest circumference, and
body mass index (BMI).

Health Assessment in Children 41


Table 3–2 Therapeutic Communication
WHAT WORKS WHAT DOES NOT WORK

Uses active listening Is an inattentive listener

Is present Is not present

Gives general leads with open-ended Gives general leads with closed-ended
questions (starts the question with questions (starts the question with why,
what, how, when) are, do)

Uses simple and understandable language Uses complicated technical or medical


when offering information terminology when offering information

Uses silence Uses unwanted chatter

Conveys acceptance Is defensive and shows disapproval

Uses exploring questions or comments Uses questions with yes/no answers

Uses reflection Asks why

States observations Ignores observations

Uses restatement or paraphrases Changes the subject


the problem

Uses clarification Gives personal opinions or advice

Uses validation Offers false reassurance (uses clichés)

Helps with problem-solving Does not help with problem-solving

Summarizes the conversation Ends the conversation abruptly

Weight, Height or Length, Head Circumference, Chest


Circumference, and Body Mass Index
The pace of the child’s growth is evaluated by serial measurements of
weight, height or length, head circumference, chest circumference, and
BMI. Growth charts from the National Center for Health Statistics
(NCHS) are found on its Web site.
When there is a deviation in measurements that fall below the fifth
percentile or above the 95th percentile for age and gender, the nurse
must alert the health-care provider.
Weight
Use an infant scale with a thin paper lining to measure the infant’s
weight. First, balance the scale. Then, remove the infant’s diaper and
clothing. Depending on the age of the infant, obtain the weight while
the child is either supine or sitting. Be sure to protect the infant from

42 Pediatric Nursing Care


an accidental fall by placing a hand over the infant without direct
contact (Ward & Hisley, 2009). Older children are weighed on a stand-
ing scale, and they may leave their underwear on while they are
weighed. It is important always to use the same scale. The child is
weighed each morning prior to eating during hospitalization and at
routine well-child visits (Table 3–3).
Height or Length
Height or length is measured in the infant while he or she is lying supine
on a measuring tray or board. If a measuring board is not available, hold
the infant’s head in midline and extend the hips and knees flat on a
paper-covered table. Points are marked at the top of the head and the
heels of the feet, and then the distance between the markings is meas-
ured. For the older child, use a stadiometer to obtain a standing height.
The child removes his or her shoes and stands with his or her back to the
stadiometer, with the back of the heels and shoulders touching the wall
(Ward & Hisley, 2009, p 672). Height or length is measured at routine
well-child visits (Fig. 3–1 and Table 3–4).
Head Circumference
Head circumference is a critical indicator of brain growth in infants and
toddlers. For the child 2 years of age and younger, be sure to measure
the head circumference at routine well-child visits. The head’s largest
circumference is measured by placing the tape over the lower forehead,
above the pinna of the ears, and over the occipital prominence. This
measurement is recorded in centimeters and is displayed as a percentile
(Ward & Hisley, 2009, p 672). The newborn’s head is larger than the
rest of the body to account for brain development, and the head grows

Table 3–3 Average Weight for the Infant and Child


Measurements for Children in the 50th Percentile
Metric conversion: 1 kilogram (kg) = 2.2 pounds (lb)

Birth: 3.2 kg or 7 lb 4 yr: 16.4 kg or 36 lb 12 yr: 39.5 kg or 87 lb

3 mo: 5.9 kg or 13 lb 5 yr: 18.6 kg or 41 lb 13 yr: 45 kg or 99 lb

6 mo: 7.7 kg or 17 lb 6 yr: 20.5 kg or 45 lb 14 yr: 50.9 kg or 112 lb

9 mo: 9.1 kg or 20 lb 7 yr: 22.7 kg or 50 lb 15 yr: 56.8 kg or 125 lb

12 mo: 10 kg or 22 lb 8 yr: 25 kg or 55 lb 16 yr: 62.3 kg or137 lb

18 mo: 11.4 kg or 25 lb 9 yr: 28.2 kg or 62 lb 17 yr: 66.4 kg or 146 lb

2 yr: 12.3 kg or 27 lb 10 yr: 31.4 kg or 69 lb 18 yr: 68.6 kg or 151 lb

3 yr: 14.5 kg or 32 lb 11 Years: 35 kg or 77 lb

Health Assessment in Children 43


F I G U R E 3 - 1 : The nurse is measuring the child’s height to ensure that
growth and development are on target. From Ward, S. & Hisley, S., (2009).
Maternal child nursing care: Optimizing outcomes for mothers, children and
families. Philadelphia: F. A. Davis, p 888.

Table 3–4 Average Height or Length for the Infant and Child
Measurements for Children in the 50th Percentile
Metric conversion: 1 centimeter (cm) = 2.54 inches

Birth: 50.8 cm or 20 inches 4 yr: 101.6 cm or 40 inches 12 yr: 149.9 cm or 59 inches

3 mo: 61 cm or 24 inches 5 yr: 109.2 cm or 43 inches 13 yr: 154.9 cm or 61 inches

6 mo: 66 cm or 26 inches 6 yr: 116.8 cm or 46 inches 14 yr: 162.6 cm or 64 inches

9 mo: 71.1 cm or 28 inches 7 yr: 121.9 cm or 48 inches 15 yr: 167.6 cm or 66 inches

12 mo: 76.2 cm or 30 inches 8 yr: 127 cm or 50 inches 16 yr: 172.7 cm or 68 inches

18 mo: 81.3 cm or 32 inches 9 yr: 132.1 cm or 52 inches 17 yr: 175.3 cm or 69 inches

2 yr: 86.4 cm or 34 inches 10 yr: 137.2 cm or 54 inches 18 yr: 177.8 cm or 70 inches

3 yr: 94 cm or 37 inches 11 yr: 142.2 cm or 56 inches

rapidly during the first months of life. Sometimes molding of the head
during the birth process affects the actual head circumference, so after
the head resumes a normal shape, the head needs to be measured again.
If the head is significantly smaller or larger than expected parameters,
the health-care provider must be notified.

44 Pediatric Nursing Care


Conditions in which the head may be
smaller than expected include microcephaly MNEMONIC
and craniostenosis (premature closure of the
sutures). Causes of increased head circumfer- This medical
mnemonic is used to
ence are caput succedaneum, cephalhematoma,
help remember head
subgaleal hemorrhage, and subdural hematoma. circumference.
By the time the infant is 1 year of age, the head Head circumference
and chest circumferences are about the same. with age: remember 3, 9,
The expected total increase in the head circum- and multiples of 5:

ference during the second year of life is 2.5 cm Newborn: 35 cm


3 months: 40 cm
or 1 inch.
9 months: 45 cm
Chest Circumference 3 years: 50 cm
At birth, the chest circumference is about 30.5 9 years: 55 cm
to 33 cm or 12 to 13 inches. During year 2, the
chest circumference continues to increase and
eventually exceeds head circumference.
Body Mass Index
BMI is also a part of assessing growth and can be tracked over time.
BMI is the number calculated from the child’s weight and height that
correlates to the percentage of body fat. The higher the child’s BMI,
the higher the percentage of body fat. The U.S. Department of Health
and Human Services, National Heart, Lung, and Blood Institute Web
site (http://nhlbi.nih.gov/) contains a BMI calculator.
Parameters:
• Underweight: BMI of less than 18.5
• Normal weight: BMI of 18.5 to 24.9
• Overweight: BMI of 25 to 29.9
• Obesity: BMI of 30 or greater

Vital Signs
Accurate assessment of vital signs is essential to monitor the child’s de-
velopment and evaluate physiological well-being. For infants and small
children, begin with the least invasive procedure first, and provide for
the child’s comfort and security. The suggested sequence for obtaining
vital signs is respirations, apical heart rate (counted for a full minute),
temperature, and blood pressure. Normal vital sign ranges change as the
child ages (Table 3–5).

Respirations
Count respirations for a full minute, either by listening or by watching
respiratory movement of the abdomen or chest wall while the child is
calm. Auscultate bilateral breath sounds, and evaluate for clarity, depth,
equality, regularity, and ease. Newborns are obligate nose breathers until
3 months of age (Jarvis, 2008), respirations are irregular with periodic
pauses of up to 10 to 15 seconds. Periods of apnea lasting longer than
15 seconds need to be investigated.

Health Assessment in Children 45


Table 3–5 Average Range for Pediatric Vital Signs
SYSTOLIC DIASTOLIC
BLOOD BLOOD
HEART RATE RESPIRATIONS PRESSURE PRESSURE
AGE (beats/min) (breaths/min) (mm Hg) (mm Hg)

Birth–1 yr 80–150 25–55 65–100 45–65

1–3 yr 70–110 20–30 90–105 55–70

3–6 yr 65–110 20–25 95–110 60–75

6–12 yr 60–95 14–22 100–120 60–75

12–18 yr 55–85 12–18 110–125 65–85

From Ward & Hisley, (2009), p. 673.

Apical Heart Rate


Allowing the child to sit in a parent’s lap or handle the stethoscope may
facilitate the assessment. Auscultate the apical pulse in infants and
children, note the cardiac rate and rhythm, and listen for murmurs. To
assess the apical heart rate, use the diaphragm of the stethoscope. The
location of the apical pulse is at the apex of the heart or the fifth inter-
costal space also known as the mitral area. Be sure to listen for the rate,
rhythm, and quality of apical pulse for a full minute. Bilateral palpation
of the radial pulse for pulse volume and regularity provides additional
information such as cardiac rate and rhythm.

Temperature
Oral and rectal temperatures provide the most accurate data about
core body temperature in children (Asher & Northington, 2008). An
infrared skin scanner in the temporal area or forehead is also used.
Because children generally dislike rectal temperature measurement,
tympanic thermometers may be used for infants who are more than
3 months old, and oral thermometers may be used for children more
than 4 to 5 years old (Wykoff, 2009). The axial route is preferred, but
if a rectal temperature is required, carefully insert a well-lubricated
thermometer no further than 1/2 to 1 inch to avoid rectal perforation.
Mercury thermometers are no longer used, and families should be
instructed to discard old mercury thermometers safely (Tables 3–6a
and 3–6b).

Blood Pressure
Blood pressure is routinely assessed in children who are more than
3 years of age (American Academy of Pediatrics, 2008). However, blood
pressure is always measured if the child has a cardiac, pulmonary, or

46 Pediatric Nursing Care


Table 3–6a Expected Temperatures in Children
AGE FAHRENHEIT (°F) CENTIGRADE (°C)

2 mo 99.4 37.4

4 mo 99.5 37.5

1 yr 99.7 37.6

2 yr 99.0 37.2

4 yr 98.6 37.0

6 yr 98.3 36.8

8 yr 98.1 36.7

10 yr 98.0 36.7

12 yr 97.8 36.6

Table 3–6b Fahrenheit to Centigrade Temperature Conversion


Formulas
°F = (°C × 9/5) + 32, or (°C × 1.8) + 32
°C = (°F − 32) × 5/9, or (°F − 32) × 0.55

°C °F °C °F °C °F

35.0 95.0 37.0 98.6 39.0 102.2

35.2 95.4 37.2 99.0 39.2 102.6

35.4 95.7 37.4 99.3 39.4 102.9

35.6 96.1 37.6 99.7 39.6 103.3

35.8 96.4 37.8 100.0 39.8 103.6

36.0 96.8 38.0 100.4 40.0 104.0

36.2 97.2 38.2 100.8 40.2 104.4

36.4 97.5 38.4 101.1 40.4 104.7

36.6 97.9 38.6 101.5 40.6 105.1

36.8 98.2 38.8 101.8 40.8 105.4

Health Assessment in Children 47


kidney disease, dehydration, or complaints of dizziness (Ward &
Hisley, 2009). Assess blood pressure in children by using an electronic
blood pressure machine with several cuff sizes available. Proper selec-
tion of the cuff size facilitates accurate blood pressure measurement.
Select a cuff with a bladder width that is approximately 40% of the
arm circumference (Ward & Hisley, 2009; Clark, Lieh-Lai, Sarnaik, &
Mattoo, 2002).

Reflexes
Primitive reflexes originate in the central nervous system and are ex-
hibited in normal infants. Controlled by the lower brain centers, primitive
reflexes are adaptive and innate mechanisms that protect the developing
infant while the brain is maturing. These reflexes are present at birth
and disappear by 9 months of age:
• The rooting reflex: The infant turns his head toward the
mother’s breast and begins to suck when his lower lip or cheek
is stroked.
• The sucking reflex: The infant moves his lips, mouth, and tongue
and shows interest to feed.
• The tonic neck reflex (or fencing posture): The infant turns his
head to one side, and the arm on that side straightens while the
opposite arm bends in a fencing position.
• The Moro reflex: The infant startles in response to a loud noise.
• The grasping reflex: An object is placed in the infant’s hand, and
the infant’s fingers close to grasp the object.
• The Babinski reflex: The sole of the foot is stroked, and the
infant responds by turning the foot inward while his toes flare
outward.
• The walking (or stepping) reflex: The soles of the infant’s feet
touch a flat surface, and he attempts to walk by placing one foot
in front of the other.

Cultural Assessment
All children belong to a culture, and all cultures have prescriptions and
proscriptions regarding child rearing and health. Categories of children
who may need a tailored cultural assessment include legal nonimmi-
grant residents, refugees and those granted asylum, legal permanent
residents, undocumented aliens, and naturalized citizens. The compe-
tent nurse understands that important components of culture are dy-
namic and always changing, are shared by other members of the same
cultural group, and are learned from birth via language, socialization,
and acquisition. In addition, the competent nurse knows that the culture
adapts to the specific conditions of the group, such as environment,
ethnicity, religion or spirituality, education, occupation, time orienta-
tion, socialization, health practices and beliefs, and prevalent health
conditions. The skilled nurse has a working knowledge of the cultural

48 Pediatric Nursing Care


variations found in the local community and supplements this under-
standing with a focused cultural assessment of the child’s family. Ask
about the ethnocultural traditions of the family, including beliefs about
nutrition, herbal or native remedies, discipline, health promotion,
disease prevention, and illness care. Adapt the child’s plan of care to
respect and support the family’s cultural beliefs whenever possible.
Assess the use of complementary and alternative nursing therapies in
a nonjudgmental manner, and document it in the child’s medical
record (Table 3–7).

Table 3–7 Physical Aspects of a Cultural Assessment


GENERAL CONDITIONS ASSOCIATED
APPEARANCE ASSESSMENT WITH CERTAIN CULTURES

Skin Melanin is responsible for the Melanoma is more common


variation in skin colors and among whites than among
tones. It protects the skin from blacks and Hispanics.
harmful ultraviolet rays.
Darker-skinned children have
lighter pigmentation on
palms, lips, and nail beds.

Endocrine Whites and blacks tend to There may be increased


sweat glands have a stronger body odor, body image disturbance with
whereas Asians and American increased body odor.
Indians have a mild body odor.

Hair In black individuals, hair is typ- In black individuals, the scalp


ically thick, spiraled, and kinky has a tendency to be dryer.
or can be straight.

Eyes, ears, nose, In light-skinned individuals, Epicanthal folds frequently


and mouth the sclera is white. In darker- occur in Asians and whites.
skinned individuals, the sclera Otitis media is more common
can be slightly yellow, with in Alaskans, American Indians,
small black marks (Ward & Hispanics. and Canadians.
Hisley, 2009). Sinusitis is more prevalent in
The eustachian tube is shorter, blacks.
wider, and more horizontal, Cleft lip and cleft palate are
and the external auditory canal more common in Native
is shorter and has a slope Americans and Asians and less
opposite to an adult’s ear in common in blacks. Blacks have
children of all races. more tooth decay than other
The appearance of the nose races. Nonwhite races have the
depends on racial characteris- poorest oral health habits.
tics (e.g., broad, flat) but
develops more fully during
adolescence in all cultures.

Continued

Health Assessment in Children 49


Table 3–7 Physical Aspects of a Cultural Assessment—cont’d
GENERAL CONDITIONS ASSOCIATED
APPEARANCE ASSESSMENT WITH CERTAIN CULTURES

Salivation begins at 3 months,


and 20 deciduous teeth erupt
between 6 and 24 months in
children of all races, depending
on the general state of health.
All 20 teeth should be present
by 2 1/2 years and are lost
starting at 6 to 12 years of
age. Patchy hyperpigmenta-
tion is normal and common in
darker-skinned people.

Heart In children of all cultures, the Heart disease and stroke are
heart’s position in the chest is more common among blacks.
more horizontal than in adults, Blacks have a higher incidence
and the apex of the heart is of hypertension. Black children
located at the fourth intercostal and adolescents have higher
space. total cholesterol levels than do
children of other cultures.

Lungs Respiratory development (size Tuberculosis and asthma are


of thoracic cavity) continues more prevalent among blacks.
throughout childhood and
reaches full development by
adolescence. Lung health
among cultures depends on
prenatal and postnatal expo-
sure to environmental toxins.
The occurrence of respiratory
tract infections or asthma
varies among cultures.

Genitourinary Darkly pigmented people Black girls begin puberty and


system have darker nipples, areola, begin menstruating about 1 to
labia majora, and scrotum. 1 1/2 years earlier than do white
girls.
The decision to circumcise
boys is based on culture. In the
United States, a high percent-
age of boys are circumcised.
However, in other countries,
such as Great Britain, Sweden,
Australia, and Canada, circumci-
sion is considered unnecessary.

Abdomen In children of all cultures, the Lactase is the digestive enzyme


abdominal wall is easier to needed for absorption of lactose
palpate because it is less (milk sugar). The incidence of
muscular than in adults. lactose intolerance is high in
American Indians, Asians, and
blacks.

50 Pediatric Nursing Care


Table 3–7 Physical Aspects of a Cultural Assessment—cont’d
GENERAL CONDITIONS ASSOCIATED
APPEARANCE ASSESSMENT WITH CERTAIN CULTURES

Musculoskeletal White boys are taller than Growth spurts mark the time
system black and Asian boys. White for significant growth. Height
girls are about the same varies in each cultural group
height as black girls. Asian and is influenced by genetics
girls are shorter than white and nutrition.
and black girls.

Neurological In children of all cultures, the No matter what the culture,


system neurological system is not fully a complete developmental
developed at birth but develops assessment is necessary at
as the child grows. Develop- routine well-child visits.
mental milestones happen in Developmental delays need to
an orderly sequence, although be documented and reported.
the exact age at which they
occur varies and is based on
many factors.

