Pediatric Variations of Nursing interventions

• General concept related to pediatric procedures
  • Informed consent
    • The person must be capable of giving consent: Age at majority (usually age 18)
    • The person must receive the information needed to make an intelligent decision
    • The person must act voluntarily when exercising freedom of choice
  • Requirements for obtaining informed consent
    • Separate informed permissions must be obtained for each surgical or diagnostic procedure, including
      • Major surgery
      • Minor surgery (e.g., cutdown, biopsy, dental extraction, suturing a laceration [especially one that may have a cosmetic effect], removal of a cyst, closed reduction of a fracture)
      • Diagnostic tests with an element of risk (e.g., bronchoscopy, angiography, lumbar puncture, cardiac catheterization, bone marrow aspiration)
      • Medical treatments with an element of risk (e.g., blood transfusion, thoracentesis or paracentesis, radiotherapy)
    • Other situations that require patient or parental consent include the following:
      • Photographs for medical, educational, or public use
      • Removal of the child from the health care institution against medical advice
      • Postmortem examination, except in unexplained deaths, such as sudden infant death, violent death, or suspected suicide
      • Release of medical information
    • Assent should include:
      • Helping the patient achieve a developmentally appropriate awareness of the nature of his or her condition
      • Telling the patient what he or she can expect
      • Making a clinical assessment of the patient’s understanding
      • Soliciting an expression of the patient’s willingness to accept the proposed procedure
    • Parents have full responsibility for rearing of their minor children, including legal control over them.
    • If children are minors, their parents or legal guardians are required to give informed consent before medical treatment is rendered or any procedure is pre-formed. 
    • If the parents are married to each other, consent from only one parent is require in nonurgent pediatric care. 
    • If parents are divorced, consent goes to who has legal custody.
  • Preparation for diagnostic and therapeutic procedures
    • Psychologic preparation
      • Selecting nonthreatening words or phrases

• Age-specific guidelines for preparation
  • Infant: Developing trust and sensorimotor thought
    • Attachment to Parent
      • Involve parent in procedure if desired.
      • Keep parent in infant’s line of vision.
      • If parent is unable to be with infant, place familiar object with infant (e.g., stuffed toy).
    • Stranger Anxiety
      • Have usual caregivers perform or assist with procedure.
      • Make advances slowly and in a nonthreatening manner.
      • Limit number of strangers entering room during procedure.
    • Sensorimotor Phase of Learning
      • During procedure, use sensory soothing measures (e.g., stroking skin, talking softly, giving pacifier).
      • Use analgesics (e.g., topical anesthetic, intravenous [IV] opioid) to control discomfort.
      • Cuddle and hug infant after stressful procedure; encourage parent to comfort infant.
    • Increased Muscle Control
      • Expect older infants to resist.
      • Restrain adequately.
      • Keep harmful objects out of reach.
    • Memory for Past Experiences
      • Realize that older infants may associate objects, places, or people with prior painful experiences and will cry and resist at the sight of them
      • Keep frightening objects out of view.
      • Perform painful procedures in a separate room, not in crib (or bed).
      • Use nonintrusive procedures whenever possible (e.g., axillary or tympanic temperatures, oral medications).
    • Imitation of Gestures
      • Model desired behavior (e.g., opening mouth).
  • Toddler: Developing Autonomy and Sensorimotor to Preoperational Thought
  • Use same approaches as for infant plus the following.
    • Egocentric Thought
      • Explain procedure in relation to what child will see, hear, taste, smell, and feel.
      • Emphasize those aspects of procedure that require cooperation (e.g., lying still).
      • Tell child it is okay to cry, yell, or use other means to express discomfort verbally.
      • Designate one health care provider to speak during procedure. Hearing more than one can be confusing to a child*
    • Negative Behavior
      • Expect treatments to be resisted; child may try to run away.
      • Use firm, direct approach.
      • Ignore temper tantrums.
      • Use distraction techniques (e.g., singing a song with child).
      • Restrain adequately.
    • Animism
      • Keep frightening objects out of view (young children believe objects have lifelike qualities and can harm them).
    • Limited Language Skills
      • Communicate using gestures or demonstrations.
      • Use a few simple terms familiar to child.
      • Give child one direction at a time (e.g., “Lie down” and then “Hold
      • my hand”).
      • Use small replicas of equipment; allow child to handle equipment.
      • Use play; demonstrate on doll but avoid child’s favorite doll because child may think doll is really “feeling” procedure.
      • Prepare parents separately to avoid child’s misinterpreting words.
    • Limited Concept of Time
      • Prepare child shortly or immediately before procedure.
      • Keep teaching sessions short (≈5 to 10 minutes).
      • Have preparations completed before involving child in procedure.
      • Have extra equipment nearby (e.g., alcohol swabs, new needle, adhesive bandages) to avoid delays.
      • Tell child when procedure is completed.
    • Striving for Independence
      • Allow choices whenever possible but realize that child may still be resistant and negative.
      • Allow child to participate in care and to help whenever possible (e.g., drink medicine from a cup, hold a dressing).
  • Preschooler: Developing Initiative and Preoperational Thought
    • Egocentric
      • Explain procedure in simple terms and in relation to how it affects child (as with toddler, stress sensory aspects).
      • Demonstrate use of equipment.