EVIDENCE FOR PRACTICE 3–1


COMPLEMENTARY AND ALTERNATIVE MEDICINE FOR CHILDREN
Research shows that many families and physicians are interested in the use
of complementary and alternative medicine (CAM) for children, especially
children with chronic conditions. This may include dietary modifications, such
as the elimination of sugar, or the use of herbs and nutritional supplements,
such as vitamins, probiotics, and fatty acids (Golnick & Ireland, 2009). Other
CAM modalities reportedly used in children include spiritual practices,
homeopathy, and chiropractic manipulation (Bull, 2009). The National
Center for Complementary and Alternative Medicine is a good resource
for practitioners interested in learning more: http://nccam.nih.gov

Physical Assessment
OFFERING SUPPORT
The four components of the physical examina-
tion are inspection, palpation, auscultation, and Not all situations are alike,
percussion. Inspection consists of careful watch- obviously, and the nurse
will want to tailor interac-
ing and completing a visual general survey of
tions to the situation, but
the body systems. Palpation uses a sense of here is a sample interaction
touch to assess the body’s temperature, organ that the nurse may find
location and size, and any swelling. Auscultation helpful to get started
means listening to sounds of the body, such as Continued

bowel sounds in the abdomen, beat of the heart,

Health Assessment in Children 51


and aeration of the lungs. Percussion is a tap-
OFFERING ping motion that uses short strokes to yield a
SUPPORT—cont’d vibration to depict the density, size, and location
of an organ.
(an interpreter may be
needed):
General Appearance
1. How do you like to
The nurse notes the child’s general appearance
be addressed and
greeted? How shall I at the beginning of the assessment, takes anthro-
address or greet other pomorphic measurements, and notes signs of
family members? nutritional status, such as body size, condition
2. What part of the world of the hair, and skin color. The general appear-
do you come from?
3. Tell me about your
ance assessment includes the following: posture
country. and gait; obvious physical deformities or in-
4. Tell me about the juries; mobility; and sensory function, such as
people in your country. speech, hearing, eyesight, sense of touch, and
5. What were the main
answers to questions about sense of taste. Be-
factors that brought
you to this country? havioral cues such as facial expression, mood,
6. How does your culture affect, and personal hygiene are also important
view family, health, in the assessment. Interactions with the parent
education, religion or or guardian help the nurse determine develop-
faith, and occupation?
7. What is the dominant
mental appropriateness and family interaction
language or dialect of style, as well as planning how best to proceed
your people? with the assessment.
8. How does your culture
perceive time? Is time Skin
a socially ingrained
aspect (being on time
Assess the child’s skin for general pigmentation,
is not important), or color, warmth, turgor, and any evidence of le-
is your culture clock- sions, bruising, cuts, or abrasions. Also note
oriented (being on freckles, birthmarks (i.e., stork bite), and moles.
time is important)?
Notice any diaphoresis or signs of dehydration.
9. What are the expected
gender roles in your Assess nail beds for shape and contour. Capil-
culture? lary refill is less than 2 seconds. Inspect the
10. Who is the head of the hair, scalp, and nails for evidence of nutritional
household, and how status. A newborn’s skin is covered with lanugo
does this relate to the
care of your child?
and/or milia, which are small, white bumps
11. What are some of the across the newborn’s cheeks, nose, and chin.
acceptable or restrictive Also assess pigmentation in infants. A Mongo-
behavior expectations lian spot is evident in darker-pigmented children
for your child?
such as blacks, American Indians, Hispanics,
12. What are the status,
roles, and traditions of and Asians. The nurse assesses for newborn
health-care providers in physiological jaundice in which yellowing of
your country? the sclera, skin, and mucous membranes devel-
13. Do you know about any ops after the third or fourth day of life. Diaper
risk factors or disease
specifically related to
dermatitis in infants may also be present. In
your culture? adolescents, increased sebaceous gland activity
Continued causes acne, and sweat glands become more
active, thus causing an increase in perspiration.

52 Pediatric Nursing Care


Head
Inspect the head for size (measure head circum- OFFERING
ference), shape, and symmetry. Assess sutures SUPPORT—cont’d
and fontanels in newborns. Inspect the child’s
14. What are your culture’s
hair for pediculosis (lice). Assess for facial struc-
typical health-seeking
ture, expression (correctly corresponding to be- behaviors?
havior), and symmetry, and palpate the sinus 15. How does your culture re-
area. Palpate the frontal and maxillary sinuses spond to and treat pain?
by gently pressing with the thumbs. In newborns, 16. What beliefs does your
culture have about phys-
assess for seborrheic dermatitis or cradle cap ical and mental illness?
when flaky white scales are present. Also assess 17. What beliefs does your
for caput succedaneum and cephalhematoma in culture have about
newborns. In infants, evaluate the anterior chronic illness, disabili-
ties, and rehabilitation?
fontanel for size and determine whether it is
18. What are your common
flat, bulging, or sunken. The posterior fontanel food choices, prepara-
closes by 3 months, and the anterior fontanel, tion methods, and
which has an average width of 2.1 cm, closes by specific food rituals?
12 to 18 months of age (Fig. 3–2). 19. Do you perceive any
nutritional deficiencies
in your child or family?
Neck 20. Do you pay attention
Palpate the cervical lymph nodes of the neck to safety measures such
for symmetry, lumps, pulsations, size, and signs as locking up hazardous
of discomfort, which may indicate infection. substances and firearms,
use of seat belts, water
Palpate the trachea and thyroid for size and safety measures, avoid-
location. The trachea should lie on the midline. ance of smokers (and
Note any signs of limitation in range of motion second-hand smoke),
of the neck. Also note neck muscle strength and avoidance of drugs and
alcohol, and use of safe
head control, especially in infants.
sex practices?
21. Does your culture have
Eyes any restrictions about
Inspect the external eye structure for the color blood and blood prod-
of the sclera and conjunctiva, for any redness ucts, organ donation,
transplantation, or
or drainage, and for alignment. Note the place-
certain medications
ment, shape, and symmetry of the eyes. Assess and remedies?
the eyelids and lashes, as well as the child’s 22. What are your child-
ability to blink. Also assess pupil size, equality, bearing and child
response to light, and the presence of the red rearing practices?
23. Tell me about your cul-
reflex. Vision at birth is limited but matures ture’s perceptions about
during early years of childhood development. death, death rituals, and
Evaluation of visual acuity can begin around 2 response to grief, mourn-
to 3 years of age. Some infants have epicanthal ing, and funeral practices.
24. Tell me about your use
folds, which are excess skin folds that extend
of spiritual practices. Do
over the inner corner of the eye. Preschoolers, these practices influence
from 3 to 6 years of age, can be screened for your health care?
visual acuity by using the picture or Snellen E 25. What can I do to help
chart. The Snellen Alphabet chart is used when your child through this
experience?
the child is 7 years old or older. Note strabismus

Health Assessment in Children 53


Anterior
fontanel Posterior
fontanel

F I G U R E 3 - 2 : Anterior and posterior fontanels. From Ward, S. & Hisley, S.,


(2009). Maternal child nursing care: Optimizing outcomes for mothers, children and
families. Philadelphia: F. A. Davis, p. 674.

or disparity of the eye axes; however, crossed eyes are considered nor-
mal in infants 3 months old and younger. An ophthalmologist assesses
internal anatomy and physiology of the eye.

Ears
Observe the size, shape, and placement of the external ears. The top of
the pinna should be about level with an imaginary line drawn from the
outer canthus of the eyes. Evaluate any drainage from the ears or signs
of discomfort on manipulation. For a child less than 3 years old, pull the
pinna down and back to facilitate otoscopic examination of the ear canal
and tympanic membrane. For older children, pull the pinna up and
back. Note the child’s response to sound, and implement hearing screens
as indicated.

Nose
Inspect the outside of the nose for symmetry and lesions. Inspect the
internal nasal mucosa for redness and edema. Test the patency of each
nostril. Evaluate any nasal discharge for amount, color, consistency, and
odor. Note whether the child predominantly breathes through the nose
or mouth.

Mouth and Throat


With a pen light, inspect the lips, mouth, and throat for color, lesions,
exudate, and odor. Inspect the teeth, gums, tongue, palate, and uvula.
Ward and Hisley (2009) suggest asking the child to say “eeehh” instead
of the usual “aaahh,” which flattens the tongue without use of a tongue
blade. Note the number and condition of teeth and the gingivae, and in-
spect the buccal mucosa for color and edema. Epstein pearls are whitish-
yellow cysts that form on the gums and roof of the newborn’s mouth.
Also with a pen light, inspect the throat and the tonsils. The color of the
tonsils should be the same pink as the oral mucosa. A tongue blade used
to press down on the tongue elicits the gag reflex.

54 Pediatric Nursing Care


Neurological System
Many of the neurological assessments can be made during other parts
of the physical examination and by watching the child. The Denver II is
used to screen fine and gross motor skills that are appropriate for the
child’s chronological age. Ask the mother to provide the birth history
and achievement of developmental milestones. Assess the child’s level
of consciousness for alertness, responsiveness, and affect. Also assess
orientation when applicable. Ask the parents whether the child has dif-
ficulty swallowing or speaking. Observe movement, and note any invol-
untary motions, balance difficulties, tremors, weakness, uncoordination,
or problems with balance or gait. Does the child have any numbness or
tingling? Ask the parent or parents whether the child has a history of
seizures. Has the child had any environmental exposure to lead? Assess
deep tendon reflexes. Assess neonatal reflexes such as rooting, sucking,
tonic neck (fencing), Moro, grasping, Babinski, and walking neck in
infants. Note the persistence of neonatal reflexes beyond 9 months as
an abnormal finding. Table 3–8 describes cranial nerve assessment.

Table 3–8 Cranial Nerve Testing


CRANIAL NERVE HOW TO TEST

I. Olfactory Ask the child to close both eyes and identify smells. This is rarely
done during a routine examination.

II. Optic Perform vision screening for visual acuity. Test for peripheral
vision and color blindness. Examine the optic disk with an
ophthalmoscope.

III. Oculomotor Ask the child to follow an object with his or her eyes through
the six cardinal positions of gaze. Assess the papillary response,
and note any drooping of eyelids.

IV. Trochlear Cranial nerves III, IV, and VI are tested together.

V. Trigeminal Observe the child chewing a cracker with his or her eyes closed.
Gently stroke different areas of the child’s face with a cotton
ball to assess sensory function.

VI. Abducens Cranial nerves III, IV, and VI are tested together.

VII. Facial Observe the child’s facial expressions during the interview and
examination. Ask the child to smile and then to frown.

VIII. Acoustic Create a loud noise, and note whether child turns toward the
sound.

IX. Glossopharyngeal Stimulate the gag reflex.

X. Vagus Assess the uvula in the midline. Ask the child to swallow.

Continued

Health Assessment in Children 55


Table 3–8 Cranial Nerve Testing—cont’d
CRANIAL NERVE HOW TO TEST

XI. Accessory As the nurse provides resistance, ask the child to shrug shoulders
and turn his or her head from side to side.

XII. Hypoglossal Observe the infant sucking. Ask the child to stick out his or her
tongue. Listen to the clarity of speech.

Adapted from Ward & Hisley, (2009), p. 681.

Chest
Inspect the shape, symmetry, and size of the chest, as well as symmetry
of the shoulders and upper muscles. Palpate the chest for expansion
equality with respiration and the presence of thrills. Visually assess in-
tercostal muscles, accessory muscle movement, and retractions. Palpate
for tactile fremitus, lumps, or any tenderness. Abdominal breathing may
be noted in children less than 6 or 7 years old. A relaxed facial expression
indicates an unconscious effort when breathing, whereas a child with
difficulty breathing exhibits anxiety. Assess breast development as ap-
propriate for age. Gynecomastia can occur in male adolescents, in whom
abnormal development of mammary glands results in breast enlarge-
ment and tenderness. This condition has psychosocial implications for
young male patients and must be addressed.

Lungs
Auscultate breath sounds in all lung lobes while the child is sitting and
taking slow deep breaths through an open mouth. If the child has respi-
ratory difficulties, having her sit in the caregiver’s lap may help decrease
anxiety and improve breathing. Using a stethoscope, the nurse notes
whether breath sounds are bilaterally clear, equal, and regular and also
listens for adventitious sounds. Count the respiratory rate for a full
minute. In infants and small children, it is easiest to count respirations
while the child is asleep. Brief periods of apnea lasting less than 10 to
15 seconds and periodic breathing are common. Percussion is not very
useful in children because of the child’s thin chest wall and the large
size of adult fingers. Apgar scoring measures the newborn’s transition
to extrauterine life. Infants breathe through the nose rather than the
mouth and are considered obligate nose breathers until 3 months of age.
Signs of respiratory distress include tachypnea, retractions, nasal flaring,
and assuming a posture leaning forward with the jaw thrust outward.
Additionally, rapid, shallow respiration at a rate of 60 breaths/minute is
another sign of respiratory difficulty (Ward & Hisley, 2009).

Heart
Palpation of peripheral pulses and auscultation of the heart provide in-
formation about the cardiovascular system (Fig. 3–3). Palpate the carotid
56 Pediatric Nursing Care
Carotid Temporal

Apical
Brachial

Aortic
area Pulmonic
area
Tricuspid Mitral or
area apical
area

Femoral

Radial

Popliteal

Posterior Dorsal
tibial pedis

F I G U R E 3 - 3 : Auscultation areas and peripheral pulses. From Holloway,


B., Moredich, C., & Aduddell, K. (2006). Ob peds women’s health notes: Nurse’s
clinical pocket guide. Philadelphia: F. A. Davis, p. 131.

pulse and first note any distention of neck veins. Note the quality and
equality of the temporal and peripheral pulses (bilaterally). Auscultate
the apical pulse by using the diaphragm of the stethoscope over the point
of maximal intensity (PMI). The PMI is located just left of the midclav-
icular line at the fourth intercostal space in children less than 7 years
old and at the fifth intercostal space in older children. A venous hum
is a benign phenomenon and is a continuous soft, hollow sound that
disappears when the child is supine (Ward & Hisley, 2009).
Use the bell of the stethoscope to auscultate heart sounds in four lo-
cations (Fig. 3–4). Normal heart sounds are S1 (the first heart sound,
which occurs with closure of the atrioventricular valves and signals the
beginning of systole) and S2 (the second heart sound, which occurs with
the closure of the semilunar valves and signals the end of systole). In
children, the nurse notes any murmurs resembling a swooshing or
blowing sound.
Health Assessment in Children 57
Clavicle

Aortic
Pulmonary valve
valve
1 2
Tricuspid
valve
3 4
Sternum Mitral valve

F I G U R E 3 - 4 : Four points of cardiac auscultation. From Ward, S. & Hisley,


S., (2009). Maternal child nursing care: Optimizing outcomes for mothers, children
and families. Philadelphia: F. A. Davis, p. 679.

Developmental delays, poor weight gain, dyspnea on exertion, and


tachycardia, tachypnea, or cyanosis indicate heart disease. Clubbing of
the fingers and toes is a late sign of cardiac disease.

Lymph Nodes
Assess the lymph nodes in the following areas: cervical, axillary,
epitrochlear, and inguinal. When exposed to a pathogen, the nodes in
that area become tender and swollen. Swollen lymph nodes require
further assessment and follow-up.

Abdomen
Inspect the abdomen while the child is lying down with knees bent and
feet flat on the surface. Note the size and shape of the abdomen, sym-
metry, contour, skin characteristics, umbilicus, and any visible peristal-
sis. Palpate each groin for the femoral pulse and inguinal lymph nodes.
Auscultate bowel sounds to assess motility in all four quadrants. Palpate
the abdomen to note any areas of discomfort or masses. Also palpate for
the liver, spleen, and kidneys. Inspect for an inguinal hernia (protrusion
of bowel through the inguinal canal) or umbilical hernia (protrusion of
the intestine through the abdominal fascia) (Ward & Hisley, 2009). Do
not palpate the abdomen if nephroblastoma or acute appendicitis is
suspected or diagnosed.

Genitourinary System
The nurse inspects the child for evidence of the development of second-
ary sex characteristics according to Tanner scoring (Table 3–9).
• Boys: Inspect the penis for size, shape, evidence of circumcision,
and placement of the urinary meatus and note any lesions, redness,
or discharge. Inspect the scrotum for size, shape, and symmetry,

58 Pediatric Nursing Care


Table 3–9 Tanner Staging of Development of Secondary Sex Characteristics
SEX CHARACTERISTIC 1 2 3 4 5

Female breast Slight to no Appearance of breast Entire breast enlarged with Enlargement of entire Mature breast with
development elevation of buds; areola widening no protrusion of the papilla breast with formation of protrusion of nipple
papilla with slight elevation or nipple secondary mound of only; no protrusion of
areola and papilla papilla

Female pubic hair None Sparse, lightly pig- Darker and increasing Coarse, thicker, curly; Adult female triangle
development mented, straight amount on labia and pubis; increasing amount, less with extension of hair
along border of labia distribution in typical female than adult onto medial thighs
inverted triangle

Male pubic hair and No pubic hair; Scant, long, slightly Pubic hair darker, starting to Pubic hair coarse, curly, Adult distribution of
genital development preadolescent pigmented pubic hair; curl, and extending across smaller quantity than pubic hair with exten-
genitalia slight enlargement of pubis; scrotum and testes adult; scrotum darker; sion to medial thighs;
scrotum and testes; continuing to enlarge; penis penis increasing in genitalia adult in size
scrotum reddening becoming longer and slightly length and breadth; and shape
and becoming more wider glans broader.
textured

From Ward & Hisley, (2009), p. 680.

Health Assessment in Children 59


and palpate for any nodules or masses.
OFFERING SUPPORT Palpate the testes for shape, size, and
descent into the scrotum. Scrotal enlarge-
Evaluation of the behavioral, ment should be further evaluated by transillu-
emotional, and social as-
mination to differentiate a hydrocele from
sessment of children and
adolescents is also pertinent a hernia.
to the health history. Not • Girls: Inspect the urinary meatus and ex-
all situations are alike, obvi- ternal genitalia for development of the
ously, and the nurse will labia majora, labia minora, clitoris, and
want to tailor interactions
to the situation, but here is
vaginal introitus. Note signs of inflamma-
a sample interaction that tion or lesions. Evaluate any vaginal dis-
the nurse may find helpful charge for color, consistency, and odor.
to get started: Pelvic examination with cervical dysplasia
1. Can you tell me about testing is deferred until the girl is 18 to
the bond that you have 21 years old or when she becomes sexually
with your baby?
2. What is it like to care
active (American Academy of Pediatrics,
for your infant? 2008).
3. Are there any issues
or problems you want Musculoskeletal System
to address about your Observe the child during the examination pe-
baby?
4. Tell me about your
riod for evidence of range of motion, movement
child’s temperament, ease, and symmetry. Assess for range of motion,
disposition, and mood. as well as specific fine and gross motor develop-
5. Describe your child’s re- mental milestones. Inspect joints for erythema,
lationships with others
and palpate for swelling, warmth, and indica-
such as family, siblings,
friends, and teachers. tions of discomfort. Evaluate upper and lower
6. Does your child get extremity muscle strength by applying resist-
along with others? Is ance bilaterally as the child presses her hands
she aloof and alone and then her feet against the nurse’s hands. Ask-
most of the day or
defiant in any way?
ing the child to push, pull, and squeeze the
7. Does your child show nurse’s hands with her hands provides informa-
signs of depression? Is tion about muscle strength and equality. Have
she happy or sad most older children participate in the musculoskeletal
of the time?
assessment by walking, hopping on one foot, or
8. How long is her atten-
tion span? Can she climbing on a step stool. Ask parents whether
focus on a particular the child has had any broken bones. In infants,
task for a reasonable check the hips for congenital dislocation using
amount of time? Ortolani’s maneuver.
9. What are her interest
areas such as favorite
television shows, games,
hobbies, or sports?
10. Tell me about her
school performance.
11. Is your child able to con-
trol her behavior? How
does she act in school,
Continued

60 Pediatric Nursing Care


NURSING CARE PLAN
OFFERING
NURSING DIAGNOSIS SUPPORT—cont’d
Risk for Poisoning related to environmental lead
in church, or during ex-
exposure tracurricular activities?
MEASURABLE SHORT-TERM GOAL 12. Can you tell me about
your parenting style?
The child’s blood lead levels will remain less than What are your meth-
10 g/dL. ods for praise and
punishment?
MEASURABLE LONG-TERM GOAL 13. Have you ever consulted
a mental health practi-
The child will not be exposed to lead in the home
tioner about your child?
environment.
14. Is your child currently
NURSING OUTCOMES CLASSIFICATION taking any medications
or herbal remedies?
Safe Home Environment (1910): Physical arrange- 15. Has your child ever been
ments to minimize environmental factors that may harmed or hurt in any
cause physical harm or injury in the home way? If so, by whom?
Are you aware of any
NURSING INTERVENTIONS CLASSIFICATION
mental health or social sup-
Environmental Risk Protection (8880) port community resources?
Home Maintenance Assistance (7180)
PARENT EDUCATION
Childrearing Family (5566)
SPEAKING OUT
NURSING INTERVENTIONS
Child maltreatment is con-
1. Evaluate the child’s environmental risk for sidered to be any action or
lead exposure (specify, e.g., whether he or failure to act by a person
she lives or plays in housing built before 1978 that endangers a child’s
or has had a sibling or playmate diagnosed physical or emotional health
with lead poisoning). and development. A person
is abusive if he or she fails to
Rationale: All children should be screened for
nurture the child, physically
lead poisoning at 1 and 2 years of age. The
injures the child, or relates
highest risk is from ingestion of lead-based sexually to the child (U.S.
paint, which was outlawed for use in homes Department of Health and
in 1978. Human Services [USDHHS],
2. Monitor the child’s blood lead levels (specify 2007). Maltreatment of
frequency). children includes physical,
Rationale: The child may have no obvious sexual, and emotional
symptoms, even with high blood lead levels. abuse, as well as neglect
(Ward & Hisley, 2009).
3. Explain the significance of the child’s blood
Assessment for domestic
lead levels to the family (specify whether
violence is done by docu-
further screening or treatment is indicated). menting a history of abuse,
Rationale: Sharing information allows the mental health problems,
family to participate in care decisions for depression, and substance
the child. abuse. The nurse must
advocate for the child and
Continued family by speaking out
about this issue.

Health Assessment in Children 61


NURSING CARE PLAN—cont’d
DOCUMENTATION
4. Monitor the behavior and developmental
Documentation of the health level of the child, and explain expected
assessment includes the characteristics for age to the family.
health history, anthropo- Rationale: Lead poisoning may cause behavior
morphic measurements,
disorders or delayed development. The family
vital signs, the cultural as-
sessment, and the physical
is most likely to notice changes in behavior
assessment. Documenting and can report on the child’s developmental
the health history is an abilities.
essential aspect of nursing 5. Teach the family about the risks of lead
care because it provides poisoning for pregnant women and small
the nurse and other health- children in terms the family can understand,
care providers with an including brain injury, mental retardation,
accurate account of the kidney damage, and anemia.
child’s assessment and
Rationale: This information can help protect
furnishes a record-keeping
system. From the legal
others in the family or neighborhood.
perspective, documentation 6. Administer chelation therapy, i.e., Succimer/
is required by all state nurse Antidote (Chemet), as ordered (specify drug,
practice acts. The electronic dose, route, and times)
medical record (EMR) is Rationale: Succimer/Antidote (Chemet) is
now a required component used to treat lead poisoning in children with
of documentation. This com- blood lead levels greater than 45 mcg/dL.
puterized medical record Main side effects are: CNS: dizziness; RESP:
allows storage, retrieval,
cough, nasal congestion; GI: nausea, vomit-
and ongoing updates of
patients’ records. The Health
ing; DERM: rashes; MISC: flu-like symptoms.
Insurance Portability and 7. Monitor lead levels and toxic side effects of
Accountability Act (HIPAA) chelation therapy (specify for the drug, e.g.,
of 1996 protects the privacy hematological, renal, and hepatic indicators).
of identifiable health Rationale: Lead levels may increase at first as
information. lead moves out of tissues into blood. (Specify
toxic side effects of the drug.)
8. Ensure adequate fluid intake and output
during drug therapy.
Rationale: Chelating agents are excreted by
the kidneys.
9. Assist the family with identifying sources of
lead in the child’s environment: old lead-based
paint, pottery not intended to hold food or
liquid, or playing in dirt contaminated with
old paint flakes (specify others as appropriate,
e.g., hobbies).
Rationale: The family may be unaware of lead
sources in their environment.
10. Provide verbal and written information to the
family on how to eliminate lead to make the
home safe: eliminate peeling paint, do not
allow child to chew on painted surfaces,
wipe down painted surfaces with a wet cloth,

62 Pediatric Nursing Care


NURSING CARE PLAN—cont’d

wet-mop floors rather than vacuuming, and do not store food in opened
cans (specify others as indicated).
Rationale: Vacuuming may spread lead dust around rather than remove it.
11. Teach parents to identify whether pottery and ceramics in the home are
intended to be used for food or liquids or are for ornamental use only.
Rationale: The family may be unaware of the risk of lead leaching out of
pottery designed for decoration only.
12. Instruct the family to drink, or mix infant formula with, water from the
cold tap only.
Rationale: Lead from the pipes dissolves more easily in hot water than
in cold.
13. Instruct family members to teach the child not to eat paint chips or dirt
and to wash his or her hands and face before eating or drinking.
Rationale: These measures help prevent
ingestion of environmental lead.
14. Notify appropriate agencies about the child’s environmental exposure,
and collaborate with other entities to improve environmental safety.
Rationale: Lead exposure is a community problem that should be addressed
as a health issue.
15. Refer the family for assistance from the local lead abatement program
(specify) or social service organizations as appropriate.
Rationale: Poor families are often the victims of lead exposure in urban
housing. The nurse acts as a patient advocate by ensuring that the
environment is cleaned up.

Adapted from Ward & Hisley, (2010).

Chapter Summary
A comprehensive health assessment provides the basis for nursing care
of children. The assessment begins with a thorough health history and
review of systems obtained from the parent or guardian, from medical
records, and from the child when appropriate. Anthropomorphic meas-
urements of weight, height or length, head circumference, chest circum-
ference, and BMI are obtained and compared with norms. A cultural
assessment, including the use of complementary and alternative nursing
therapies, helps the nurse plan sensitive and culturally competent care.
The physical examination proceeds from least invasive first, and the
nurse uses knowledge of developmental stages to encourage cooperation
from the child. Evaluation of the child’s behavioral, emotional, and social
status is also pertinent to the examination. Issues about child maltreat-
ment must be considered. Documentation of the health assessment is
an essential nursing role.

Health Assessment in Children 63


4 Nursing Care of Children
Care Measures 66
Fluid and Electrolyte Balance 71
Infection Control 73
Intravenous Therapy 73
Medication Administration 75
Growth and Development Factors 76
Calculating Safe Drug Dosages 78
Pain and Its Management 79
Procedures, Treatments, and Specimen
Collections 81
Rest and Sleep 83

Nursing Care
Safety 83
Vital Signs 84
Nursing Care Plan 86
Chapter Summary 86
CHAPTER 4

Nursing Care of Children

P
ediatric nursing practice focuses on the
care of children and their families in a QSEN APPLICATION
variety of settings (Pediatric Nursing Scope
and Standards of Practice, 2008, p 152). Compe- Patient-centered care
includes attitudes such as
tent care of children is demonstrated through
the following:
the nursing process and includes assessment,
• Valuing seeing health-
diagnosis, identification of outcomes, planning, care situations “through
implementation, and evaluation (ANA, 2010). patients’ eyes”
Standards of practice for the pediatric nurse • Respecting and encour-
include quality of practice, integration of ethical aging individual expres-
sion of patients’ values,
principles, and promoting safety as well as
preferences, and ex-
ensuring advocacy. The pediatric nurse is pressed needs
expected to evaluate one’s own cultural and • Valuing the patient’s
ethical sensitivity when providing care. Partici- expertise with his or her
pation in nursing and interdisciplinary educa- own health and symptoms
• Seeking learning oppor-
tional activities related to clinical knowledge tunities with patients who
and professional issues is essential. Through represent all aspects of
collegiality and collaboration, the pediatric human diversity
nurse creates a supportive work environment. • Recognizing personally
held attitudes about
The pediatric nurse uses evidence-based prac-
working with patients
tice as a “problem-solving approach to clinical from different ethnic,
care that incorporates the conscientious use of cultural, and social back-
current best evidence from well-designed stud- grounds
ies, a clinician’s expertise, and patient values • Willingly supporting
patient-centered care for
and preferences” (Fineout-Overholt, Melnyk, & individuals and groups
Schultz, 2005, p. 335). Resource utilization and whose values differ from
accurate documentation are also important one’s own
aspects of care. The pediatric nurse provides • Recognizing personally
held values and beliefs
leadership in the practice setting (Pediatric
about the management
Nursing Scope and Standards of Practice, 2008). of pain or suffering
Abiding by these principles and standards Continued
ensures that the pediatric nurse provides

Nursing Care of Children 65


competent care to every child and his or her
QSEN APPLICATION family when they access the health-care system.
—cont’d Important nursing care measures are described
to enhance the nurse’s understanding of quality
• Appreciating the role of
practice.
the nurse in relief of all
types and sources of pain
or suffering Care Measures
• Recognizing that patients’
expectations influence Nurses use a variety of care measures to meet
outcomes in management the holistic health needs of children and their
of pain or suffering families. It is expected that nurses will deliver
• Valuing active partner- these care measures in a family-centered, safe,
ship with patients or
designated surrogates
effective, timely, and efficient manner.
in planning, implementa-
tion, and evaluation Bathing
of care • Become acquainted with the child during
• Respecting patients’ bath time. Smile, sing, play with, and talk to
preferences for the
degree of active engage-
the child.
ment in the care process • Be careful of IV lines, drains, tubes, casts, and
• Respecting the patient’s other devices (always unplug or suspend elec-
right to access to personal trical devices and monitors).
health records
• Be careful that no restrictive clothing or
• Acknowledging the
tension that may exist bedding is used.
between patients’ rights • Complete a thorough assessment of the skin,
and the organizational motor activity, development, social skills,
responsibility for profes- and other assessments as deemed necessary.
sional, ethical care
• Appreciating shared
• Observe parent-child interaction and bond-
decision making with ing during bath time.
empowered patients • Understand the types of baths: infant bath
and families, even when (in a portable tub), tub bath, shower (for
conflicts occur
older children), and sponge or bed bath (for
• Valuing continuous
improvement of one’s the child who prefers this type of bath, is
own communication and very ill or uncooperative, or has IV lines,
conflict resolution skills tubes, and drains).
In this chapter, along • Take special precautions for each child, and
with information about tailor the bath to the child’s medical condition.
nursing care of children,
For instance, prevent water from entering the
Quality and Safety Educa-
tion Safety for Nurses child’s cast; ensure that a tracheostomy does
(QSEN) competencies not become dislodged during bath time; or
ensure delivery of the best when a child has anemia, bathe only essential
nursing care. areas, to prevent further fatigue.
From Quality and Safety
Education Safety for Nurses
• Use home care practices for bathing and
(2011). Retrieved from shampooing if possible.
http://www.qsen.org/ksas_
prelicensure.php#patient- Feeding and Nutrition
centered_care A nutritional assessment, based on the child’s
age, is necessary.

66 Pediatric Nursing Care


BEST PRACTICES 4–1
SPEAKING OUT
The nurse carefully inspects the child’s skin during
bath time. The nurse notes any dryness, redness, The nurse can advocate for
scaling or flaking, excoriation, rashes, lesions, the child and family by:
breakdown, signs of infection, and wounds: edges, • Following the Health
drainage, diameter, and depth. Insurance Portability
Important care measures include: and Accountability Act
• Keeping bedding and clothing wrinkle-free (HIPAA) (see http://www.
hhs.gov/ocr/privacy/)
• Using air, water, or gel mattresses
• Developing a plan of care
• Keeping the child’s skin clean and dry to attain the expected
• Changing diapers often patient outcomes
• Starting skin care at the first sign of • Being honest with the
breakdown child and family
• Addressing anemia • Addressing the child’s
• Ensuring a diet that includes protein, fat, and family’s fears
and zinc • Tailoring nursing care
• Decreasing the use of adhesives measures to meet the
family’s needs and
• Reducing the effects of urination by applying
preferences
an emollient (white petrolatum jelly or Lanolin) • Maintaining open and
to the diaper area positive communication
• Using other skin care products such as Tega- • Asking parents to partici-
derm, DuoDerm, barrier dressings, and pate in the child’s care
creams • Informing siblings about
• Using the Braden Scale (bradenscale.com) to their brother’s or sister’s
assess pressure ulcer risk condition
• Using the Neonatal Skin Condition Score for • Explaining all care
measures: procedures,
at-risk neonates
treatments, specimen
collections, medications,
and surgical procedures
• Teaching the family about
Infants hospital and home care
The nurse asks the parents the following ques- • Teaching the family how
tions: (1) Is your infant breastfed or bottle fed? to access community
(2) How many wet diapers a day does your resources
• Asking parents to
infant have? (3) How many soiled diapers a day
demonstrate proper
does your infant have? (4) How has this condi- care measures: use of
tion or hospitalization changed your infant’s equipment, medication
feeding patterns? administration, nasogas-
• With adequate intake, the infant has six or tric or orogastric tube
insertion, and any other
more wet diapers a day, two to three procedures that will be
stools, and steady weight gain. done in the home
• If the infant is breastfed, parents can be setting
instructed to call a lactation consultant if • Asking parents about any
special adaptations
difficulties arise. Guidelines for breast milk
needed for the home
storage can be found on the American environment
Academy of Pediatrics Web site. Continued
• If the infant is bottle fed, the health-care
provider will recommend a certain kind
of formula. Parents can prepare a formula
Nursing Care of Children 67
feeding by following the directions that accom-
SPEAKING OUT— pany the formula. If the infant does not toler-
cont’d ate the formula, parents can be instructed to
call their health-care provider, who will deter-
• Asking parents about
mine whether a special kind of formula is
cultural preferences,
rituals, or traditions that necessary. The formula may be soy based or
may affect care have increased calories, depending on the
• Providing good discharge infant’s specific needs.
planning Infant Feedings
Birth to 1 Month
• Breast every 2 to 3 hours
• Bottle every 3 to 4 hours
ALERT
• 2 to 3 oz per feeding
• Maintain the Two to 4 Months
water tempera- • Breast or bottle every 3 to 4 hours
ture so it does not exceed • 3 to 4 oz per feeding
100°F (37.8°C).
Four to 6 Months
• Never leave a child alone
during bath time. • Breast or bottle four to six times per day
• Prevent slipping by • 4 to 5 oz per feeding
ensuring that floors are dry. Six to 8 Months
• Take measures to prevent • Iron-fortified rice cereal
drafts.
• Breast or bottle four times per day
• 6 to 8 oz per feeding
Eight to 10 Months
• Finger foods (when the pincer grasp is present, the child is devel-
opmentally ready for finger foods)
• Chopped or mashed foods
• Sippy cup with formula, breast milk, juice, or water
• Breast or bottle four times per day
• 6 to 8 oz per feeding
Ten to 12 Months
• Self-feeding with fingers and spoon
• Most table foods allowed
• Breast or bottle four times per day
• 6 to 8 oz per feeding
Children 1 Year and Older
The nurse asks the parents the following questions: (1) What kind of
dietary intake does your child have in a day? (2) What kinds of food does
your child eat in a day? (3) What kinds of fluid does your child drink
in a day? (4) Does your child have any food allergies? (5) What are
your child’s voiding and stooling patterns? (6) How has this condition or
hospitalization changed your child’s feeding patterns?
• With adequate intake, the child has regular voiding and stooling
patterns, along with steady weight gain based on age and body
mass index (BMI).
• Go to http://www.mypyramid.gov.kids/index.html for the Food
Pyramid Guide.

68 Pediatric Nursing Care


Other ways to meet the growing child’s nutritional needs are as follows:
• Ask parents about dietary habits and concerns.
• Assess the child’s food and fluid preferences. Remember, the
child may be a “picky eater,” so the nurse can encourage parents
to offer a variety of foods in small amounts. If the child refuses a
particular food, it can be reintroduced later.
• Call the nutritionist to assist the family with food choices and
understand the prescribed diet.
• Encourage parents to bring food from home.
• Ask about cultural dietary preferences.
• Ensure that the child maintains a nutritious diet while hospitalized.
• Know important information: infants require about 24 to 32 oz of
breast milk or iron-fortified formula a day.
• Serve the correct special or restricted diet ordered by the physician.
• Understand that the child is often prescribed a diet “as tolerated.”
• Understand that foods are important for their fluid content.
Average Daily Caloric Requirements for Children
Caloric requirements should be appropriate for
the child’s age (Table 4–1) (Ward & Hisley, 2009,
p 683). TIP

Fever-reducing Measures An ongoing assessment


is necessary. Take the
The normal oral temperature ranges from about
child’s temperature every
97.5°F (36.4°C) to 99.7°F (37.6°C). However, there 30 minutes to every hour,
are variations because normal temperature can as deemed necessary by
fluctuate during the day (lowest in the morning the child’s condition
and highest in the late afternoon) (Venes, 2013). (emergency, critical, or
noncritical). Temperature in
A child’s fever is an important indicator of children is usually taken by
inflammation or infection. Tending to children’s the axillary method. An
fevers is a priority nursing action. axillary temperature is
• Administer antipyretics according to the usually 0.5°F (0.3°C) to 1°F
(0.6°C) lower than an oral
medical order and safe dosage range.
temperature. See Chapter
• Administer antibiotic therapy according to 3 for information about
the medical order and safe dosage range. temperature.

Table 4–1 Average Daily Caloric Requirements for Children


AGE DAILY CALORIC REQUIREMENTS

0–1 mo 100–110 kcal/kg/day

2–4 mo 90–100 kcal/kg/day

5–60 mo 70–90 kcal/kg/day

>5 yr 1500 kcal for first 20 kg + 25 kcal for each additional kg/day

From Ward & Hisley, (2009), p. 683.

Nursing Care of Children 69


• Reduce the heat or increase the coolness of
ALERT the environment by adjusting the thermostat.
• Remove blankets and clothing (depending on
Neutropenic the situation, keep the diaper on the child
children often do
not show signs of infection.
and a lightweight sheet or blanket covering
The only sign of infection the child).
may be a fever. The nurse • Offer fluids such as water, juice, juice pops,
understands that fever in an soda, or ice chips.
oncology patient is 38.5°C
• Place a cool cloth on the child’s forehead, in
(101.2°F) in a 24-hour period
or 38.0°C (100.4°F) three the axilla, behind the knees, or in the groin.
times in a 24-hour period • Obtain a medical order for a cooling blanket
(Ward & Hisley, 2009). if necessary.
• Obtain a medical order to start an IV line
immediately if the child’s condition warrants
it or the child is dehydrated.
ALERT
Acetaminophen (Children’s Tylenol) or
• Salicylates ibuprofen (Children’s Advil) is given for fever or
(aspirin) are pain. Before administration, the nurse confirms
contraindicated in children the child’s weight and medication dosage. If the
for antipyretic use because
child has lost weight, the nurse reweighs the
of the connection of these
drugs with an increased child and consults the health-care provider for
risk of Reye’s syndrome. the correct medication dosage. Acetaminophen
• A physician determines (Children’s Tylenol) is administered orally or via
whether acetaminophen rectal suppository, so the correct route for this
(Children’s Tylenol) and
ibuprofen (Children’s
medication must be confirmed. Ibuprofen (Chil-
Advil) can be alternated. dren’s Advil) is given orally.
• Parents need to be • Dosage recommendations for oral acetamin-
advised that acetamino- ophen (Children’s Tylenol) are given in
phen (Children’s Tylenol)
Table 4–2.
is found in over-the-
counter products such as • Dosage recommendations for oral ibuprofen
cold remedies, so it is (Children’s Advil) are given in Table 4–3.
important to read drug
labels and consult with a
pharmacist.