      • Allow child to play with miniature or actual equipment.
      • Encourage “playing out” experience on a doll both before and after procedure to clarify misconceptions.
      • Use neutral words to describe the procedure.
    • Increased Language Skills
      • Use verbal explanation but avoid overestimating child’s comprehension of words.
      • Encourage child to verbalize ideas and feelings.
    • Limited Concept of Time and Frustration Tolerance
      • Implement same approaches as for toddler but may plan longer teaching session (10 to 15 minutes); may divide information into more than one session.
    • Illness and Hospitalization Viewed as Punishment
      • Clarify why each procedure is performed; child will find it difficult to understand how medicine can make him or her feel better and can taste bad at the same time.
      • Ask child thoughts regarding why a procedure is performed.
      • State directly that procedures are never a form of punishment.
    • Animism
      • Keep equipment out of sight except when shown to or used on child.
    • Fears of Bodily Harm, Intrusion, and Castration
      • Point out on drawing, doll, or child where procedure is performed.
      • Emphasize that no other body part will be involved.
      • Use nonintrusive procedures whenever possible (e.g., axillary temperatures, oral medication).
      • Apply an adhesive bandage over puncture site.
      • Encourage parental presence.
      • Realize that procedures involving genitalia provoke anxiety.
      • Allow child to wear underpants with gown.
      • Explain unfamiliar situations, especially noises or lights.
    • Striving for Initiative
      • Involve child in care whenever possible (e.g., hold equipment, remove dressing).
      • Give choices whenever possible but avoid excessive delays.
      • Praise child for helping and attempting to cooperate; never shame child for lack of cooperation.
  • School-Age Child: Developing Industry and Concrete Thought
    • Increased Language Skills; Interest in Acquiring Knowledge
      • Explain procedure using correct scientific and medical terminology.
      • Explain procedure using simple diagrams and photographs.
      • Discuss why procedure is necessary; concepts of illness and bodily functions are often vague.
      • Explain function and operation of equipment in concrete terms.
      • Allow child to manipulate equipment; use doll or another person as model to practice using equipment whenever possible (doll play may be considered childish by older school-age child).
      • Allow time before and after procedure for questions and discussion.
    • Improved Concept of Time
      • Plan for longer teaching sessions (≈20 minutes).
      • Prepare up to 1 day in advance of procedure to allow for processing of information.
    • Increased Self-Control
      • Gain child’s cooperation.
      • Tell child what is expected.
      • Suggest several ways of maintaining control the child may select from (e.g., deep breathing, relaxation, counting).
    • Striving for Industry
      • Allow responsibility for simple tasks (e.g., collecting specimens).
      • Include child in decision making (e.g., time of day to perform procedure, preferred site).
      • Encourage active participation (e.g., removing dressings, handling equipment, opening packages).
    • Developing Relationships With Peers
      • Prepare two or more children for same procedure or encourage one to help prepare another.
      • Provide privacy from peers during procedure to maintain self-esteem.
  • Adolescent: Developing Identity and Abstract Thought
    • Increasing Abstract Thought and Reasoning
      • Discuss why procedure is necessary or beneficial.
      • Explain long-term consequences of procedures; include information about body systems working together.
      • Realize adolescent may fear death, disability, or other potential risks.
      • Encourage questioning regarding fears, options, and alternatives.
    • Consciousness of Appearance
      • Provide privacy; describe how the body will be covered and what will be exposed.
      • Discuss how procedure may affect appearance (e.g., scar) and what can be done to minimize it.
      • Emphasize any physical benefits of procedure.
    • Concern More with Present Than With Future
      • Realize that immediate effects of procedure are more significant than future benefits.
    • Striving for Independence
      • Involve adolescent in decision making and planning (e.g., time, place, individuals present during procedure, clothing, whether they will watch procedure).
      • Impose as few restrictions as possible.
      • Explore what coping strategies have worked in the past; they may need suggestions of various techniques.
      • Accept regression to more childish methods of coping.
      • Realize that adolescents may have difficulty accepting new authority figures and may resist complying with procedures.
    • Developing Peer Relationships and Group Identity
      • Same as for school-age child but assumes even greater significance.
      • Allow adolescents to talk with other adolescents who have had the same procedure.
• Developmental and cognitive ability

• Establish trust and provide support
• Parental presence and support
  • Support parents who do not want to be present in their decision and encourage them to remain close by so that they can be available to support the child immediately after the procedure. 
  • Parents should also know that someone will be with their child to provide support. 
    • This person should inform the parents after the procedure about how the child did.
• Provide an explanation
  • Age-appropriate explanations
• Physical preparation
  • Preparing children for procedures
    • Determine details of exact procedure to be performed.
    • Review parents’ and child’s present understanding.
    • Base teaching on developmental age and existing knowledge.
    • Incorporate parents in the teaching if they desire, especially if they plan to participate in care.
    • Inform parents of their supportive role during procedure, such as standing near child’s head or in child’s line of vision and talking softly to child, as well as typical responses of children undergoing the procedure.
    • Allow for ample discussion to prevent information overload and ensure adequate feedback.
    • Use concrete, not abstract, terms and visual aids to describe procedure. For example, use a simple line drawing of a boy or girl, and mark the body part that will be involved in the procedure. Use nonthreatening but realistic models.