Table 4–2 Dosage Recommendations for Oral Acetaminophen


(Children’s Tylenol)
AGE DOSAGE (mg) AGE DOSAGE (mg)

0–3 mo 40 every 4 hr 4–5 yr 240 every 4 hr

4–11 mo 80 every 4 hr 6–8 yr 320 every 4 hr

12–23 mo 120 every 4 hr 9–10 yr 400 every 4 hr

2–3 yr 160 every 4 hr 11 yr 480 every 4 hr

Data from Davis’s Drug Guide for Nurses, 12th ed. (2011), Philadelphia, PA: F.A. Davis.

70 Pediatric Nursing Care


Table 4–3 Dosage Recommendations for Oral Ibuprofen
(Children’s Advil)
AGE DOSAGE (mg) AGE DOSAGE (mg)

6–11 mo 50 mg every 6–8 hr 6–8 yr 200 mg every 6–8 hr

12–23 mo 75 mg every 6–8 hr 9–10 yr 250 mg every 6–8 hr

2–3 yr 100 mg every 6–8 hr 11 yr 300 mg every 6–8 hr

4-5 yr 150 mg every 6–8 hr

Data from Davis’s Drug Guide for Nurses, 12th ed. (2011), Philadelphia, PA: F.A. Davis.

Fluid and Electrolyte Balance


It is essential to regulate the amount of fluid in the child’s body. The body’s
intake and output of fluid in a 24-hour period are approximately the same.
A fluid deficit occurs when fluids are lost by diarrhea, vomiting, diaphoresis,
or bleeding. A fluid overload occurs from the excessive administration of
IV fluids, from water intoxication, or in diseases marked by impaired fluid
excretion, such as congestive heart failure, cirrhosis, or renal failure. Useful
means of gauging changes in fluid balance are (1) to measure fluid inputs
and outputs and (2) to measure day-to-day variations in body weight (Venes,
online, 2009). A 5% change in body weight is considered significant.
• Calculation of daily maintenance fluid requirements is given in
Box 4–1.
• Liquid measure conversion (ounces to milliliters = no. of ounces
× 30 mL) is given in Table 4–4.

Box 4–1 Calculation of Daily Maintenance Fluid Requirements


0–10 kg: 100 mL/kg body weight
11–20 kg: 1000 mL + 50 mL/kg for each kilogram higher than 10
More than 20 kg: 1500 mL + 20 mL/kg for each kilogram higher than 20
The method used to measure normal urinary output is 1–2 mL/kg per hour.

Table 4–4 Liquid Measure Conversion


OUNCES MILLILITERS OUNCES MILLILITERS

0.25 7.5 8.0 240

.50 15 9.0 270

1.0 30 10.0 300

2.0 60 11.0 330

Continued

Nursing Care of Children 71


Table 4–4 Liquid Measure Conversion—cont’d
OUNCES MILLILITERS OUNCES MILLILITERS

3.0 90 12.0 360

4.0 120 13.0 390

5.0 150 14.0 420

6.0 180 15.0 450

7.0 210

Sodium, potassium, calcium, and chloride are the main electrolytes


and must also be kept in balance. Normal serum electrolyte laboratory
values are shown in Box 4–2.
The nurse must recognize the underlying cause of the electrolyte
disturbance and treat the cause.

Box 4–2 Normal Serum Electrolyte


DEHYDRATION AND Laboratory Values
OVERHYDRATION
Sodium: 130–150 mEq/L
Depending on the cause of Potassium: 3.5–5.5 mEq/L
the fluid loss, a child will Calcium: 8.8–10.8 mEq/L
lose water and electrolytes. Chloride: 95–105 mEq/L
• Isotonic dehydration
occurs when electrolyte
and water deficits are
present in balanced BEST PRACTICES 4–2
proportions (sodium and
water are lost in equal Nursing care measures include the following:
amounts). Serum sodium • Assess hydration status: signs of dehydration
remains in normal limits, include poor skin turgor, absence of tears,
130 to 50 mEq/L. This is sunken anterior fontanel (up to 18 months),
the most common type sticky mucous membranes, sunken eyeball
of dehydration. Hypo- sockets, decreased urine and stool output,
volemic shock is the
change in vital signs, weight loss, verbaliza-
greatest concern.
• Hypotonic dehydration
tion of thirst, and scaphoid abdomen.
occurs when the elec- • Obtain daily weights by using the same scale
trolyte deficit exceeds at the same time of day. Infants are weighed
the water deficit. Serum naked, and older children are weighed in
sodium concentration is their underwear.
less than 130 mEq/L. • Accurately measure intake and output (for
Physical signs are more infants, weigh diapers to assess output;
severe with smaller fluid 1 mL = 1 g [approximately]).
losses.
• Monitor laboratory values: electrolytes,
• Hypertonic dehydration is
the most dangerous type
specific gravity, hematocrit, blood urea
nitrogen (BUN), and creatinine.

72 Pediatric Nursing Care


BEST PRACTICES 4–2—cont’d
DEHYDRATION AND
• Calculate 24-hour intake and output. Report OVERHYDRATION—
significant discrepancies to the health-care cont’d
provider.
• Give clear liquids as ordered by the physician. and occurs when water
• Start an IV line (fluid and electrolyte replace- loss is in excess of elec-
trolyte loss. Sodium serum
ment).
concentration is greater
• Before administering potassium (K+), ensure
than 150 mEq/L. Seizures
that the child has voided. are likely to occur.
• Keep perineal area clean, and apply protec- • Overhydration signs and
tive ointment if necessary. symptoms include fluid in
• Educate parents about signs and symptoms the lungs, shortness of
of dehydration. breath, edema in the
• Encourage parents to participate in the extremities, puffy eye
child’s care. sockets, decreased
level of consciousness,
dizziness, confusion,
irritability, headache,
Infection Control flushed cheeks, weight
gain, increased urine
The nurse adheres to institutional procedures output, and vital signs
and policies for monitoring and controlling the changes (increased pulse
transmission of communicable diseases. These rate and blood pressure).
include establishing mandatory sanitation, ster- From Ward & Hisley, 2009,
pp. 1035–1036.
ilization, hand hygiene, and isolation procedures
(Venes, online, 2013) (Table 4–5).

Intravenous Therapy
IV therapy is the fastest way to deliver and maintain fluid balance
throughout the body. Dehydration is a main reason for IV therapy; other
indications include administering medications and increasing calorie

Table 4–5 Basic Guidelines for Infection Control


INFECTION CONTROL
RECOMMENDATION SUMMARY OF USEFUL PRACTICES

Cleaning and disinfection Disinfect or sterilize surfaces, such as bed rails, com-
puter keyboards, nightstands, phones, and toilets.

Cough etiquette and Wear masks and/or cover mouth and nose when
respiratory courtesy coughing or sneezing. Maintain 3-feet distances from
others when you have a cold or flu.

Drug formulary restrictions Limit prescribing privileges for antibiotics to designated


specialists.

Hand hygiene Use alcohol-based rubs or wash hands after contact


with any blood, body fluids, or potentially contami-
nated items or patients.

Continued

Nursing Care of Children 73


Table 4–5 Basic Guidelines for Infection Control—cont’d
INFECTION CONTROL
RECOMMENDATION SUMMARY OF USEFUL PRACTICES

Isolation procedures Follow protocols for isolation of patients who are


bleeding, coughing, or giving off other excretions,
secretions, or potentially hazardous body fluids.
Segregate patients during outbreaks of infectious
diseases. Separate immune-suppressed patients from
others with potentially communicable diseases.

Laundry or linen and food Gather patients’ clothing, eating utensils, gowns,
service management sheets, and towels without contaminating other
objects used in patient care. Gown and glove while
collecting and washing laundry. Perform hand hygiene
after laundry management procedures.

Personal protective Wear gloves, goggles, gowns, masks, and shoe covers
equipment (PPE) use while performing patient care procedures whenever
there is exposure to blood, body fluids, or aerosols or
when splashes are possible. Dispose of PPEs in desig-
nated containers.

Resuscitation and invasive Avoid mouth-to-mouth contact with patients, and


airway management wear PPEs, such as particulate respirators or masks, at
all times. Disinfect or sterilize endoscopes, intubation
equipment, nebulizers, face masks (e.g., for continu-
ous positive airway pressure or supplemental oxygen),
or other respiratory care devices.

Sharps (e.g., management Maintain sharps in open view, to avoid accidental


of needles, wires) injuries. Never recap or manipulate needles used in
patient care. Dispose of sharp objects in puncture-proof
solid waste containers.

Source control Supply or apply anti-infective rubs or soaps to patients


to limit their colonization by disease-causing bacteria.

Standard or universal Follow universal precautions during every patient


precautions encounter.

From Venes, D. (ed.). (2013). Taber’s cyclopedic medical dictionary online, 22nd ed. Philadelphia, PA:
F. A. Davis.

EVIDENCE FOR PRACTICE 4–1


DRUG-RESISTANT MICROBES
Drug-resistant microbes are a growing health issue, in both hospital and
community settings, as microbes continually evolve. Antimicrobial resist-
ance is also cultivated by a lack of diagnostic testing to identify infectious
agents rapidly, as well as by poor hand hygiene and infection control
measures (National Institute of Allergy and Infectious Diseases, 2010).

74 Pediatric Nursing Care


intake. IV line insertion is also necessary
preoperatively, for blood or blood product OFFERING SUPPORT
administration, before diagnostic testing, or for
chemotherapy. The purpose of IV therapy has The care of children must
be individualized. Not all
implications for site selection, choice of equip-
situations are alike, obvi-
ment, and patient teaching (Box 4–3). ously, and the nurse will
want to tailor interactions
Medication Administration to the situation, but here
are sample interactions
Administering medication to children safely is an that the nurse may find
essential nursing role. The nurse must have cur- helpful to get started:
rent knowledge about medication administration, 1. Reading stories or
playing with the child
2. Talking about the
hospital experience
Box 4–3 Types of Intravenous Therapy
3. Encouraging the child to
• Peripheral line ask questions and draw
• Normal saline locks pictures
4. Adhering to home rou-
• Central venous access devices
tines as much as possible
• Peripherally inserted central catheter line (PICC)
during the hospital stay
• Vascular access port (Infus-A-Port)

BEST PRACTICES 4–3


Important steps in IV therapy include:
• Verifying the physician’s order
• Calculating safe dose range for medication administration
• Calculating 24-hour fluid intake and output
• Calculating the IV flow rate
• Knowing the action of the fluid (e.g., saline, dextrose), medication (e.g.,
antibiotic therapy, insulin administration), calorie replacement (e.g.,
hyperalimentation, lipids), or contrast dye
• Understanding side effects of the administered fluid and/or medication
• Knowing institutional protocol in an emergency situation
• Using and assembling the correct equipment
• Double-checking the IV solution with a second registered nurse
• Determining the proper site for insertion
• Using proper insertion techniques (based on the type of IV therapy
ordered)
• Assessing the tubing for tight connections, kinks, or leaks
• Setting the proper calculated rate of infusion
• Checking the infusion volume on the pump according to institutional
policy (every 1–4 hours, or more often if a bolus of fluid is given)
• Securing the IV line properly, based on institutional policy
• Validating that the amount of ordered fluid has been infused in the
correct time period
• Assessing the IV site for pain, erythema, tenderness, change in skin
temperature (heat or coolness), edema, or exudate
• Documenting the insertion time, site condition, administered fluid, vital
signs (if deemed necessary), and response to IV therapy

Nursing Care of Children 75


as well as double-check medications, follow insti-
MNEMONIC tutional policy, calculate safe dose range, and per-
form accurate administration steps to maintain
A medical individual accountability and to minimize error.
mnemonic used to help
The nurse applies current knowledge about the
remember safe drug
administration is PDART. five rights of medication administration and
• Right Patient
accurately documents the medication and child’s
• Right Drug tolerance of the medication.
• Right Amount The correct route for each medication admin-
• Right Route istration is followed. Figure 4–1 provides a visual
• Right Time
display of medication routes.

Growth and Development Factors


Growth and developmental factors play an important part in the adminis-
tration of medication to children. The skilled nurse applies these principles
during medication administration (Table 4–6).

EVIDENCE FOR PRACTICE 4–2


MEDICATION ERRORS
The Institute of Medicine (IOM) (2006) declared that medication errors are
pervasive in nursing practice. Wright (2008) stated that mathematical com-
petence and accurate drug dosage calculations are essential to provide safe
care and prevent medication errors. The Joint Commission (TJC) (2009)
established a National Patient Safety Goal to improve medication adminis-
tration safety. Pediatric nurses have a professional and ethical duty to fol-
low standards of care that promote safety and quality care (International
Council of Nurses, 2006).

Oral

Inhalation Intravenous

PEDIATRIC
Gastrostomy MEDICATION Topical
tube ADMINISTRATION

Intermuscular Rectal
Subcutaneous
Eyes, ears, nose
F I G U R E 4 - 1 : Routes of medication administration.
76 Pediatric Nursing Care
BEST PRACTICES 4–4
Medication administration is individualized as follows:
• Allow the child to express both positive and negative feelings.
• Allow parents to administer certain medications (with supervision).
• Allow parents to express any concerns they may have about the medication.
• Always approach each child based on his or her developmental level.
• Be honest.
• Give realistic choices to the child during medication administration.
• Help parent discern ways to administer the medication at home.
• Understand that parents want to know how the medication helps their
child and whether it has any harmful effects.
• Obtain information about the medication before administration (allergies,
ability to take medication, how it is taken at home).
• Offer reward and praise because this is important for gaining trust and
cooperation.
• Understand that restraints are seldom necessary.
• Understand that each age group (infants, toddlers, preschoolers, school-
age children, and adolescents) respond to medication administration
differently.

Table 4–6 Growth and Developmental Factors Related to


Medication Administration in Children
Infants Infants are easier to medicate than toddlers, but they cannot follow
directions.
Assistance may be needed to medicate a squirming infant.
Intramuscular injections are administered in the vastus lateralis.
Cuddling and comfort are important immediately after medication
administration.

Toddlers Remember that toddlers are magical thinkers.


Medication may be viewed as a punishment.
Use play for explanations.
Allow the child to see or play with some instruments (ensure safety).
For a child younger than 3 years old, the pinna is pulled down and back
to facilitate the administration of ear drops.
Praise, cuddle, and offer rewards immediately after medication
administration.

Preschoolers Preschoolers continue to be magical thinkers, have fear of the unknown


and pain, and believe that bandages “make it better.”
Use therapeutic play.
Allow some control.
Praise, cuddle, and offer rewards immediately after medication
administration.

School-age They fear loss of control, as well as pain and anxiety.


children Allow some choice and control.
They can cooperate and follow directions.
They need distraction and support.
Offer praise and rewards immediately after medication administration.

Continued

Nursing Care of Children 77


Table 4–6 Growth and Developmental Factors Related to
Medication Administration in Children—cont’d
Adolescent Adolescents fear separation from peers and loss of control.
They understand adult explanations.
They may be able to assist in decisions.
They may exhibit a hyperresponse that may seem inconsistent with their
age.
Use distraction.
Offer praise and rewards immediately after medication administration.

Calculating Safe Drug Dosages


Helpful hints for calculating safe drug dosages
ALERT include the following:
• Drugs for children are dosed according to
• Calculate drug body weight (mg/kg) or body surface area
dosages (safe (BSA) (mg/m2).
dose range).
• When calculating dosages for children using
• Double-check medications
against the nursing plan of body weight, first convert their weight in
care and medical orders. pounds (lb) to kilograms (1 kg = 2.2
• Ensure that another RN pounds [lb]).
checks insulin, narcotics, • Remember that dosages are expressed as
chemotherapy, digoxin,
anticoagulants, potassium,
mg/kg/day or mg/kg/dose.
calcium, cardiotoxic, • In addition, dosing medications can differ
epinephrine, and sedatives. based on the child’s condition, so diagnostic
• Remember, the nurse is or laboratory test results may be needed for
obligated to report a med-
accurate dosing; check with the health-care
ication error when it occurs.
• Use two patient identifiers. provider and pharmacist for complete
information.
• For accurate information on calculating
a safe dose range, visit http://davisplus.
SPEAKING OUT fadavis.com/Calculating Drug Dosages: An
Interactive Approach to Learning Nursing
The nurse can advocate for Math, 2nd Edition.
the child by being knowl- • Or use Calculating Drug Dosages: An Interactive
edgeable when families ask
the following questions:
Approach to Learning Nursing Math, 2nd ed:
1. What is the drug, and ISBN-13: 978-0-8036-1532-8 and ISBN-10:
what is it for? 0-8036-1532-9.
2. Will there be a problem Sample question: A child weighing 22 lb
with another drug or
(10 kg) is to receive cefuroxime (Ceftin) 250 mg
other drugs my child is
taking? every 8 hours. The medication safe dose range
3. How often and how is 50 to 100 mg/kg/day. What is the individual
long does my child safe dose range for this medication? Answer:
need to take the drug? 166.66 to 333.33 mg every 8 hours.
4. What happens if my
child misses a dose?
Sample question: A child weighing 13 lb
(6 kg) has an order for cephalexin (Keflex)

78 Pediatric Nursing Care


40 mg IV every 6 hours. The safe dose is 25 to
50 mg/kg/day. What is the individual safe SPEAKING OUT—
dose range for this medication? Answer: 37. 5 to cont’d
75 mg every 6 hours.
5. What side effects does
Pain and Its Management the drug have?
6. Does the drug affect or
Pain is an unpleasant sensory and emotional ex- interfere with herbal
remedies?
perience associated with actual or potential tissue
7. Does the drug follow
damage or described in terms of such damage cultural rituals, prac-
(International Association for the Study of Pain, tices, or traditions?
1979). It is an unpleasant sensation that can range 8. How soon will the drug
from mild or moderate discomfort to severe pain, start working?
9. How do I store the
and it has both physical and emotional compo- drug?
nents. Pain can be acute or chronic. The gate con- 10. What is the cost of the
trol theory of pain, in which the opening or drug?
closing of a gate at the level of the spinal cord is Be sure to assess the
family’s level of understand-
the mechanism that controls the perception of
ing. Explain the aministra-
pain, is useful in understanding pain. Addition- tion of the drug, and have
ally, the neuromatrix theory of pain recognizes the family repeat the in-
that other aspects influence the perception of structions and give a return
pain, such as past experience, cultural factors, demonstration. Give written
instructions, and help the
emotional state, cognitive input, stress regulation, family identify important
immune system, and immediate sensory input home routines. Identify the
(Trout, 2004 p. 483). An ongoing pain assessment person the family can con-
is recognized as the fifth vital sign. tact with questions or con-
cerns about the drug.
Based on the child’s age and developmental
level, the nurse determines which pain scale is
appropriate to use. The same pain scale is used for consistency in pain
assessment. Several developmentally appropriate pain assessment scales
are used in the care of children:
• Numeric Pain Scale: Figure 4–2. The numeric pain scale is assessed
on a numerical scale in which 0 = no pain, 1 to 3 = mild pain, 4 to
6 = moderate pain, and 7 to 10 = severe pain.
• Wong FACES Pain Scale: Figure 4–3
• FLACC (Face, Legs, Activity, Cry, Consolability) Pain Scale:
Table 4–7
• Premature Infant Pain Profile (PIPP): Table 4–8

No Mild Moderate Severe Worst


pain pain pain pain pain

0 1 2 3 4 5 6 7 8 9 10

F I G U R E 4 - 2 : Numeric pain scale. From Ward, S. & Hisley, S., (2009).


Maternal child nursing care: Optimizing outcomes for mothers, children and families.
Philadelphia: F. A. Davis.
Nursing Care of Children 79
F I G U R E 4 - 3 : Wong FACES pain scale. From Ward, S. & Hisley, S., (2009).
Maternal child nursing care: Optimizing outcomes for mothers, children and families.
Philadelphia: F. A. Davis.

Table 4–7 FLACC Pain Scale


SCORING

CATEGORIES 0 1 2

Face No particular Occasional grimace or Frequent to constant


expression or smile; frown; withdrawn frown, clenched jaw,
disinterested quivering chin

Legs Normal position Uneasy, restless, tense Kicking, or legs


or relaxed drawn up

Activity Lying quietly, normal Squirming, shifting Arched, rigid,


position, moves easily back and forth, tense or jerking

Cry No cry Moans or whimpers, Crying steadily,


(awake or asleep) occasional complaint screams or sobs, fre-
quent complaints

Consolability Content, relaxed Reassured by occasional Difficult to console


touching, hugging, or or comfort
talking; distractible

Each of the five categories, consisting of (F) Face, (L) Legs, (A) Activity, (C) Cry, and (C)
Consolability, is scored from 0 to 2, which results in a total score between 0 and 10.

From Ward & Hisley, (2009), p. 693.

Table 4–8 Premature Infant Pain Profile (PIPP)


0 1 2 3

GESTATIONAL 36 WK 32–35 28–31 UP TO


AGE OR MORE 6/7 WK 6/7 WK 28 WK

Behavioral state Active/awake Quiet/awake Active/sleep Quiet/sleep

Heart rate 0–4 beats/min 5–14 beats/min 15–24 beats/min 25 beats/min or


Increase Increase Increase more Increase

80 Pediatric Nursing Care


Table 4–8 Premature Infant Pain Profile (PIPP)
0 1 2 3

GESTATIONAL 36 WK 32–35 28–31 UP TO


AGE OR MORE 6/7 WK 6/7 WK 28 WK

Oxygen 0–2.4% 2.5–4.9% 5–7.4% 7.5% or more


saturation Decrease Decrease Decrease Decrease

Brow bulge None Minimum Moderate Maximum

Eye squeeze None Minimum Moderate Maximum

Nasolabial furrow None Minimum Moderate Maximum

Modified from Ward & Hisley, (2009), p. 608.

Nurses also can use a wide range of nonphar-


macological care measures to help alleviate chil- PAIN IN CHILDREN
dren’s pain:
• Active listening Children may be under-
• Application of cold and heat treated for pain. Therefore,
to ensure adequate pain
• Being present relief, it is important to
• Distraction or play dispel common myths
• Medication administration about children’s pain:
• Music, television, videos, video games • Infants and children
• Massage do not experience or
• Positioning remember pain.
• Children tolerate pain
• Relaxation techniques better than do adults.
• Sleeping or active children
Procedures, Treatments, and are not in pain.
Specimen Collections • Children will become
addicted to pain
Numerous procedures, treatments, and speci- medications.
men collections are used in the care of the child. • All children experience
pain in the same way.
• Medication administration
BEST PRACTICES 4–5 is the only way to manage
children’s pain.
The nurse explains procedures, treatments, and
• Pain is an expected
specimen collections to the child at a develop- part of the hospitalized
mentally appropriate level. experience.
• Describe the procedure to the child (if • Children will admit to or
appropriate) and parents. tell the truth about their
• Explain what will happen during the pain.
procedure. • Children do not need
• Explain how long the procedure is expected consistent pain
medication.
to take.
• The nurse always knows
• Encourage the child (if appropriate) and
when children hurt.
parents to ask questions. Continued
Continued

Nursing Care of Children 81


BEST PRACTICES 4–5—cont’d
PAIN IN
CHILDREN—cont’d • Allow parents to decide whether they would
like to be present for the procedure.
• It is better to wait until the • Allow the parents to touch or speak to their
pain is severe rather than child during the procedure.
prevent pain altogether.
• Be honest about any discomfort the child
• If children do not look
like they are in pain, they
may experience during the procedure.
are not. • Allow the child to touch the equipment or
• It is better to not tell practice using (if appropriate).
children that a certain • Identify what restraints may be used, and
procedure or treatment explain why they are needed.
will hurt. • Use play to demonstrate or prepare for the
• Pain caused by needles procedure.
cannot be prevented. • After the procedure is over, praise the child
Remember, children for completing the procedure.
express and react to pain • Allow the child to verbalize feelings after the
differently, based on their procedure.
age and level of develop-
• Hold and cuddle the child after the procedure.
ment. Children in pain may:
• Have a high-pitched cry From Ward & Hisley, (2009).
or cry continuously
• Have a tantrum or
misbehave The nurse follows institutional protocols for
• Have poor feeding or common procedures, treatments, and specimen
appetite (refuse to eat) collections, as listed here.
• Lie very still (like a statue)
• Become restless and
Procedures
cannot get comfortable
• Touch or rub the body • Aerosol therapy
part that hurts • Blood glucose monitoring
• Act stoic • Blood transfusion and blood product admin-
• Hide or run away istration
• Sleep more than usual
• Lie about their pain
• Catheter insertion (Foley and straight)
• Show regressive behaviors • Chest tube procedures
(suck their thumb or wet • Colostomy care
the bed) • IV line insertion
• Ignore their pain
• Gastrostomy insertion, medication adminis-
The nurse uses astute tration, and feeding
assessment skills along with
the proper developmen-
• Measuring oxygen saturation (pulse oximetry)
tally appropriate pain tool • Nasogastric insertion, medication adminis-
to assess children’s pain. tration, and feeding
• Orogastric insertion, medication administra-
tion, and feeding
• Ostomy care
• Performing postural drainage
• Procedures related to neurologic status: external drain manage-
ment, use of the pediatric coma rating scale, and increased in-
tracranial pressure assessment
• Suction (oral, nasal, or tracheostomy)
• Wound care (dressing change)
82 Pediatric Nursing Care
Treatments
• BiliBlanket or bili (bilirubin) lights MNEMONIC
• Chemotherapy
• Cast care (splint care) A medical
mnemonic used to
• Oxygen administration help remember important
• Respiratory treatments aspects of pain assessment
• Range of motion is COLDER.
• Tracheostomy care Character
• Traction Onset
Location
Duration
Specimen Collections
Exacerbate
• Blood sample Relieve
• Cerebrospinal fluid
• Respiratory secretions (nasal)
• Sputum
• Stool sample PAIN SCALES
• Throat culture
• CRIES (Crying, Requires
• Urine sample
oxygen, Increased vital
signs, Expression, Sleep)
Rest and Sleep Pain Scale is used for
infants 6 months and
Promoting rest and sleep is an important care younger. The nurse
measure. It allows the child to recover and heal, assesses crying, oxygena-
and it promotes growth. To avoid disturbed tion, vital signs, facial
sleep patterns for the child and family: expression, and sleep-
lessness.
• Interview the parent about normal rest • Oucher Scale: This vertical
and sleep patterns. numerical scale helps
• Allow the child and family to “sleep in” children communicate
whenever possible. how much pain they have.
Older children count from
• Maintain the child’s home sleep routines
1 to 100, and younger
as much as possible. children point to facial ex-
• Promote grouping care measures to keep pressions that correspond
interruptions to a minimum. to the numbers 1 to10.
• Post a “do not disturb” sign to provide an • Neonatal Infant Pain Scale
(NIPS) is a behavioral
uninterrupted rest or sleep time. assessment tool for pain
• Ask the health-care provider about the use measurement in preterm
of melatonin in children to promote natu- and full-term neonates.
ral sleep and wake cycles. The nurse assesses facial
expression, cry, breathing
pattern, arms, legs, and
Safety state of arousal.
• Visual Analog Pain Scale
The nurse provides a safe environment for the
is a 10-cm line scale with
child by: one end marked “no
• Assessing the bed situation. A child less pain” and the other end
than 4 years of age requires a crib (a bubble “worst pain.” This pain
top on the crib may be needed). Older chil- assessment method is used
for children 10 to 12 years
dren can be placed in a bed with siderails of age and older.
raised, yet they still need supervision.

Nursing Care of Children 83


• Educating parents, siblings, and visitors
ANESTHESIA about the importance of the child’s safety.
AND CONSCIOUS • Elevating the crib and bed side rails at all
SEDATION times. A parent or health-care provider must
be at the bedside continuously if side rails
Anesthesia, or conscious
are in the down position.
sedation, is used for some
procedures. In this case, • Ensuring a safe environment by removing
follow the institution’s anes- clutter and observing for cords and other
thesia or conscious sedation equipment that impose a safety hazard.
preprotocol and postproto- • Keeping the bed or crib in the lowest position.
col tools and scales. (See
Children’s Hospital Central
• Posting a sign when the child is off the unit.
California’s Web site at • Knowing the whereabouts of the child when
http://www.chccsedation. he or she is on the unit.
org/index.asp for examples • Knowing the missing child alert protocol.
of sedation tools.) After anes-
• Providing continual observation by involving
thesia or sedation, closely
monitor and record the parents, family members, other health-care
child’s level of conscious- providers, volunteers, or sitters to stay with
ness, vital signs, cardiac the child.
status, respiratory status • Keeping medical devices, medicines, and
(including pulse oximetry),
hydration status, and
toxic materials out of the child’s reach.
response to pain, as well as • Staying vigilant for choking hazards (keeping
nausea or vomiting status small items away from the child).
until the child is awake and • Transporting the child safely via wheelchair,
alert. Criteria for discharge
crib, gurney, bed, wagon, or carry.
to home or the hospital
medical or surgical unit in- • Using safety features on highchairs and
clude patent airway, stable strollers and reporting broken devices.
vital signs, adequate hydra- • Verifying the child’s identity often (before
tion status, pain and nausea medication administration, treatments, and
or vomiting control, return
to baseline level of con-
procedures) by checking the name band
sciousness, and a stable (name and identification number).
assessment of all body • Implementing a fall prevention policy.
organs and systems.
Vital Signs
Vital signs consist of pulse, rate of respiration, blood pressure, and tem-
perature and provide objective data about the child’s health status.
Because vital signs vary with age, the nurse can recognize the pattern
of vital signs when making a quick assessment:
• Temperature remains the same throughout the life span.
• Pulse rate decreases as the child ages.
• Respiratory rate decreases as the child ages.
• Blood pressure increases as the child ages.

84 Pediatric Nursing Care


ALERT SPEAKING OUT
Restraining the child is a physical or pharma- The nurse obtains informed
cological method that restricts movement, phys- consent:
ical activity, or normal access to his or her body. It may be • This is required before
necessary to restrain the child to ensure safety during a medical treatments, diag-
procedure or treatment, prevent injury to an operative nostic testing, surgical
site, or help stabilize the child during transport. procedures, or other
• A physician’s order is needed for physical or pharmaco- circumstances such as
logical restraints and is renewed every 24 hours. taking photographs,
• Conduct a complete nursing assessment at least every postmortem examina-
2 hours while restraints are in place. tions, and release of
• Inform the child (if appropriate) and parents why medical information.
restraining is needed. • The person signing the
• Inform the child (if appropriate) and parents how consent form is the legal
restraining is done. parent or guardian and
• Encourage the parents or caregiver to remain at the is of legal age.
bedside or stay with the child during restraint. • A witness is necessary to
• Physical restraints consist of elbow, wrist, ankle, or papoose. sign the consent.
• Physical restraints require that the extremity is checked • The consent form
every 15 minutes for the first hour after initial application. provides the family with
• Physical restraints require that the child’s skin condition accurate information
and other applicable assessments are checked and so they can make an
documented every 1 to 2 hours or as needed. informed decision
• Restraints are removed at least every 2 hours, and if about their child’s health
indicated, range of motion is performed. care and subsequent
• Pharmacological restraints are medications used to measures.
sedate the child for safety purposes. There must be a • The consent form
medical order, and the child’s health status is checked presents the information
every 1 to 2 hours or as needed. Chloral hydrate in a clear and concise
(Aquachloral) is an example of a medication used in manner that matches the
pharmacological restraint. level of comprehension
and language level.
• The consent form
communicates to the
family that informed
ALERT
consent implies that they
understand the risks and
Identify the child at risk for falling by posting
benefits of treatment (or
a sign on the door, labeling the chart, and apply-
the refusal of treatment).
ing a special armband. Documentation of a child’s fall is a
• The signer understands
priority nursing action.
that the decision is volun-
Assess the child’s risk factors for falls:
tary, without coercion.
• Altered mental status; brain injury • Immunizations also
• Altered mobility (use of assistive devices, crutches, or require informed consent.
walkers; age and developmental abilities; casts or • An emancipated minor
splints, tubes, and drains; and disease process) can sign an informed con-
• Crib or bed side rails left in the down position sent for his or her child.
• History of falls or seizures
• Improper use of safety devices such as highchair straps
or brake locks on gurneys or wheelchairs
• Medications such as sedatives, analgesics, narcotics, or
anesthetics
• The nurse coveys a caring demeanor, actively listens, and is
“present in the moment” when caring for the child and family

Nursing Care of Children 85


NURSING CARE PLAN: IMBALANCED NUTRITION
PRIORITY NURSING DIAGNOSIS
Imbalanced Nutrition: Less Than Body Requirements related to inadequate intake
GOAL
The child will demonstrate appropriate growth for age on a normal curve.
NURSING OUTCOMES CLASSIFICATION
• Appetite (1014) Desire to eat when ill or receiving treatment
• Nutritional Status (1004) Extent to which nutrients are available to meet
metabolic needs
NURSING INTERVENTIONS
1. Monitor weight daily on the same scale and at the same time during
hospitalization and at every encounter in community-based care.
Rationale: Monitoring assists in early identification and correction of nutri-
tional deficiencies to prevent complications from malnutrition.
2. Provide favorite high-protein, high-calorie, nutritious foods and drinks in
small, frequent meals (specify for the child).
Rationale: Child is more likely to eat familiar foods and small frequent
meals may be better tolerated during illness.
3. Ensure that mealtime is pleasant and uninterrupted. Be sure to schedule
treatment and procedures at times other than feeding time. Do not mix
medications in food offered during mealtimes.
Rationale: Child may refuse to eat essential foods if they have been
associated with unpleasant activities, smells, or tastes.
4. Encourage additional nutritious, high-calorie snacks (e.g., milkshakes,
string cheese) as tolerated by the child.
Rationale: Supplemental nutrition may provide the additional calories
and nutrients via the preferred oral route.
5. Initiate orogastric or nasogastric supplementation as appropriate.
Rationale: The ill child may be unable to ingest adequate calories and
nutrients orally.
From Ward & Hisley, (2009), p. 671.

Chapter Summary
TIP
Pediatric nursing practice focuses on the care of
See Chapter 3 for the aver- children and their families in a variety of settings
age range for pediatric in which the nurse provides competent care.
vital signs and expected
Competent care is demonstrated through the
temperatures in children.
nursing process including assessment, diagnosis,
identification of outcomes, planning, implemen-
tation, and evaluation. Through numerous care measures, the nurse can
meet the holistic needs of the entire family. It is expected that the nurse
will deliver these care measures in a family-centered, culturally appro-
priate, safe, effective, timely, and efficient manner. Evidence-based prac-
tice, resource utilization, and documentation are important aspects of
care. The pediatric nurse can be a leader in the health-care arena.
86 Pediatric Nursing Care
5 Communicable and
Immunologic Conditions
in Children
Anatomy and Physiology 87
Common Childhood Conditions and
Disease Processes: Communicable Diseases 89
Immunologic Diseases 96
Infections 101
Critical Nursing Assessment 106
Important Aspects of Communicable
and Immunological Care 106
Laboratory Tests 113
Medications 115
Nursing Care Plan 117
Chapter Summary 118

Immunological
CHAPTER 5

Communicable and
Immunological
Conditions in Children

T
he pediatric nurse plays a critical role in
disease prevention and health promotion QSEN APPLICATION
for children of all ages. Children are at
increased risk of contracting communicable Teamwork and collabora-
tion mean functioning
diseases as physiological and immune systems
effectively within nursing
continue to develop during childhood. Children and interprofessional
are continuously exposed to infectious agents teams and fostering
and usually can overcome common childhood open communication,
diseases. However, those children with com- mutual respect, and
shared decision making
promised immunity must be protected from in- to achieve high-quality
fectious agents to avoid further negative impact patient care. Teamwork
on their health. Primary prevention of commu- and collaboration include
nicable disease begins with the recommended knowledge that:
childhood immunizations. The Centers for • Describes own strengths,
Disease Control and Prevention (CDC) immu- limitations, and values in
functioning as a member
nization schedules for children from birth to of a team
6 years and from 7 to 18 years, as well as a • Describes scopes of prac-
“catch-up” schedule, are available on the CDC tice and roles of health-
Web site in printable formats suitable for care team members
• Describes strategies for
providers and for parents (CDC, 2010a).
identifying and managing
overlaps in team member
Anatomy and Physiology roles and accountabilities
• Recognizes contributions
Children are more susceptible to infection of other individuals and
than are adults. Continuing development of groups in helping the
respiratory anatomy during childhood in- patient and family
creases susceptibility to respiratory illness. achieve health goals
Continued
The skin and mucous membranes act as the

Communicable and Immunological Conditions in Children 87


EVIDENCE FOR PRACTICE 5–1
QSEN APPLICATION
—cont’d VACCINATIONS AND THIMEROSAL

• Analyzes differences in After hearing unfounded claims in the media


communication style connecting autism and vaccination, many
preferences among parents are concerned about the safety of
patients and families, vaccines, specifically those containing the
nurses, and other mem- mercury-based preservative thimerosal. Parents
bers of the health team mistakenly believe that they are protecting
• Describes the impact of
their children by not having them immunized,
his or her own communi-
cation style on others
when in fact they are placing their children and
• Discusses effective strate- the rest of society at increased risk from pre-
gies for communicating ventable communicable diseases. A review of
and resolving conflict current research evidence shows no connection
• Describes examples of between autism and thimerosal (Miller &
the impact of team Reynolds, 2009). Nurses, as the most trusted
functioning on safety health-care providers, are in a position to edu-
and quality of care cate caregivers that thimerosal has not been
• Explains how authority
used in childhood vaccines since 2001, whereas
gradients influence team-
work and patient safety
autism rates have continued to rise. Nurses
• Identifies system barriers can reassure parents that thimerosal was never
and facilitators of effec- used in the measles, mumps, rubella (MMR),
tive team functioning varicella, inactivated polio (IPV), or pneumococ-
• Examines strategies for cal conjugate vaccines (CDC, 2010b). Con-
improving systems to cerned caregivers should be referred to the
support team functioning CDC vaccine safety Web site for more in-depth
In this chapter, along information.
with information about com-
municable and immunologi-
cal conditions in children,
QSEN competencies ensure
body’s first line of defense against pathogens.
delivery of the best nursing
care. From Quality and These tissues are thinner, are more fragile,
Safety Education Safety forand constitute a larger surface area in children
Nurses (2011). Retrieved than in adults. The second line of defense, the
from http://www.qsen.org/
ksas_prelicensure.php#
immune response, is immature in infants and
patient-centered_care young children. Immunity is classified as pas-
sive and active. Newborns obtain passive im-
munity from maternal immunoglobulin G
(IgG) antibodies. These antibodies cross the
placenta during the third trimester of pregnancy and protect the infant
for the first 6 months of life from diseases to which the mother is im-
mune. Infants born before 34 weeks of gestation do not receive this
advantage. Maternal immunoglobulin A (IgA) is transferred passively
to the breastfed infant in colostrum and breast milk and helps protect
against respiratory and gastrointestinal infections. Adult levels of all
the immunoglobulins are not attained until 5 years of age. Active im-
munity develops as the child is exposed to antigens through illness or
immunization. In addition, their immature inflammatory response

88 Pediatric Nursing Care


and ability to regulate body temperature make diagnosis more difficult
in infants and young children.