    • Emphasize that no other body part will be involved.
    • If the body part is associated with a specific function, stress the change or noninvolvement of that ability (e.g., after tonsillectomy, child can still speak).
    • Use words and sentence length appropriate to child’s level of understanding (a rule of thumb for the number of words in a child’s sentence is equal to his or her age in years plus 1).
    • Avoid words and phrases with dual meanings unless child understands such words.
    • Clarify all unfamiliar words (e.g., “Anesthesia is a special sleep”).
    • Emphasize sensory aspects of procedure—what child will feel, see, hear, smell, and touch and what child can do during procedure (e.g., lie still, count out loud, squeeze a hand, hug a doll).
    • Allow child to practice procedures that will require cooperation (e.g., turning, deep breathing, using incentive spirometry).
    • Introduce anxiety-inducing information last (e.g., starting an intravenous [IV] line).
    • Be honest with child about unpleasant aspects of a procedure but avoid creating undue concern. When discussing that a procedure may be uncomfortable, state that it feels differently to different people.
    • Emphasize end of procedure and any pleasurable events afterward (e.g., going home, seeing parents).
    • Stress positive benefits of procedure (e.g., “After your tonsils are fixed, you won’t have as many sore throats”).
    • Provide a positive ending, praising efforts at cooperation and coping.
• Performance of the procedure
  • Expect success
    • Approach children with confidence and convey the impression that you expect to be successful
  • Involve the child
    • Permitting choices gives them some measure of control.
      • But don’t state “Do you want to take your medicine now?” leads them to believe they have an option and provides them the opportunity to legitimately refuse or delay the medication.
      • Instead be firm, “It’s time to drink your medicine now.” 
        • Children usually like to make choices, but the choice must be one that they do indeed have (e.g., “It’s time for your medicine. Do you want to drink it plain or with a little water?”).
  • Provide distraction
  • Allow expression of feelings
• Postprocedural support
  • Encourage expression of feelings
    • Playing with medical objects provides children with the opportunity to play out fears and concerns with supervision by a nurse or child life specialist
  • Positive reinforcement
    • Children need to hear from adults that they did the best they could in the situation—no matter how they behaved. 
    • It is important for children to know that their worth is not being judged based on their behavior in a stressful situation. 
      • Reward systems, such as earning stars, stickers, or a badge of courage, are appealing to children.
  • Play activities for specific procedures
    • Fluid Intake
      • Make ice pops using child’s favorite juice.
      • Cut gelatin into fun shapes.
      • Make a game out of taking a sip when turning page of a book or in games, such as Simon Says.
      • Use small medicine cups; decorate the cups.
      • Color water with food coloring or powdered drink mix.
      • Have a tea party; pour at a small table.
      • Let child fill a syringe and squirt it into mouth, or use it to fill small, decorated cups.
      • Cut straws in half, and place in a small container (much easier for child to suck liquid).
      • Use a “crazy” straw.
      • Make a “progress poster;” give rewards for drinking a predetermined quantity.
    • Deep Breathing
      • Blow bubbles with a bubble blower.
      • Blow bubbles with a straw (no soap).
      • Blow on a pinwheel, feather, whistle, harmonica, balloon, or party blower.
      • Practice band instruments.
      • Have a blowing contest using balloons, boats, cotton balls, feathers, marbles, ping-pong balls, or pieces of paper; blow such objects on a tabletop over a goal line, over water, through an obstacle course, up in the air, against an opponent, or up and down a string.
      • Suck paper or cloth from one container to another using a straw.
      • Dramatize stories, such as “I’ll huff and puff and blow your house down” from the “Three Little Pigs.”
      • Do straw-blowing painting.
      • Take a deep breath and “blow out the candles” on a birthday cake.
      • Use a little paint brush to “paint” nails with water and blow nails dry.
    • Range of Motion and Use of Extremities
      • Throw beanbags at a fixed or movable target or throw wadded-up paper into a wastebasket.
      • Touch or kick Mylar balloons held or hung in different positions (if child is in traction, hang balloon from a trapeze).
      • Play “tickle toes;” have the child wiggle them on request.
      • Play Twister game or Simon Says.
      • Play pretend and guessing games (e.g., imitate a bird, butterfly, or horse).
      • Have tricycle or wheelchair races in a safe area.
      • Play kickball or throw ball with a soft foam ball in a safe area.
      • Position bed so that child must turn to view television or doorway.
      • Climb wall with fingers like a “spider.”
      • Pretend to teach aerobic dancing or exercises; encourage parents to participate.
      • Encourage swimming if feasible.
      • Play video games or pinball (fine motor movement).
      • Play hide and seek: hide toy somewhere in bed (or room if ambulatory), and have child find it using specified hand or foot.
      • Provide clay to mold with fingers.
      • Paint or draw on large sheets of paper placed on floor or wall.
      • Encourage combing own hair; play “beauty shop” with “customer” in different positions.
    • Soaks
      • Play with small toys or objects (cups, syringes, soap dishes) in water.
      • Wash dolls or toys.
      • Pick up marbles or pennies* from bottom of bath container.
      • Make designs with coins on bottom of container.
      • Pretend a boat is a submarine by keeping it immersed.
      • Read to child during soaks; sing with child; or play game, such as cards, checkers, or other board game (if both hands are immersed, move board pieces for child).