Common Childhood Conditions and Disease


Processes: Communicable Diseases
Viral Diseases
Chickenpox (Varicella Zoster)
This highly contagious disease is caused by varicella zoster virus (VZV),
a member of the herpesvirus family. The disease is transmitted
through respiratory secretions, contact, and aerosolization of the virus
from moist lesions. The incubation period is 13 to 17 days, and
children are considered contagious from 1 day before the rash appears
until all lesions have crusted over or 6 days
after the appearance of the rash.
Signs and Symptoms TIP
Signs and symptoms include acute onset of
Use of salicylates (aspirin)
fever, irritability, and malaise followed by devel- products in children with
opment of a severely pruritic rash on the face chickenpox and other viral
and trunk that may spread anywhere on the illnesses has been linked
body. The rash consists of red macules with clear to Reye’s syndrome.
Vaccination can prevent
central vesicles that later break open and form
chickenpox (Heymann,
a crust (Fig. 5–1). Chickenpox complications in- 2008; Ward & Hisley,
clude bacterial skin infection, encephalitis, and 2009).
varicella pneumonia.
Fifth Disease (Erythema Infectiosum)
This mild, often nonfebrile disease is caused by human parvovirus
B19. The virus is transmitted across the placenta and in respiratory
secretions. The incubation period is 4 to 20 days before appearance
of the rash, and the child is contagious before the rash appears.

F I G U R E 5 - 1 : Chickenpox (viral). From


Ward, S. & Hisley, S., (2009). Maternal
child nursing care: Optimizing outcomes for
mothers, children and families. Philadelphia:
F. A. Davis, p. 832.

Communicable and Immunological Conditions in Children 89


Signs and Symptoms
Signs and symptoms are as follows: The illness begins with mild sys-
temic flu-like symptoms that are followed in 2 to 3 days by a character-
istic red “slapped face” rash on the child’s face (Fig. 5–2) and a lacy red
rash on the trunk that last 1 to 3 weeks. Complications are unusual in
children, but adults may experience arthralgias or arthritis. Children
with sickle cell anemia may develop transient aplastic crisis (Heymann,
2008; Ward & Hisley, 2009).
Infectious Mononucleosis
This disease is caused by the Epstein-Barr virus (EBV), a herpesvirus.
Transmission occurs from person to person via saliva, hence the nick-
name “kissing disease” in adolescents. The incubation period is from
4 to 6 weeks, with prolonged communicability of up to a year; around
20% of patients will become lifetime carriers.
Signs and Symptoms
Signs and symptoms include fatigue, fever, sore throat (often with
exudative pharyngotonsillitis), lymphadenopathy, and splenomegaly
lasting from 1 to several weeks. The disease is generally mild in young
children, although steroids may be prescribed if airway swelling be-
comes problematic. Adolescents and young adults often exhibit abnor-
mal liver function tests (95%) or splenomegaly (50%), and a few (4%)
may develop jaundice (Heymann, 2008; Ward & Hisley, 2009).
Influenza (Seasonal)
The “flu” is an acute upper respiratory illness caused by influenza viruses
A, B, or sometimes C. Only human influenza A subtypes H or HN (H1N1,
H3N2), to which most people have not been exposed, have caused pan-
demic outbreaks. Influenza is more common during the winter, when
people are frequently indoors and in contact with others. Transmission
of influenza occurs from person to person via droplets. The incubation
period averages 2 days, with communicability up to 10 days in children.
Signs and Symptoms
Signs and symptoms include acute onset of fever, sore throat, headache,
myalgia, runny nose, and dry cough. Young children also may exhibit eme-
sis. Symptoms may last up to a week, with the cough continuing for 2 weeks
or more. Otitis media and pneumonia are secondary bacterial infections
that often develop after influenza. A flu vaccination is recommended
yearly for those children more than 6 months old and especially those
with comorbidities such as asthma (Heyman, 2008; Ward & Hisley, 2009).

F I G U R E 5 - 2 : Fifth disease (erythema in-


fectiosum) (viral). From Ward, S. & Hisley, S.,
(2009). Maternal child nursing care: Optimizing
outcomes for mothers, children and families.
Philadelphia: F. A. Davis, p. 833.
90 Pediatric Nursing Care
Mumps (Parotitis)
This acute viral disease is caused by a paramyxovirus transmitted by
direct contact with saliva or airborne droplets from an infected person.
The incubation period is 14 to 21 days, with the greatest communicabil-
ity 2 days before and for 4 days after swelling begins.
Signs and Symptoms
Signs and symptoms begin with low-grade fever, malaise, anorexia, and
headache aggravated by chewing. Painful, bilateral or unilateral
swelling of the parotid and possibly sublingual and submaxillary glands
follows by day three and lasts up to 6 days (Fig. 5–3). Complications
include respiratory symptoms in children younger than 5 years old
(40% to 50%), sensorineural hearing loss, aseptic meningitis (10%), or-
chitis (20% to 30% of postpubertal males) followed rarely by sterility,
and pancreatitis (4%). Mumps vaccination is recommended to prevent
this illness (Heyman, 2008; Hockenberry & Wilson, 2011; Ward &
Hisley, 2009).
Poliomyelitis (Polio, Infantile Paralysis)
This disease is caused by three poliovirus types: type 1 is the most com-
mon, type 2 has not been seen since 1999, and type 3 is the second most
common and is seen most often in infants and young children. These
enteroviruses are found in the gastrointestinal tract and are transmitted
primarily by the oral-fecal route. The incubation period for polio is 1 to
2 weeks, with the greatest risk for communicability 7 to 10 days before
and 7 to 10 days after symptoms begin. The virus may persist in feces
for 3 to 6 weeks.
Signs and Symptoms
Signs and symptoms may begin with low-grade fever, headache, nau-
sea, and vomiting, with transient pain in the neck, back, and legs. The
more severe paralytic polio progresses to acute flaccid paralysis ac-
companied by severe pain and stiffness in the neck, back, and legs.
Asymmetric paralysis most often affects the legs but is also possible
in the arms and muscles of respiration, depending on the location
of nerve cell destruction in the spinal cord or brainstem. Paralytic
symptoms peak by day three to four. Complications include permanent

F I G U R E 5 - 3 : Mumps (parotitis)
(viral). From Ward, S. & Hisley, S., (2009).
Maternal child nursing care: Optimizing out-
comes for mothers, children and families.
Philadelphia: F. A. Davis, p. 834.
Communicable and Immunological Conditions in Children 91
paralysis, respiratory arrest, and aseptic meningitis. This disease can
be prevented by childhood immunization (see the CDC immunization
schedules for children) (Heyman, 2008; Hockenberry & Wilson, 2011;
Ward & Hisley, 2009).
Roseola (Exanthem Subitum)
This acute febrile illness with a subsequent rash is usually caused
by human herpesvirus-6 (HH-6). It is most common between ages 6
and 15 months, when acquired maternal antibody protection wanes.
Transmission is believed to be by salivary contamination, mainly from
caregivers. Incubation is between 5 and 15 days, and the illness is
communicable during the febrile period.
Signs and Symptoms
Signs and symptoms begin with the sudden onset of a persistent high
fever, up to 106°F (41°C) lasting 3 to 4 days in an otherwise healthy infant.
The fever then drops, and a nonpruritic, red maculopapular rash devel-
ops on the trunk and spreads to the head and extremities before it fades
away in 1 to 2 days. Febrile seizures are possible complications, but
otherwise the illness is generally mild (Heyman, 2008; Hockenberry &
Wilson, 2011; Ward & Hisley, 2009).
Rubeola (Measles)
This acute, highly contagious illness is caused by a morbillivirus. The
disease is most common in winter and spring. It is transmitted primarily
by droplets in direct or airborne contact from respiratory secretions of
an infected individual. The incubation period is about 10 days (14 days
before the rash appears) and is communicable from 1 day before symp-
toms occur until 4 days after the rash appears.
Signs and Symptoms
Signs and symptoms occur in phases. The prodromal phase lasts 3 to
5 days, with high fever, cough, coryza, conjunctivitis, and Koplik’s spots
(small white or bluish-white spots on a red base) appearing on the buccal
mucosa. This phase is followed by development of a characteristic blotchy,
deep red, maculopapular rash appearing first on the face and spreading
downward, accompanied by generalized lymphadenopathy, anorexia,
malaise, and fatigue. The rash begins to fade after 4 to 7 days, sometimes
with brownish desquamation over extensively involved areas. Complica-
tions may include superimposed bacterial pneumonia, otitis media, croup,
and encephalitis (rare), and the disease is more severe in infants and
adults than in children. This disease can be prevented by immunization
(Heyman, 2008; Hockenberry & Wilson, 2011; Ward & Hisley, 2009).

Bacterial Diseases
Diphtheria
This is an acute bacterial infection of the mucous membranes of the
upper respiratory tract (nose, tonsils, pharynx, and larynx) or skin that
is more prevalent in fall and winter. Diphtheria is caused by toxin-
producing strains of Corynebacterium diphtheriae transmitted by direct
contact with a patient or carrier and occasionally by contact with
92 Pediatric Nursing Care
contaminated articles or raw milk. The incubation period is 2 to 7 days,
although it may be longer. The disease is communicable until virulent
bacilli are no longer present, usually less than 2 weeks but possibly up
to 4 weeks. Rarely, chronic carriers may shed the bacteria for 6 months
or more.
Signs and Symptoms
Signs and symptoms depend on the location of the infection. Nasal
diphtheria resembles the common cold, with a serosanguineous nasal
discharge. Skin lesions are variable and may look much like impetigo.
Tonsillar, pharyngeal, and laryngeal symptoms include low-grade
fever, sore throat, cough, stridor, and development of the characteristic
asymmetric, grayish-white, adherent membrane occurring in response
to a strong exotoxin produced by the bacteria. The membrane may
cover the posterior pharynx, tonsils, and hard and soft palates and
extend down into the trachea, thus causing respiratory distress. The
child may exhibit a sore throat and greatly enlarged cervical lymph
nodes resulting in a “bull’s neck” appearance (Fig. 5–4). Airway
obstruction with profound respiratory distress may occur, giving rise
to a consistent fatality rate of 5% to 10% even with treatment. Com-
plications of diphtheria include toxic cardiomyopathy with congestive
heart failure developing about a week after infection and toxic neu-
ropathies beginning 2 weeks later. Diphtheria is a reportable disease.
Adequate immunization can prevent it (Heyman, 2008; Hockenberry
& Wilson, 2011; Ward & Hisley, 2009).
Haemophilus influenzae Type b (Hib) Infection
This disease, caused by a gram-negative coccobacillus, affects children
less than 5 years of age. This pathogen was the leading cause of
bacterial meningitis in this population before the development of the
Hib vaccine. Hib infection most often occurs in child care settings
in a bimodal pattern of March through May and September through
December. The disease is presumably transmitted by respiratory
droplets from an infected person. The incubation period is unknown,
and communicability is assumed to be greatest in the first 3 days after
symptom onset.

F I G U R E 5 - 4 : Diphtheria (bacterial).
From Ward, S. & Hisley, S., (2009). Maternal
child nursing care: Optimizing outcomes for
mothers, children and families. Philadelphia:
F. A. Davis, p. 832.
Communicable and Immunological Conditions in Children 93
Signs and Symptoms
Signs and symptoms include fever, weakness, vomiting, and a stiff
neck. Other symptoms depend on the affected part of the body. The
organism may colonize only the nasopharynx (asymptomatic carrier),
or it may become invasive, leading to a variety of complications:
meningitis (50% to 60%) with neurological sequelae, pneumonia,
epiglottitis, septic arthritis, cellulitis, osteomyelitis, otitis media, and
acute bronchitis. Vaccination can prevent this reportable disease
(CDC, 2010c; Ward & Hisley, 2009).
Pertussis (Whooping Cough)
This acute respiratory tract infection is caused by Bordetella pertussis.
Transmission occurs by direct contact with respiratory secretions. Incu-
bation averages 9 to 10 days, and the disease is highly contagious during
the early mild stage until 5 to 7 days after antibiotic treatment begins.
Mortality is rare in vaccinated individuals; all deaths reported in indus-
trialized countries in recent years have been in infants less than
6 months old. Infants less than 2 months old are not vaccinated yet
and are at increased risk for developing pertussis. In addition, based on
the increasing rates of pertussis, the highest-risk categories are unim-
munized or partially immunized infants, children, and adolescents.
Signs and Symptoms
Signs and symptoms of pertussis begin with mild upper respiratory
symptoms, including a nonproductive cough progressing after 1 to
2 weeks to paroxysmal coughing spells, often at night, with the char-
acteristic high-pitched inspiratory stridor or “whoop” (Fig. 5–5). The
paroxysms end with expectoration of thick, clear, stringy mucus and
often vomiting, with resultant dehydration and weight loss. Coughing
continues for about 4 weeks and gradually subsides. Complications
include pneumonia, atelectasis, seizures, encephalopathy, and death.
This illness can be prevented by adhering to immunization recommen-
dations. Pertussis is a reportable disease (Heyman, 2008; Hockenberry
& Wilson, 2011; Ward & Hisley, 2009).

F I G U R E 5 - 5 : Pertussis (bacterial).
From Ward, S. & Hisley, S., (2009). Maternal
child nursing care: Optimizing outcomes for
mothers, children and families. Philadelphia:
F. A. Davis, p. 835.

94 Pediatric Nursing Care


Pneumococcal Disease
This disease is caused by Streptococcus pneumoniae, a gram-positive
diplococcus that often asymptomatically colonizes the nares of children.
This pathogen is the most common cause of community-acquired pneu-
monia in all age groups, but may also cause sinusitis and otitis media.
Transmission is through contact with respiratory secretions, more fre-
quently during the winter months, when people are contained indoors.
The incubation period is 1 to 3 days. The infection is presumed to be
communicable until 24 hours after initiation of antibiotics.
Signs and Symptoms
Signs and symptoms include sudden onset of high fever, tachypnea, dys-
pnea, pleuritic chest pain, and cough with “rusty” sputum in older chil-
dren and adolescents, and fever, vomiting, and seizures in infants and
young children. Complications may include bacteremia, endocarditis,
meningitis, brain abscess, osteomyelitis, and septic arthritis. Immuniza-
tion can prevent this disease and is recommended for all children less
than 5 years of age, with additional immunization at 2 years for high-
risk children (Heyman, 2008; Ward & Hisley, 2009).
Scarlet Fever
This disease is caused by group A, beta-hemolytic Streptococcus pyogenes,
the organism that commonly causes streptococcal pharyngitis and ton-
sillitis (strep throat) and skin infections such as pyoderma and impetigo,
as well as other illnesses. The organism is usually transmitted by large
respiratory droplets and direct contact with infected persons. The incu-
bation period is 2 to 5 days, and the infection remains communicable
until 24 hours after adequate treatment with antibiotic begins. Children
with untreated streptococcal infections may carry the organism for
weeks to months.
Signs and Symptoms
Signs and symptoms begin with acute onset of fever, sore throat, rhinitis,
headache, and swollen cervical lymph nodes. A fine, red, sandpaper-like
rash (exanthema) appears 12 to 24 hours later and is located mostly on
the neck, chest, and in skin folds, but not on the face, which becomes
flushed with circumoral pallor. The rash blanches with pressure and is
easily felt. The rash fades in 3 to 4 days, with possible peeling of the tips
of the fingers and toes. The pharynx and tonsils are swollen and red, with
exudative patches on the tonsils. The tongue is first coated white with
swollen, red papillae (white strawberry tongue), and then the white coat-
ing is sloughed off, leaving the tongue red with swollen papillae by day 4
to 5 (red strawberry tongue) (Fig. 5–6). Additional red, punctate lesions
occur on the mucous membranes of the palate (exanthema). Complica-
tions of untreated streptococcal infection include retropharyngeal ab-
scess, acute glomerulonephritis, and acute rheumatic fever, among others
(Heyman, 2008; Hockenberry & Wilson, 2011; Ward & Hisley, 2009).
Tetanus
This acute neurological illness is caused by an exotoxin of the anaerobic
bacillus Clostridium tetani. The spores are introduced into the child’s

Communicable and Immunological Conditions in Children 95


First day of rash Third day of rash

Flushed cheeks Paleness of skin around mouth


(circumoral pallor)
White strawberry
tongue (inset) Red strawberry tongue (inset)
Neck density Increased density in axillary
lymph nodes

Pastia lines
Positive blanching test
Increased (Shultz-Charlton) phenomenon
density in
groin First day Third day

White strawberry Red strawberry


tongue tongue

F I G U R E 5 - 6 : Scarlet fever. From Hockenberry, M. J. & Wilson, D., (2011).


Wong’s nursing care of infants and children, 9th ed. St. Louis, MO: Elsevier
Mosby, p. 614.

body usually via a puncture wound or laceration contaminated with


soil or feces. In the developing world, unsanitary cutting and care of the
newborn umbilical cord may cause the spores to be introduced at birth,
with resulting neonatal tetanus. The incubation period is 2 to 14 days.
Signs and Symptoms
Signs and symptoms begin with headache and restlessness and progress
to abdominal rigidity and painful contractions of the masseter, neck, and
trunk muscles. Muscle spasms cause severe arching of the back known
as opisthotonos (Fig. 5–7) and a facial grimace called risus sardonicus.
Complications may include respiratory muscle spasm leading to death.
Immunization can prevent this reportable illness (Heyman, 2008; Ward
& Hisley, 2009). Check the Red Book Online developed by the American
Academy of Pediatrics (AAP) (2012) The Committee on Infectious
Diseases to learn more about a child who has had a recent injury or has
not been vaccinated in several years.

Immunological Diseases
Immunodeficiency Disorders
Acquired Immunodeficiency Syndrome (AIDS)
This disease is caused by human immunodeficiency virus subtype 1
(HIV-1) in the United States and by HIV-2 infection more commonly
in Africa. Vertical or perinatal transmission from an infected mother

96 Pediatric Nursing Care


F I G U R E 5 - 7 : Opisthotonos. Tetanus.
From Hockenberry, M. J. & Wilson, D.,
(2011). Wong’s nursing care of infants and
children, 9th ed. St. Louis, MO: Elsevier
Mosby, p. 838.

to her child during pregnancy, birth, or breast-


feeding is the most common route of infection CONGENITAL
in children younger than 13 years of age (CDC, IMMUNODEFICIENCY
2009). Adolescent HIV infection mimics adult DISORDERS
horizontal or person-to-person viral transmis-
sion during unprotected vaginal or anal sex, Congenital immunodefi-
ciency disorders begin in
IV drug use with contaminated equipment, and infancy and materialize as
transfusion with infected blood or tissue trans- the child grows.
plants. The incubation period from HIV infec- Signs and symptoms
tion to the development of clinical AIDS varies depend on the exact disor-
der. A child with a B-cell
from 1 to 15 years, although antibodies can usu-
disorder has recurrent in-
ally be detected within a month of infection fections, usually respiratory
(Heyman, 2008). The HIV retrovirus invades and skin. T-cell disorders
the body’s CD4 T lymphocytes and causes do not occur in isolation
them to replicate HIV, thereby compromising but are usually a part of a
combined disorder such as
the patient’s cell-mediated immunity. in Di George’s syndrome.
Signs and Symptoms Because loss or dysfunction
Signs and symptoms common in children in- of T cells can cause sec-
clude lymphadenopathy, hepatosplenomegaly, ondary B-cell deficiency,
some disorders have signs
parotitis, chronic diarrhea, oral candidiasis, skin
and symptoms of com-
infections, fever, and failure to thrive. Signs of bined B-cell and T-cell
immunodeficiency occur in the form of multi- deficiency such as in
ple or recurrent opportunistic bacterial, fungal, Wiskott-Aldrich syndrome.
and viral infections. Complications may include In B-lymphocyte disorders,
evident in the first few
progressive neurological involvement leading months of life, children
to developmental delays and impaired cognitive have an inadequate num-
ability. Recommended prevention strategies for ber of antibodies and ex-
vertical transmission include voluntary prena- perience multiple bacterial
infections and failure to
tal HIV testing, treatment with antiretroviral
thrive (Ward & Hisley,
medications during pregnancy and labor, and 2009). Combined immun-
elective cesarean delivery for HIV-positive odeficiency disorders are
women. Infants of HIV-positive mothers should complex, affecting many
not be breastfed if formula is available. Adoles- components of the immune
system, and are often fatal.
cents should be educated about HIV/AIDS and Care of the child with any
taught how to avoid high-risk behaviors such as type of immunodeficiency
engaging in unprotected sex and IV drug use disorder is tailored to the
with unclean needles (Heyman, 2008; Ward & Continued

Hisley, 2009).