      • Sitz bath: Give child something to listen to (music, stories) or look at (View-Master, book).
      • Punch holes in bottom of plastic cup, fill with water, and let it “rain” on child.
    • Injections
      • Let child handle syringe, vial, and alcohol swab and give an injection to doll or stuffed animal.
      • Draw a “magic circle” on area before injection; draw smiling face in circle after injection but avoid drawing on puncture site.
      • If multiple injections or venipunctures are planned, make a “progress poster;” give rewards for predetermined number of injections.
      • Have child count to 10 or 15 during injection.
    • Ambulation
      • Give child something to push:
        • Toddler: Push-pull toy
        • School-age child: Wagon or a doll in a stroller or wheelchair
        • Adolescent: Decorated intravenous (IV) stand
      • Have a parade; make hats, drums, and so on.
    • Extending Environment (e.g., for Patients in Traction)
      • Make bed into a pirate ship or airplane with decorations.
      • Put up mirrors so that patient can see around room.
      • Move bed frequently to playroom, hallway, or outside.
  • Preparing the family
    • General principles of family education
      • Establish a rapport with the family.
      • Avoid using any specialized terms or jargon. 
        • Clarify all terms with the family.
      • When possible, allow family members to decide how they want to be taught (e.g., all at once or over 1 or 2 days). 
        • This gives the family a chance to incorporate the information at a rate that is comfortable.
      • Provide accurate information to the family about the illness.
      • Assist family members in identifying obstacles to their ability to comply with the regimen and in identifying the means to overcome those obstacles. 
        • Then help family members find ways to incorporate the plan into their daily lives.
    • Family preparation for procedures
      • Name of the procedure
      • Purpose of the procedure
      • Length of time anticipated to complete the procedure
      • Anticipated effects
      • Signs of adverse effects
      • Assess the family’s level of understanding
      • Demonstrate and have family return demonstration (if appropriate)
• Surgical Procedures 
  • Preoperative care
    • Parental presence
    • Preoperative sedation
  • Postoperative care
    • Continuous monitoring
    • Vital signs assessment
      • Potential causes of Postoperative vital sign alterations in children

• Managing pain
• Respiratory tract infection
• Patient education
• Discharge instructions
• Postoperative Care
  • Ensure that preparations are made to receive child:
    • Bed or crib is ready.
    • Intravenous (IV) pumps and poles, suction apparatus, and oxygen flow meter are at bedside.
  • Obtain baseline information:
    • Take vital signs, including blood pressure; keep blood pressure cuff in place and deflated to lessen disturbance to child.
    • Take and record vital signs more frequently if any value fluctuates.
    • Inspect operative area.
  • Check dressing if present.
    • Outline any bleeding area on dressing or cast with pen.
    • Reinforce, but do not remove, loose dressing.
    • Observe areas below surgical site for blood that may have drained toward bed.
    • Assess for bleeding and other symptoms in areas not covered with a dressing, such as throat after tonsillectomy.
  • Assess skin color and characteristics.
    • Assess level of consciousness and activity.
    • Notify primary care provider of any irregularities in child’s condition.
    • Assess for evidence of pain.
    • Review surgeon’s orders after completing initial assessment, and check that preoperative orders, such as seizure or cardiac medications, have been reordered and can be given by available routes (oral preparations may be contraindicated).
    • Monitor vital signs as ordered and more often if indicated.
    • Check dressings for bleeding or other abnormalities.
    • Check bowel sounds.
    • Observe for signs of shock, abdominal distention, and bleeding.
    • Assess for bladder distention.
    • Observe for signs of dehydration.
    • Detect presence of infection:
      • Take vital signs every 2 to 4 hours as ordered.
      • Collect or request needed specimens.
      • Inspect wound for signs of infection: redness, swelling, heat, pain, and purulent drainage.
• The child with fever
  • Call Office Immediately If:
    • Your child is younger than 2 months of age.
    • The fever is over 40.6° C (105° F).
    • Your child looks or acts very sick, including a stiff neck, persistent vomiting, purplish spots on the skin, confusion, trouble breathing after you have cleansed his or her nose, or inability to be comforted.
  • Call Within 24 Hours If:
    • The fever is between 40° and 40.6° C (104° and 105° F), especially if your child is younger than 2 years of age.
    • Your child has had a fever for more than 24 hours without an obvious cause or location of infection.
    • Your child has had a fever for more than 3 days.
    • Your child has burning or pain with urination.
    • Your child has a history of febrile seizures.
    • The fever went away for more than 24 hours and then returned.
    • You have other concerns or questions.

• Safety
  • Environmental factors
    • Electrical equipment
    • Furniture
    • Strangulation
    • Toys
    • Preventing falls
      • Risk factors for hospitalized children 
        • Medication effects: 
          • Postanesthesia or sedation; analgesics or narcotics, especially in those who have never had narcotics in the past and in whom effects are unknown
        • Altered mental status: 
          • Secondary to seizures, brain tumors, or medications
        • Altered or limited mobility: 
          • Reduced skill at ambulation secondary to developmental age, disease process, tubes, drains, casts, splints, or other appliances; new to ambulation with assistive devices such as walkers or crutches
        • Postoperative children: 
          • Risk for hypotension or syncope secondary to large blood loss, a heart condition, or extended bed rest
        • History of falls
        • Infants or toddlers in cribs with side rails down or on the daybed with family members
        • Once children at risk for falls have been identified, alert other staff members by posting signs on the door and at the bedside, applying a special-colored armband labeled “Fall Precautions,” labeling the chart with a sticker, or documenting information on the chart.
      • Prevention of falls requires alterations in the environment, including the following:
        • Keep the bed in the lowest position with the brakes locked and the side rails up.
        • Place the call bell within reach.
        • Ensure that all necessary and desired items are within reach (e.g., water, glasses, tissues, snacks).
        • Offer toileting on a regular basis, especially if the patient is taking diuretics or laxatives.
        • Keep lights on at all times, including dim lights while sleeping.
        • Lock wheelchairs before transferring patients.
        • Ensure that the patient has an appropriate size gown and nonskid footwear. Do not allow gowns or ties to drag on the floor during ambulation.
        • Keep the floor clean and free of clutter. Post a “wet floor” sign if the floor is wet.
        • Ensure that the patient has glasses on if he or she normally wears them.
        • Preventing falls also relies on age-appropriate education of patients. Assist the child with ambulation even though he or she may have ambulated well before hospitalization. Patients who have been lying in bed need to get up slowly, sitting on the side of the bed before standing.
        • The nurse also needs to educate family members:
        • Call the nursing staff for assistance, and do not allow patients to get up independently.
        • Keep the side rails of the crib or bed up whenever the patient is in the crib or bed.
        • Do not leave infants on the daybed; put them in the crib with the side rails up.
        • When all family members need to leave the bedside, notify the staff and ensure that the patient is in the bed or crib with the side rails up and call bell within reach (if appropriate).
  • Infection control
    • Role of Centers for Disease Control and Prevention
    • Standard Precautions
      • Involve the use of barrier protection, such as gloves, goggles, gown, or mask, to prevent contamination from
        • Blood
        • All body fluids
        • Secretions and excretions except sweat, regardless of whether they contain visible blood
        • Nonintact skin
        • Mucous membrane
    • Transmission-based precautions
    • Airborne, droplet, and contact precautions
      • Airborne Precautions
        • In addition to Standard Precautions, use Airborne Precautions for patients known or suspected to have serious illnesses transmitted by airborne droplet nuclei. 
        • Examples of such illnesses include measles, varicella (including disseminated zoster), and tuberculosis.
      • Droplet Precautions
        • In addition to Standard Precautions, use Droplet Precautions for patients known or suspected to have serious illnesses transmitted by large-particle droplets. 
        • Examples of such illnesses include the following:
          • Invasive Haemophilus influenzae type b disease, including meningitis, pneumonia, epiglottitis, and sepsis
          • Invasive Neisseria meningitidis disease, including meningitis, pneumonia, and sepsis
          • Other serious bacterial respiratory tract infections spread by droplet transmission, including diphtheria (pharyngeal), mycoplasmal pneumonia, pertussis, pneumonic plague, streptococcal pharyngitis, pneumonia, and scarlet fever in infants and young children
          • Serious viral infections spread by droplet transmission, including adenovirus, influenza, mumps, parvovirus B19, and rubella
      • Contact Precautions
        • In addition to Standard Precautions, use Contact Precautions for patients known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient’s environment. 
        • Examples of such illnesses include the following:
          • Gastrointestinal, respiratory, skin, or wound infections or colonization with multidrug-resistant bacteria judged by the infection control program based on current state, regional, or national recommendations, to be of special clinical and epidemiologic significance
          • Enteric infections with a low infectious dose or prolonged environmental survival, including Clostridium difficile; for diapered or incontinent patients: enterohemorrhagic Escherichia coli O157:H7, Shigella organisms, hepatitis A, or rotavirus
          • Respiratory syncytial virus (RSV), parainfluenza virus, or enteroviral infections in infants and young children
          • Skin infections that are highly contagious or that may occur on dry skin, including diphtheria (cutaneous), herpes simplex virus (neonatal or mucocutaneous), impetigo, major (noncontained) abscesses, cellulitis or decubitus, pediculosis, scabies, staphylococcal furunculosis in infants and young children, zoster (disseminated or in the immunocompromised host)
      • Viral or hemorrhagic conjunctivitis
        • Viral hemorrhagic infections (Ebola, Lassa, or Marburg)
• Restraining methods
  • Alternative methods: Consider first
    • Diversional activities
    • Parental participation
    • Therapeutic holding
  • Use least restrictive 
  • Behavioral restraints
    • Used when significant risk present
    • Determine cause of behavior first
  • Mummy restraint or swaddle

• Structural manipulation and energetic therapies:
  • Acupressure, chiropractic medicine, massage, reflexology, rolfing, therapeutic touch, Qi Gong
• Pharmacologic and biologic therapies: 
  • Antioxidants, cell treatment, chelation therapy, metabolic therapy, oxidizing agents
• Bioelectromagnetic therapies: 
  • Diagnostic and therapeutic application of electromagnetic fields (e.g., transcranial electrostimulation, neuromagnetic stimulation, electroacupuncture)

• Hospital admission
  • Preadmission
    • Assign a room based on developmental age, seriousness of diagnosis, communicability of illness, and projected length of stay.