Communicable and Immunological Conditions in Children 97


Autoimmune Disorders
CONGENITAL Systemic Lupus Erythematosus (SLE)
IMMUNODEFICIENCY This chronic multisystemic autoimmune disor-
DISORDERS—cont’d der of connective tissue and blood vessels is char-
acterized by exacerbation and remission. The
exact syndrome and in-
cludes maintaining the
cause of SLE is unknown, but the disease is cur-
immune system, offering rently thought to result from a combination of
supportive care, or helping genetic predisposition and hormonal and envi-
the child with a peaceful ronmental triggers. In SLE, the immune system
death.
produces antibodies against the patient’s own
proteins, with resulting immune complex de-
posits causing inflammation, injury, and damage
ALERT to tissues. The illness is most common in adoles-
cent and young adult women and in African
Immunocompro- American, Asian, and Hispanic populations.
mised children must Signs and Symptoms
be protected from oppor-
Signs and symptoms occur between the ages of
tunistic infections.
10 and 19 years, and female patients are five to
ten times more likely to be affected than are
male patients (Lupus Foundation of America, 2009). The signs, symp-
toms, severity, and progression of the disease vary widely, depending
on which body systems are affected. Children may initially exhibit
fever, malaise, aches, and pains and may show a lack of interest in
school, friends, and usual activities. Less than one-third of children
will exhibit the characteristic malar “butterfly” rash on the face. Chil-
dren with vague, unexplained symptoms should be tested for antinu-
clear antibodies (ANAs), and, if test results are
positive, a diagnosis of SLE should be consid-
ered using the American College of Rheumatol-
ALERT
ogy (2010) adult criteria. A child with four of
Serious manifes- the conditions listed should be further evaluated
tations of SLE for SLE (Table 5–1).
include asymptomatic Treatment of SLE rests on management of
nephritis, neuropsychiatric
pain and inflammation with nonsteroidal anti-
disorders such as psychosis
or seizures, atherosclerosis, inflammatory drugs (NSAIDs), corticosteroids,
and myocardial infarction. antimalarials, and immunosuppressive med-
ications (Hockenberry & Wilson, 2011; Ward &
Hisley, 2009).
Juvenile Arthritis
This autoimmune inflammatory disease is thought to be triggered by an
infection in a genetically predisposed child. Chronic synovial inflamma-
tion with effusion in the joints results in damage and fibrosis of the ar-
ticular cartilage. The onset occurs in children in two age groups: between
1 and 3 years and between 8 and 12 years of age. Girls are affected twice
as often as are boys. The disease is characterized by exacerbation and
remissions, and outcomes are variable.

98 Pediatric Nursing Care


Table 5–1 Classification Criteria for Systemic Lupus
Erythematosus
SKIN DISORDERS

Malar “butterfly” rash across the nose and cheeks


Discoid rash: patchy erythematous rash on sun-exposed skin
Oral and nasal ulceration
Photosensitivity

SYSTEMIC DISORDERS

Arthritis: arthralgia, myalgia


Serositis: pleuritis, atelectasis, pericarditis, myocarditis
Renal disorders: hematuria, proteinuria, glomerulonephritis, hypertension
Neurological disorders: change in behavior, headaches, seizures, psychosis

LABORATORY TESTS

Hematological disorders: test for hemolytic anemia, leukopenia, lymphopenia,


thrombocytopenia.
Immunological disorders: use antiphospholipid antibody test, lupus anticoagulant,
positive anti–double-stranded DNA, false-positive syphilis test (rapid plasma reagent
[RPR]), or positive anti-Smith test (e.g., anticardiolipin).

Signs and Symptoms


Signs and symptoms include intermittent episodes of painful, warm,
swollen joints with morning stiffness and decreased movement lasting
longer than 6 weeks. The child may refuse to bear weight on or move
the affected joint. Possible systemic symptoms include an erythema-
tous rash on the chest and thighs, late afternoon spike of fever, malaise,
and fatigue.
Juvenile arthritis has been classified into three types (Table 5–2).
Diagnosis relies on ruling out other causes of the child’s symptoms,
laboratory testing, and radiographs or bone scans. Complications of
juvenile arthritis include disability and blindness resulting from inflam-
mation of the eye. Joint contractures from limited movement, erosion
of joints and bone, and the development of adhesions may result in de-
formity and growth restriction. Treatment of juvenile arthritis relies on
medication to decrease inflammation and pain, individual physical ther-
apy to maintain joint movement, optimal nutrition and rest, and atten-
tion to the growth and development needs of the child. Drugs prescribed
for this condition include NSAIDs, disease-modifying antirheumatic
drugs (see disease-modifying antirheumatic drugs [DMARDs] in Davis’s
Drug Guide for Nurses, 12th ed., 2011), corticosteroids, and some newer
biological agents. Attention should be paid to potential medication side
effects, such as growth restriction or Cushing’s syndrome with steroid
use (Hockenberry & Wilson, 2011; Ward & Hisley, 2009).

Communicable and Immunological Conditions in Children 99


Table 5–2 Types of Juvenile Arthritis
POLYARTICULAR PAUCIARTICULAR SYSTEMIC ONSET

Number of Five or more Four or fewer Any number


joints
involved

Joints Usually small joints of Usually large joints, Any joint


affected fingers and hands knees, ankles, elbows

Weight-bearing joints Usually particular joint


Same joint on both sides on one side of body

Gender Girls more than boys Girls more than boys Boys and girls
affected (most common type) equally

Body Low-grade fever Low-grade fever High spiking fever


temperature lasting for weeks or
months

Other Stiffness and minimal Iridocyclitis (eye Macular rash on


symptoms joint swelling inflammation) chest, thighs

Rheumatoid nodules on Painless joint swelling Inflammation of


elbow with little redness heart and lungs

Areas on the body ANA titer (possible) Anemia


that have pressure
from external objects HLA antigen (possible Enlarged lymph
such as wheel chairs in boys) nodes, liver, and
or shoes spleen

Rheumatoid factor is Rheumatoid factor


noted in 20% of the cases and ANA titer noted

ANA titer (possible) Elevated WBC

Elevated WBC, comple-


ment, erythrocyte, and
sedimentation rate values

ANA, antinuclear antibody; HLA, human leukocyte antigen; WBC, white blood cell.

Allergic Reaction
Anaphylaxis
This condition is an overwhelming inflammatory allergic response to an
antigen. Common antigens that may cause severe allergic response in
allergic children are peanuts and tree nuts including cashews, insect
bites, latex products, medication such as penicillin, immunizations,
blood products, and radiographic dyes.
Signs and Symptoms
The susceptible child who comes in contact with the antigen responds by
an immediate generalized release of chemical mediators that results in
100 Pediatric Nursing Care
the symptoms of anaphylaxis: wheezing, bron-
chospasm, laryngospasm, tachycardia, hypoten- ALERT
sion, cyanosis, rhinitis, facial edema, urticaria,
hives, abdominal pain, nausea and vomiting, anx- The EpiPen Jr
Auto-Injector is
iety, vascular collapse, and death. Seek medical
used for children experi-
emergency care immediately. encing a life-threatening
Treatment of anaphylaxis includes the fol- reaction. An injection of
lowing: rapid identification and removal of 0.15 mg of epinephrine
the antigen, if possible; cardiopulmonary resus- (Adrenalin) is used for
children up to 33 lb (15 kg),
citation and support, including endotracheal and an injection of 0.3 mg
intubation as needed; and administration of is used for older children
epinephrine, antihistamines, corticosteroids, and adults.
and inhaled beta agonists. The family and
child is counseled about the seriousness of
the reaction and helped to plan actions to avoid
exposure to the antigen in the future.
MNEMONIC
Infections A medical
mnemonic used to help
Bacterial Infections
remember anaphylaxis care
Bronchiolitis (Respiratory Syncytial Virus is SAFE:
[RSV] Infection) Seek support
This acute viral infection of the bronchioles is Allergen identification
often caused by RSV in young children. The ill- and avoidance
ness occurs most frequently before age 2 years in Follow-up for specialty
care
the winter and early spring months. Boys are
Epinephrine for
affected more often than are girls, and children emergencies
usually contract the illness more than once be-
fore immunity is obtained. Breastfeeding appears
to offer some protection, whereas prematurity, lung disease, and congen-
ital heart disease increase risk. RSV is transmitted by direct contact with
infected respiratory secretions on hands or objects to the mucous mem-
branes of the eye, mouth, or nose. The incubation period is 5 to 8 days.

EVIDENCE FOR PRACTICE 5–2


ANAPHYLAXIS
Australian researchers de Silva, Mehr, Tey, and Tang (2008) performed a
retrospective chart review of 123 episodes of 117 children with anaphylaxis
who presented to the emergency department of one hospital in Melbourne
over a 5-year period. Anaphylaxis occurred most often in the home, and the
most common antigen (85%) was food, with peanuts and tree nuts, including
cashews, heading the list. The median time from exposure to symptoms
was 10 minutes, but the median time to provision of emergency care was
significantly delayed, at 40 minutes. The children were mostly experiencing
their first episode of anaphylaxis (83%), and 97% presented with respiratory
symptoms.

Communicable and Immunological Conditions in Children 101


Signs and Symptoms
Signs and symptoms include upper respiratory infection with nasal con-
gestion, rhinorrhea, low-grade fever, and mild cough. Otitis media and
conjunctivitis may develop concurrently. The illness may progress to
the lower respiratory tract, with thick secretions and mucosal edema
causing symptoms of obstruction and impaired gas exchange: wheezing,
tachypnea, retractions, decreased breath sounds, cyanosis, and respira-
tory acidosis. Complications include apnea and RSV pneumonia. Treat-
ment is supportive with oxygen and IV fluids, as necessary. Synagis
(palivizumab), a monoclonal antibody, may be given in monthly injec-
tions during RSV season to prevent RSV infection in vulnerable infants
and children.
Cellulitis
This spreading bacterial infection in the soft tissues is commonly caused
by strains of Staphylococcus and Streptococcus. The bacteria gain access
to the body through a break in the skin from a lesion or trauma. The
face, back, and extremities are frequent sites of infection.
Signs and Symptoms
Signs and symptoms include erythema, heat, pain, edema, and induration
at the infected site. Fever, chills, malaise, and adjacent lymphadenitis may
occur. Cases of pediatric necrotizing fasciitis were reported in children
with varicella infections before immunization programs (Eneli & Davies,
2007; Fustes-Morales et al, 2002). Oral antibiotics or IV antibiotics in
severe cases, warm compresses, and mild analgesics are employed as
treatment. Preventive measures for cellulitis focus on good hygiene.
Conjunctivitis (Pinkeye)
Conjunctivitis is an inflammation of the conjunctiva caused by bacteria,
viruses, or chemical or allergic reactions. “Pinkeye” is a common acute
bacterial conjunctivitis seen in children.
Signs and Symptoms
Signs and symptoms include erythema and edema of the eyelids with
inflamed conjunctiva and purulent drainage that forms crusts, especially
on awakening. Conjunctivitis caused by Chlamydia trachomatis, Neisseria
gonorrhoeae, and herpes simplex virus contracted during birth may lead
to ocular damage and blindness. Treatment includes warm soaks to re-
move crusts, cool compresses, and ophthalmic antibiotics as indicated.
Prevention focuses on good hand hygiene and not sharing personal
items with others (Ward & Hisley, 2009).
Encephalitis
Encephalitis is most often a viral infection of the central nervous system
(CNS), but it may also be caused by bacteria, fungi, parasites, and expo-
sure to toxins, as well as being a side effect of cancer. Mosquitoes are
the most common vectors in the United States, followed by herpes
simplex virus type 1.
Signs and Symptoms
Signs and symptoms range from mild to severe and are the result of
inflammation of the CNS. They include fever, headache, nausea and

102 Pediatric Nursing Care


vomiting, nuchal rigidity, photophobia, mental status changes, lethargy,
hallucinations, seizures, and coma. Complications of encephalitis in-
clude increased intracranial pressure, CNS tissue damage resulting in
motor and cognitive deficits, impaired hearing or vision, and seizure
disorders (Blume & Szperka, 2010). Treatment is supportive, with med-
ications depending on the causal organism. Preventive measures include
adherence to childhood immunization recommendations for measles,
mumps, rubella, and varicella and measures to avoid insect bites.
Meningitis
Meningitis is an acute infection of the meninges (the membranes sur-
rounding the brain and spinal cord) and the cerebrospinal fluid (CSF).
About half of all cases occur in infants and children younger than 5 years
old. Meningitis is classified as either septic (bacterial origin) or aseptic
(viral origin). Aseptic meningitis typically occurs in the fall and winter
when viral illnesses are more common. Causative bacteria in septic
meningitis include S. pneumoniae, Neisseria meningitidis (meningococ-
cal), Escherichia coli, and Haemophilus influenzae type B (Ward & Hisley,
2009). The infective agent may be introduced directly into the CSF
through trauma or medical procedures, or it may spread from a primary
infection in another part of the body such as the nasopharynx.
Signs and Symptoms
Signs and symptoms result from a severe inflammatory response and
include irritability, malaise, bulging fontanel in infants, fever, senso-
rium changes, nausea and vomiting, nuchal rigidity, seizures, and pos-
itive Brudzinski’s and Kernig’s signs. Infection with N. meningitidis may
cause meningococcal septicemia characterized by a maculopapular
rash that progresses to petechiae and coalesces to purpura (Donovan
& Blewitt, 2010). Additional acute complications of meningitis include
disseminated intravascular coagulation (DIC) and syndrome of inap-
propriate antidiuretic hormone (SIADH). Residual complications occur
in about 15% of children and include cognitive and motor deficits
or paralysis, impaired vision or hearing, and seizure disorders. Treat-
ment is supportive, with antibiotic administration for septic meningitis.
Immunization with the Hib vaccine has greatly reduced the number
of cases caused by H. influenzae type B (Donovan & Blewitt, 2010;
Ward & Hisley, 2009).
Otitis Media
This infection of the middle ear is common in early childhood because
the short, straight, horizontal structure of the eustachian tube does not
promote drainage as well as in the older child and adult. S. pneumoniae,
H. influenzae, and Moraxella catarrhalis are the most common bacteria
involved, but RSV and influenza viruses may also cause otitis media.
Signs and Symptoms
Signs and symptoms include ear pain resulting from the pressure of col-
lected fluid in the middle ear. The infant or child may hold or pull on
the affected ear, roll from side to side, and have a loss of appetite and
lack of interest in feedings. Additional symptoms include fever up to

Communicable and Immunological Conditions in Children 103


104°F (40°C), swollen lymph glands, rhinorrhea, emesis, diarrhea, and
anorexia. Complications can result in hearing loss. Treatment includes
the judicious use of antibiotics if the infection is bacterial and manage-
ment of discomfort. Preventive measures include breastfeeding or for-
mula feeding in an upright position, as well as avoidance of second-hand
smoke and environmental allergens.
Sinusitis
This infection in the sinus cavities causes inflammation and swelling
that block sinus drainage and result in typical symptoms. The infection
most often follows an upper respiratory infection as bacteria migrate
and colonize in the sinuses.
Signs and Symptoms
Signs and symptoms include facial pain, headache, periorbital edema,
purulent nasal drainage, and low-grade fever with a history of a recent
urinary tract infection (URI) lasting longer than 2 weeks. Treatment
includes antibiotics as appropriate and decongestants, saline nose drops,
and steam inhalation as needed to relieve swelling.
Tonsillitis
Tonsillitis is an infection with inflammation of the tonsils, which are
bilateral masses of lymphoid tissue in the pharynx. The most common
causes of tonsillitis are viruses and group A, beta-hemolytic Streptococ-
cus, known as strep throat.
Signs and Symptoms
Signs and symptoms begin abruptly with sore throat, fever, malaise, en-
larged red tonsils often with exudate, halitosis, dysphagia, referred ear
pain, and enlarged cervical lymph nodes. Complications of tonsillitis
include peritonsillar abscess, chronic tonsillitis, and subsequent acute
nephritis or scarlet or rheumatic fever as sequelae of streptococcal in-
fection. The treatment of tonsillitis consists of antipyretics, and anal-
gesics with antibiotics are prescribed for strep throat. Chronic tonsillitis
may be treated by tonsillectomy. Preventive measures include good
hand hygiene and avoidance of contact with persons who are ill.

EVIDENCE FOR PRACTICE 5–3


CHICKEN SOUP
Many caregivers in multiple cultures prepare some form of chicken soup
for family members with symptoms of upper respiratory tract infections. A
landmark scientific study by Rennard, Ertl, Gossman, and Rennard (2000)
demonstrated that chicken soup significantly inhibits neutrophil movement,
with resulting mild anti-inflammatory properties. Homemade chicken soup
with vegetables and some canned preparations produced these effects,
but chicken broth alone did not. Additional therapeutic effects of chicken
soup during illness were suggested to be related to nutritional benefits,
added hydration, and steam inhalation which helps to clear mucus from the
upper airway.

104 Pediatric Nursing Care


Viral Infections
Cytomegalovirus (CMV) Infection
This infection, caused by human (beta) herpesvirus 5, is spread by intimate
contact with infected body fluids and tissue, including prenatal and peri-
natal transmission or in breast milk from an infected mother. Transfusion
and tissue transplant may also spread CMV. The incubation period is 3 to
8 weeks. The virus remains dormant after the primary infection and may
recur. Active illness is often asymptomatic or mild, but it may be severe
depending on age and immunocompetence. Some children exhibit signs
of mononucleosis with prolonged fever, fatigue, hepatosplenomegaly, and
jaundice. Congenital CMV infection is severe in 5% to 10% of cases and
may result in stillbirth.
Signs and Symptoms
Signs and symptoms include petechiae, purpuric rash, seizures,
hepatosplenomegaly, jaundice, cerebral calcifications, and micro-
cephaly. Complications include sensory and neural deficits including
seizure disorders, deafness, and mental retardation. Treatment of
severe cases consists of antiviral medications. Immunocompromised
children should receive only CMV-negative blood transfusions or tis-
sue transplants. Consistent use of universal precautions, including
gloving when changing wet or soiled diapers, can prevent the spread
of CMV in health-care environments. Families and day-care facilities
should employ good hand washing techniques (Heyman, 2008; Ward
& Hisley, 2009).
Herpes Zoster (Shingles)
This infection is caused by a reactivation of VZV, the virus that causes
chickenpox.
Signs and Symptoms
VZV lies dormant in dorsal root ganglia, and reactivation causes erup-
tion of painful, pruritic vesicles along the nerve pathways on the face,
trunk, and back. Herpes zoster is more likely to develop in immuno-
compromised children and older adults.
Complications include pneumonia, encephalitis, and permanent
neurological damage. Blindness may result from ophthalmic shingles.
Antiviral medication may be used to treat severe cases of shingles
in immunocompromised children. Varicella vaccination has resulted
in fewer and less severe cases of pediatric herpes zoster (Civen
et al, 2009).