    • Prepare roommate(s) for the arrival of a new patient; when children are too young to benefit from this consideration, prepare parents.
    • Prepare room for child and family, with admission forms and equipment nearby to eliminate need to leave child.
  • Admission
    • Introduce primary nurse to child and family.
    • Orient child and family to inpatient facilities, especially to assigned room and unit; emphasize positive areas of pediatric unit.
    • Room: Explain call light, bed controls, television, bathroom, telephone, and so on.
    • Unit: Direct to playroom, desk, dining area, or other areas.
    • Introduce family to roommate and his or her parents.
    • Apply identification band to child’s wrist, ankle, or both (if not already done).
    • Explain hospital regulations and schedules (e.g., visiting hours, mealtimes, bedtime, limitations [give written information if available]).
    • Perform nursing admission history.
    • Take vital signs, blood pressure, height, and weight.
    • Obtain specimens as needed, and order needed laboratory work.
    • Support child and assist practitioner with physical examination (for purposes of nursing assessment).
• Special hospital admission
  • Emergency admission
    • Lengthy preparatory admission procedures are often impossible and inappropriate for emergency situations.
    • Focus assessment on airway, breathing, and circulation; weigh child whenever possible for calculation of drug dosages.
    • Unless an emergency is life-threatening, children need to participate in their care to maintain a sense of control.
    • Focus on essential components of admission counseling, including the following:
      • Appropriate introduction to the family
      • Use of child’s name, not terms such as “honey” or “dear”
      • Determination of child’s age and some judgment about developmental age (If the child is of school age, asking about the grade level will offer some evidence of intellectual ability.)
      • Information about child’s general state of health, any problems that may interfere with medical treatment (e.g., allergies), and previous experience with hospital facilities
      • Information about the chief complaint from both the parents and the child
  • Admission to Intensive Care Unit
    • Prepare child and parents for elective intensive care unit (ICU) admission, such as for postoperative care after cardiac surgery.
    • Prepare child and parents for unanticipated ICU admission by focusing primarily on the sensory aspects of the experience and on usual family concerns (e.g., people in charge of child’s care, schedule for visiting, area where family can stay).
    • Prepare parents regarding child’s appearance and behavior when they first visit child in ICU.
    • Accompany family to bedside to provide emotional support and answer questions.
    • Prepare siblings for their visit; plan length of time for sibling visitation; monitor siblings’ reactions during visit to prevent them from becoming overwhelmed.
    • Encourage parents to stay with their child:
      • If visiting hours are limited, allow flexibility in schedule to accommodate parental needs.
      • Give family members a written schedule of visiting times.
      • If visiting hours are liberal, be aware of family members’ needs and suggest periodic respites.
      • Assure family they can call the unit at any time.
    • Prepare parents for expected role changes, and identify ways for parents to participate in child’s care without overwhelming them with responsibilities:
      • Help with bath or feeding.
      • Touch and talk to child.
      • Help with procedures.
    • Provide information about child’s condition in understandable language:
      • Repeat information often.
      • Seek clarification of understanding.
      • During bedside conferences, interpret information for family members and child or, if appropriate, conduct report outside room.
    • Prepare child for procedures even if it involves explanation while procedure is performed.
    • Assess and manage pain; recognize that a child who cannot talk, such as an infant or child in a coma or on mechanical ventilation, can be in pain.
    • Establish a routine that maintains some similarity to daily events in child’s life whenever possible:
      • Organize care during normal waking hours.
      • Keep regular bedtime schedules, including quiet times when television or radio is lowered or turned off.
      • Provide uninterrupted sleep cycles (60 minutes for infants; 90 minutes for older children).
      • Close and open drapes and dim lights to allow for day and night.
      • Place curtain around bed for privacy.
      • Orient child to day and time; have clocks or calendars in easy view for older children.
    • Schedule a time when child is left undisturbed (e.g., during naps, visit with family, playtime, or favorite program).
    • Provide opportunities for play.
    • Reduce stimulation in the environment:
      • Refrain from loud talking or laughing.
      • Keep equipment noise to a minimum.
      • Turn alarms as low as safely possible.
      • Perform treatments requiring equipment at one time.
      • Turn off bedside equipment that is not in use, such as suction and oxygen.
      • Avoid loud, abrupt noises.

• Preventing or minimizing separation
  • Nurses must have an appreciation of the child’s separation behaviors.
    • The child is allowed to cry. 
  • Even if the child rejects strangers, the nurse provides support through physical presence.
  • The use of cellular phones can increase the contact between the hospitalized child and parents or other significant family members and friends.
• Preventing or minimizing parental absence
• Minimizing loss of control
  • Promoting freedom of movement
  • Maintaining child’s routine
  • Encouraging independence and industry
• Providing developmentally appropriate activities
• Providing opportunities for play and expressive activities
  • Functions of Play in the Hospital
    • Provides diversion and brings about relaxation
    • Helps the child feel more secure in a strange environment
    • Lessens the stress of separation and the feeling of homesickness
    • Provides a means for release of tension and expression of feelings
    • Encourages interaction and development of positive attitudes toward others
    • Provides an expressive outlet for creative ideas and interests
    • Provides a means for accomplishing therapeutic goals
    • Places the child in active role and provides opportunity to make choices and be in control
      • Diversional activities
      • Toys 
      • Expressive activities
      • Creative expression
      • Dramatic play
• Maximizing the potential benefits of hospitalization
  • Fostering parent-child relationships
  • Providing educational opportunities
  • Promoting self-mastery
  • Providing socialization

• Nursing care of the family
  • Supporting family members
    • Supporting Siblings During Hospitalization
    • Trade off staying at the hospital with spouse or have a surrogate who knows the siblings well stay in the home.
    • Offer information about the child’s condition to young siblings as well as older siblings; respect the sibling who avoids information as a means of coping with the situation.
    • Arrange for children to visit their brother or sister in the hospital if possible.
    • Encourage phone visits and mail between brothers and sisters; provide children with phone numbers, writing supplies, and stamps.
    • Help each sibling identify an extended family member or friend to be their support person and provide extra attention during parental absence.
    • Make or buy inexpensive toys or trinkets for siblings, one gift for each day the child will be hospitalized.
      • Wrap each gift separately, and place them in a basket, box, or other container at the child’s bedside.
      • Instruct siblings to open one gift at bedtime and to remember that he or she is in their parent’s thoughts.
    • If the child’s condition is stable and distance is not prohibitive, plan a special time at home with the siblings or have spouse or another relative or friend bring the children to meet parent(s) at a restaurant or other location near the hospital.
      • Have extended family members or friends schedule a visit to the child in the hospital during parental absence.
      • Arrange a pass for the child to leave the hospital to join the family if the child’s condition permits.
  • Providing information
    • The disease, its treatment, prognosis, and home care
    • The child’s emotional and physical reactions to illness and hospitalization
    • The probable emotional reactions of family members to the crisis.
  • Encouraging parent participation
  • Preparing for discharge and home care
    • In planning appropriate teaching, nurses need to assess 
      • The actual and perceived complexity of the skill
      • The parents’ or child’s ability to learn the skill
      • The parents’ or child’s previous or present experience with such procedures.

Family-Centered Care of the Child During Illness and Hospitalization

• Stressors of hospitalization and children’s reactions
  • Separation anxiety
    • Protest phase
      • Behaviors observed during later infancy include
        • Crying
        • Screaming
        • Searches for parent with eyes
        • Clinging to parent
      • Additional behaviors observed during toddlerhood
        • Verbally attacks strangers (e.g., “Go away”)
        • Physically attacks strangers (e.g., kicks, bites, hits, pinches)
        • Attempts to escape to find parent
        • Attempts to physically force parent to stay
      • Behaviors may last from hours to days.
      • Protest, such as crying, may be continuous, ceasing only with physical exhaustion.
      • Approach of stranger may precipitate increased protest.
    • Despair phase
      • Observed behaviors include
        • Is inactive
        • Withdraws from others
        • Is depressed, sad
        • Lacks interest in environment
        • Is uncommunicative
        • Regresses to earlier behavior (e.g., thumb sucking, bed-wetting, use of pacifier, use of bottle)
      • Behaviors may last for variable length of time.
      • Child’s physical condition may deteriorate from refusal to eat, drink, or move.
    • Detachment phase
      • Observed behaviors include
        • Shows increased interest in surroundings
        • Interacts with strangers or familiar caregivers
        • Forms new but superficial relationships
        • Appears happy
      • Detachment usually occurs after prolonged separation from parent; it is rarely seen in hospitalized children.
      • Behaviors represent a superficial adjustment to loss.
    • Effect of hospitalization on the child
      • Post-Hospital Behaviors in Children
        • Young Children
          • They show initial aloofness toward parents; this may last from a few minutes (most common) to a few days.
          • This is frequently followed by dependency behaviors:
            • Tendency to cling to parents
            • Demands for parents’ attention
            • Vigorous opposition to any separation (e.g., staying at preschool or with a babysitter)
          • Other negative behaviors include the following:
            • New fears (e.g., nightmares)
            • Resistance to going to bed, night waking
            • Withdrawal and shyness
            • Hyperactivity
            • Temper tantrums
            • Food peculiarities
            • Attachment to blanket or toy
            • Regression in newly learned skills (e.g., self-toileting)
        • Older Children
          • Negative behaviors include the following:
            • Emotional coldness followed by intense, demanding dependence on parents
            • Anger toward parents
            • Jealousy toward others (e.g., siblings)
      • Risk factors that increase children’s vulnerability to the stresses of hospitalization
        • “Difficult” temperament
        • Lack of fit between child and parent
        • Age (especially between 6 months and 5 years of age)
        • Male gender
        • Below-average intelligence
        • Multiple and continuing stresses (e.g., frequent hospitalizations)
  • Parental reactions
    • Factors affecting parents’ reactions to their child’s illness
      • Seriousness of the threat to the child
      • Previous experience with illness or hospitalization
      • Medical procedures involved in diagnosis and treatment
      • Available support systems
      • Personal ego strengths
      • Previous coping abilities
      • Additional stresses on the family system
      • Cultural and religious beliefs
      • Communication patterns among family members
      • Overall sense of helplessness
      • Questioning the skills of staff
      • Accepting the reality of hospitalization
      • Dealing with fear
      • Coping with uncertainty
      • Seeking reassurance
  • Sibling reactions
    • Experiencing many changes and being too young to understand them
    • Being cared for by nonrelatives or outside of the home
    • Receiving little information about the ill brother or sister
    • Perceiving that parents will treat the sick child differently

• Nursing care of the child who is hospitalized
  • Preparation for hospitalization
    • Preparing child for admission
      • Nursing admission history according to functional health patterns
        • Health Perception/Health Management Pattern
          • Why has your child been admitted?