Fungal Infections
Candida albicans Infection (Oral Thrush)
Candida albicans is a fungus that most often exists in the form of yeast,
although it can produce spores. It is naturally present in the mouth,
gut, and vagina of many individuals. Decreased immunity or loss of
normal competing flora through antibiotic or steroid use may cause
an overgrowth of the organism. Overgrowth in the mouth results in
oral thrush.

Communicable and Immunological Conditions in Children 105


Signs and Symptoms
Signs and symptoms include mouth pain and white patches that
adhere to the tongue, palate, and buccal surfaces. The pain may inhibit
feedings. In infants more than 6 months of age, thrush is a warning sign
of a compromised immune system. The antifungal medication Nystatin
(Mycostatin) is used to treat oral thrush. Caregivers are taught to use
good hand hygiene and ensure that bottle feeding equipment and paci-
fiers are cleaned thoroughly in hot water to prevent transmission of the
organism (Heyman, 2008; Ward & Hisley, 2009).

Critical Nursing Assessment


A nursing assessment for communicable and immunological conditions
is multifaceted. The nurse gathers data by assessing for autoimmune dis-
orders, decreased response to acute infections, delayed hypersensitivity
reactions, increased incidence of malignancy, or recurrent latent herpes
zoster or tuberculosis (Dillon, 2007). Recurrent infections, fatigue, and un-
explained swollen glands indicate an immunological condition. To assess
the lymph nodes, gently palpate each lymph node and compare the two
sides of the neck symmetrically. Normal cervical lymph nodes should be
less than 1 cm in diameter, discrete, soft, movable, and nontender. In
particular, impairment of the immune system may cause skin rashes,
lesions, and pruritus. Assessment of vital signs, anthropometric measure-
ments, and a typical physical assessment are essential (see Chapter 3).

Important Aspects of
Communicable and
OFFERING Immunological Care
SUPPORT
Important aspects of care for children with com-
Preventing infection before municable and immunological conditions in-
it occurs is an important
aspect of care. Not all situ-
clude supporting the immune system through
ations are alike, obviously, disease prevention and health promotion.
and the nurse will want to
tailor interactions to the Comfort Measures
situation, but here are ex- Comfort measures such as good hygiene, oral
amples that the nurse may
care, clean bedding, and comfortable clothes
find helpful to start:
may help the child’s healing process.
• Tell me about your child’s
hand hygiene. How often
do you wash, or does Isolation
your child wash, her Communicable and immunological treatments
hands? How often does include the following measures taken to care for
your child bathe? a child with methicillin-resistant Staphylococcus
• How many hours per night
does your child sleep?
aureus (MRSA) (CDC, 2010d):
• Does your child nap? • Isolate the child by assigning the patient to a
How often does she nap? private room.
How long are her naps? • Use standard precautions throughout the
Continued
hospital stay.

106 Pediatric Nursing Care


• Wash hands with a chlorhexidine-soap
solution. OFFERING
• Don disposable nonsterile gloves when SUPPORT—cont’d
coming in contact with body fluids or
• Tell me about how you
wounds.
avoid exposing your child
• Wear a protective gown when entering the to people who are sick,
patient’s room. have a cold, flu, or cough.
• Wear a filtered mask if the child has a • Tell me about your child’s
productive cough or when handling respi- dietary habits. What
kinds of foods does she
ratory secretions. like? Do you consider
• Caps and overshoes are not required. your child’s diet healthy
• Change protective garments between or nutritious?
patients. • Tell me about dressing
your child. Do you dress
• Close the patient’s door.
her according the weather?
• Keep all equipment such as thermometers, • Can you demonstrate
stethoscopes, and sphygmomanometers in how you take your child’s
the patient’s room, and disinfect or destroy temperature?
them after use. • Do you call your health-
care provider if her fever is
• Place laundry in water-soluble bags, and more than 101°F (38°C)?
use designated waste bags. • Can you name the most
• Use labeled biohazard bags for contami- common signs and symp-
nated waste or specimens that are collected toms of infection?
• What care measures do
and need to be sent to the laboratory.
you provide to your child
• Special precaution for food trays and when she is sick or has an
dishes or utensils is not needed. infection?
• Avoid transfer to other areas if possible. • Tell me about your
However, if transport is necessary, use health-care provider or
where you take your child
standard precautions. when she is sick or injured.
• Document pertinent data. • What kinds of medica-
• Notify the environmental services depart- tions or herbal remedies
ment to clean the room thoroughly after does your child take?
• If you have a question
the patient is discharged.
about your child’s med-
ication, whom do you call
Maintaining the Body’s Defense System for information?
Maintain the body’s defense system through ac- • What kinds of childhood
tive and passive immunity, and protect the diseases has your child
had?
child’s skin. Active immunity matures as the
• Can you tell me about
child is exposed to or is vaccinated against dis- your child’s immuniza-
eases (Fig. 5–8). Newborns obtain passive immu- tions? Are your child’s
nity from maternal IgG antibodies that cross the immunizations up to date?
placenta during the third trimester of pregnancy
and protect the infant for the first 6 months of
life. Maternal IgA immunoglobulin is also passively transferred to the
breastfed infant in colostrum, so encouraging the mother to breastfeed
is essential. Nurses can implement skin care measures and teach parents
about skin care as a way to protect the child’s immune system.
(text continues on page 112)

Communicable and Immunological Conditions in Children 107


108 Pediatric Nursing Care
F I G U R E 5 - 8 : CDC Recommended Immunization Schedules for Persons Aged 0 through 6 (A) and 7 through 18
F I G U R E 5 - 8 : —cont’d

Communicable and Immunological Conditions in Children 109


110 Pediatric Nursing Care
F I G U R E 5 - 8 : —cont’d (B). From Centers for Disease Control and Prevention.
F I G U R E 5 - 8 : —cont’d

Communicable and Immunological Conditions in Children 111


Nutrition
Good nutrition is essential to support the child’s immune system. The
dietary reference intake (DRI) was developed by the U.S. Department
of Agriculture (USDA) to broaden the guidelines known as recom-
mended dietary allowances (RDAs). DRI is a system of nutritional rec-
ommendations with four components: estimated average requirements
(estimated average dietary requirements for age and gender), recom-
mended dietary allowances (estimated daily dietary intake of a nutri-
ent considered sufficient to meet the requirements of individuals),
adequate intake (used when no RDA has been established to determine

BEST PRACTICES 5–1


SKIN CARE MEASURES
• Assess the child’s skin frequently to identify skin breakdowns or problems
before they become advanced.
• Use the Braden Scale, which is available online, for predicting pressure
sore risk.
• Assess the child’s nutritional status. Hyperalimentation may be considered
for the child with poor dietary intake.
• Consult the health-care provider for wound care products.
• Use pressure-reducing devices such as gel pressure pads that conform
to the child’s body contours and use alternating-pressure, air, or gel
mattresses.
• Keep the infant’s diaper area clean and dry by changing diapers often and
using zinc oxide or petroleum jelly–based products to help keep moisture
away from the baby’s skin.
• Moisturize the child’s skin with products that contain no perfumes or alcohols.
• Use gentle and specially formulated soap products for bathing.
• Use a mild shampoo and soft brush for the child’s hair.
• Teach the child to wash his or her hands to protect them against bacteria
and viruses.
• Apply sunscreen before the child goes outside, starting at 6 months of age.
• Use bug repellent products that are approved for children. Apply the
repellent to the child’s clothing rather than to his or her skin.
• Protect the child’s skin during the winter months with hats, gloves, and
protective clothing.
• Seek professional advice for skin care products for children with sensitive or
problematic skin.
• Educate older children and parents about the risks of tattoos and body
piercings.
• Use a minimum of adhesives and tape on the child’s skin.
• Alternate placement of electrode sites, and assess the child’s skin under the
electrodes.
• Keep the child’s skin free of excess moisture such as urine, feces, wound
drainage, and perspiration.
• Use first aid care measures to treat cuts, scrapes, blisters, bruises, and minor
burns.
• Seek early diagnosis and treatment for more serious skin problems and burns.

112 Pediatric Nursing Care


adequate intake for individuals in that demographic group), and toler-
able upper intake levels (established to caution against excessive intake
of nutrients). Specific dietary information about DRI is found on the
USDA Web site.

Supportive Care
Supportive care includes tending to developmental needs, offering sup-
port, listening, using therapeutic communication, being present, encour-
aging play, and allowing social interaction with others. It also includes
maintaining fluid intake (oral and IV) and controlling fever and symp-
toms. See Chapter 6 for airway and oxygenation treatments.

Laboratory Tests
Laboratory testing is essential in the diagnosis and treatment of commu-
nicable and immunological conditions.

Complete Blood Count (CBC)


The CBC is a common blood test to assess health status. See Chapter 6
for details of CBC components and for normal values.

Blood Cultures
Blood cultures are used to uncover the presence of yeast or bacteria
in the blood and to identify any microorganism that is present so
proper treatment can be started. Two or more consecutive blood cul-
tures are ordered (one aerobic and one anaerobic), and the nurse is
responsible for collecting or contacting laboratory personnel to collect
the blood, labeling the specimens, storing them properly in a biohaz-
ard bag, and then ensuring transport of the samples to the laboratory
for study. Blood cultures may take up to 3 days before organisms are
apparent. Usually, if a bacterial infection is suspected, the child has
blood cultures ordered first, and then immediate treatment with in-
travenous broad spectrum antibiotic is begun while the test results are

EVIDENCE FOR PRACTICE 5–4


STEM CELL TRANSPLANTATION
Researchers are contemplating the use of stem cell transplantation for se-
lective autoimmune disorders such as lupus and rheumatoid arthritis (Stem
Cell Information, the National Institutes of Health resource for stem cell
research, 2009). After stem cell transplantation, children are placed in a
medically induced state of immunosuppression to maintain sufficient im-
mune system function to resist infection while at the same time suppress-
ing the immune system just enough to decrease the possibility of tissue
rejection (Ward & Hisley, 2009, p 827).Corticosteroids are potent anti-
inflammatory agents and are used to induce the immunosuppression.
Nursing care also includes protection against infection.

Communicable and Immunological Conditions in Children 113


pending. If blood cultures are positive, and the child has a yeast or
bacterial infection in the bloodstream, the medication may then need
to be changed to be more specific to the microorganism detected.

Cerebrospinal (CSF) Analysis


The CSF specimen is obtained by lumbar puncture (Fig. 5–9) and is
analyzed to discover the cause of bleeding, to identify brain injury, or to
diagnose infections and cancer, as well as degenerative and autoimmune
diseases of the brain and spinal cord. Before the test, the nurse reviews
it with the family. During the test, the nurse helps the child follow direc-
tions and monitors vital signs. After the procedure, the nurse positions
the child with the head of the bed elevated not more than 30 degrees,
and other care measures are resumed or new
orders are implemented. After CSF analysis, the
ALERT report is sent to the health-care provider, who
will discuss results with the family. Parents may
During the be anxious while waiting for results, so the nurse
collection of cere-
offers support. It is important to tell parents that
brospinal fluid, the nurse
ensures that emergency other diagnostic testing and/or treatments may
equipment is available. be ordered based on test results (Van Leeuwen
& Poelhuis-Leth, 2009).

Immunodiagnostic Studies
Antinuclear antibodies (ANAs): assists in the diagnosis of SLE
and immune disorders such as rheumatoid arthritis and connec-
tive diseases
Candida albicans: assists in the isolation and identification of the
fungal overgrowth of Candida albicans
Coombs’ antiglobulin, direct (DAT): detects antigen-antibody
complexes present on red blood cells; used in the diagnosis of
hemolytic disease of the newborn, autoimmune hemolytic ane-
mias, SLE, and drug-induced red blood cell (RBC) sensitization

F I G U R E 5 - 9 : Lumbar puncture. From Ward, S. & Hisley, S., (2009). Mater-


nal child nursing care: Optimizing outcomes for mothers, children and families.
Philadelphia: F. A. Davis, p. 1108.

114 Pediatric Nursing Care


Coombs’ antiglobulin, indirect (IAT): detects the presence of
antibodies in the bloodstream; used to identify Rh-negative preg-
nant women who have become sensitized to the Rh antigen and
to screen for antibodies before blood transfusions
Antistreptolysin O titer (ASO): assists in the diagnosis of a strep-
tococcal infection and monitors related therapy
Anti–cyclic citrullinated peptide antibody (Anti-CCP): assists
in the diagnosis of rheumatoid arthritis
C-reactive protein (CRP): a marker of in-
flammation used to assist in the diagno-
sis of SLE and rheumatoid arthritis and SPEAKING OUT
to monitor response to therapies for
The nurse can advocate
autoimmune disorders for the family by speaking
Epstein-Barr virus antibodies (EBV): out about the overuse of
assists in the diagnosis of infectious antibiotics. According to
mononucleosis studies reported by the
CDC, almost 50% of the
Enzyme-linked immunosorbent assay antibiotics administered
(ELISA): identifies the presence of HIV in hospitals are not neces-
antibodies sary or are inappropriate
Herpes test (HSV): assists in the diagnosis for the patient’s illness.
Overuse of antibiotics is
of herpes simplex virus (HSV).
one of the primary causes
Immunoglobulin tests: measure the level of the development of
of immunoglobulin (or antibodies) in the antibiotic-resistant mi-
blood: IgA, IgG, IgM, IgE, and IgD croorganisms, a global
Polymerase chain reaction (PCR): iden- health challenge. Patients
are placed in jeopardy
tifies proviral DNA specific to HIV when microorganisms
Rheumatoid factor (RF): measures the become resistant to the
amount of the RF antibody present in the antibiotics used to treat
blood and assists in diagnosing rheuma- their illnesses. The CDC
has developed programs
toid arthritis
called Get Smart: Know
Rubella test: IgM and IgG antibody tests When Antibiotics Work
ordered to confirm protection against for the public and Get
the rubella virus, detect a recent or past Smart for Healthcare to
infection, identify children who have provide education about
safe and appropriate use
never been exposed to the virus, and of antibiotics. Nurses can
identify children who have not been refer care providers and
vaccinated caregivers to these helpful
(Data from Van Leeuwen & Poelhuis-Leth, resources through the
CDC Web site.
2009.)

Medications
Medications are an essential part of caring for the child with communi-
cable and immunological conditions (Table 5–3).

Communicable and Immunological Conditions in Children 115


Table 5–3 Medication
MEDICATION INDICATION ACTION

Trimethoprim- Prevention of bacterial Bactericidal action against


sulfamethoxazole infections in an immunosup- susceptible bacteria
(Bactrim or Septra) pressed child
(oral)

Acyclovir (Zovirax) Treatment of recurrent genital Interferes with viral DNA


(oral) herpes infections synthesis

Ganciclovir Treatment of cytomegalovirus Inhibits viral DNA synthesis


(Cytovene) (oral or (CMV)
intravenous)

Maraviroc Treatment of HIV infection Blocks a specific receptor on


(Selzentry) (oral) with other antiretrovirals CD4 and T-cell surfaces that
prevents CCR5-tropic HIV-1,
which results in viral replication

Amphotericin B Treatment of fungal infections Fungistatic action


lipid complex
(Abelcet)
(intravenous)

Nystatin Treatment of cutaneous or Acts by binding to sterols in


(Mycostatin) mucocutaneous mycotic the cell membrane of suscepti-
(topical) infections caused by Candida ble species, thus resulting in a
albicans and other susceptible change in membrane perme-
Candida species ability and the subsequent
leakage of intracellular
components

Epinephrine Management of reversible Produces bronchodilation


(Adrenalin) airway disease
(subcutaneous,
intravenous, or
inhalation)

Methylprednisolone An anti-inflammatory or Suppresses inflammation and


(A-Methapred) immunosuppressant agent the normal immune response
(intravenous or
intramuscular)

Mupirocin ointment Used to treat certain skin An antibiotic that stops the
(Bactroban) (topical) infections (e.g., impetigo). growth of certain bacteria

From Vallerand & Deglin (2011).

116 Pediatric Nursing Care


NURSING CARE PLAN: THE CHILD WITH
IMMUNOSUPPRESSION

NURSING DIAGNOSIS
Risk for infection related to immunosuppression
MEASURABLE SHORT-TERM GOAL
The child remains free from symptoms of infection.
MEASURABLE LONG-TERM GOAL
The child regains natural resistance to infection.
NURSING OUTCOMES CLASSIFICATION
Immune Status (0702) Natural and acquired appropriately targeted resist-
ance to internal and external antigens.
Infection Severity (0703) Severity of infection and associated symptoms
NURSING INTERVENTIONS CLASSIFICATION
Infection Protection (6550)
Infection Control (6540)
NURSING INTERVENTIONS
1. Institute universal precautions, and designated isolation precautions as
appropriate.
Rationale: Precautions protect the nurse, child, and family members from
the transfer of microorganisms.
2. Demonstrate and instruct visitors to wash hands on entering and leaving
the patient’s room and to use protective equipment properly.
Rationale: Hand washing and proper use of gloves, masks, or cover
gowns eliminate major transmission routes for many organisms.
3. Monitor for systemic and localized signs of infection every 2 to 4 hours
when the child is hospitalized and at each interaction in providing
community-based health care. Assess temperature, lung sounds, and
condition of skin, as well as mucous membranes, for pain, redness,
and edema.
Rationale: Fever or respiratory symptoms may be the only overt signs of
infection in an immunosuppressed child. Systematic monitoring allows
early recognition and treatment of infection.
4. Monitor laboratory values as obtained: absolute granulocyte count,
white blood cell (WBC) count, and differential results.
Rationale: Changes in laboratory values alert the caregiver to developing
infection. The immunosuppressed patient may not exhibit overt signs of
an inflammatory response.
5. Promote a balanced diet of favorite foods, prepared and presented attrac-
tively. Allow only cooked fruits and vegetables if the child is neutropenic.
Rationale: Deficient intake of protein, of vitamins A, C, or E, of iron, or of
zinc may have a detrimental effect on the immune system and place the
child at increased risk for infection. Cooking fruits and vegetables helps
to eliminate harmful organisms.

Continued

Communicable and Immunological Conditions in Children 117


NURSING CARE PLAN: THE CHILD WITH
IMMUNOSUPPRESSION—cont’d

6. Encourage rest and sleep by providing a quiet environment.


Rationale: Sufficient rest and sleep will help bolster the body’s immune
system.
7. Administer antibiotics and immunizations as prescribed, following CDC
and AAP recommendations.
Rationale: Antibiotics may be prescribed prophylactically or to treat
identified infections. Most children who are able to produce antibodies
are given killed vaccines.

From Ward & Hisley, (2009), p. 823.

Chapter Summary
Infants and children have immature physiological and immune systems
that place these patients at increased risk of contracting communicable
and immunological conditions and experiencing complications. Im-
munocompromised children must be protected from opportunistic in-
fections. The pediatric nurse plays a critical role in disease prevention
and health promotion for children of all ages through education, immu-
nization, and the care of ill children.

118 Pediatric Nursing Care