          • How has your child’s general health been?
          • What does your child know about this hospitalization?
            • Ask the child why he or she came to the hospital.
            • If the answer is “For an operation or for tests,” ask the child to tell you about what will happen before, during, and after the operation or tests.
          • Has your child ever been in the hospital before?
            • How was that hospital experience?
            • What things were important to you and your child during that hospitalization? How can we be most helpful now?
          • What medications does your child take at home?
            • Why are they given?
            • When are they given?
            • How are they given (if a liquid, with a spoon; if a tablet, swallowed with water; or other)?
            • Does your child have any trouble taking medication? If so, what helps?
            • Is your child allergic to any medications?
          • What, if any, forms of complementary medicine practices are being used?
        • Nutrition/Metabolic Pattern
          • What is the family’s usual mealtime?
          • Do family members eat together or at separate times?
          • What are your child’s favorite foods, beverages, and snacks?
            • Average amounts consumed or usual size of portions
            • Special cultural practices, such as family eats only ethnic food
          • What foods and beverages does your child dislike?
          • What are your child’s feeding habits (bottle, cup, spoon, eats by self, needs assistance, any special devices)?
          • How does your child like the food served (warmed, cold, one item at a time)?
          • How would you describe your child’s usual appetite (hearty eater, picky eater)?
            • Has being sick affected your child’s appetite? In what ways?
          • Are there any known or suspected food allergies?
          • Is your child on a special diet?
          • Are there any feeding problems (excessive fussiness, spitting up, colic); any dental or gum problems that affect feeding?
            • What do you do for these problems?
        • Elimination Pattern
          • What are your child’s toileting habits (diaper, toilet trained—day only or day and night, use of word to communicate urination or defecation, potty chair, regular toilet, other routines)?
          • What is your child’s usual pattern of elimination (bowel movements)?
          • Do you have any concerns about elimination (bed-wetting, constipation, diarrhea)?
            • What do you do for these problems?
          • Have you ever noticed that your child sweats a lot?
        • Sleep/Rest Pattern
          • What is your child’s usual hour of sleep and awakening?
          • What is your child’s schedule for naps; length of naps?
          • Is there a special routine before sleeping (bottle, drink of water, bedtime story, night light, favorite blanket or toy, prayers)?
          • Is there a special routine during sleep time, such as waking to go to the bathroom?
          • What type of bed does your child sleep in?
          • Does your child have a separate room or share a room; if shares, with whom?
          • Does your child sleep with someone or alone (e.g., sibling, parent, other person)?
          • What is your child’s favorite sleeping position?
          • Are there any sleeping problems (falling asleep, waking during night, nightmares, sleep walking)?
          • Are there any problems in awakening and getting ready in the morning?
            • What do you do for these problems?
        • Activity/Exercise Pattern
          • What is your child’s schedule during the day (preschool, daycare center, regular school, extracurricular activities)?
          • What are your child’s favorite activities or toys (both active and quiet interests)?
          • What is your child’s usual television-viewing schedule at home?
          • What are your child’s favorite programs?
          • Are there any television restrictions?
          • Does your child have any illness or disabilities that limit activity? If so, how?
          • What are your child’s usual habits and schedule for bathing (bath in tub or shower, sponge bath, shampoo)?
          • What are your child’s dental habits (brushing, flossing, fluoride supplements or rinses, favorite toothpaste); schedule of daily dental care?
          • Does your child need help with dressing or grooming, such as hair combing?
          • Are there any problems with these patterns (dislike of or refusal to bathe, shampoo hair, or brush teeth)?
            • What do you do for these problems?
          • Are there special devices that your child requires help in managing (eyeglasses, contact lenses, hearing aid, orthodontic appliances, artificial elimination appliances, orthopedic devices)?
            • Note: Use the following code to assess functional self-care level for feeding, bathing and hygiene, dressing and grooming, toileting:
              • 0: Full self-care
              • I: Requires use of equipment or device
              • II: Requires assistance or supervision from another person
              • III: Requires assistance or supervision from another person and equipment or device
              • IV: Is totally dependent and does not participate
        • Cognitive/Perceptual Pattern
          • Does your child have any hearing difficulty?
            • Does the child use a hearing aid?
            • Have “tubes” been placed in your child’s ears?
          • Does your child have any vision problems?
            • Does the child wear glasses or contact lenses?
          • Does your child have any learning difficulties?
          • What is the child’s grade in school?
        • Self-Perception/Self-Concept Pattern
          • How would you describe your child (e.g., takes time to adjust, settles in easily, shy, friendly, quiet, talkative, serious, playful, stubborn, easygoing)?
          • What makes your child angry, annoyed, anxious, or sad? What helps?
          • How does your child act when annoyed or upset?
          • What have been your child’s experiences with and reactions to temporary separation from you (parent)?
          • Does your child have any fears (places, objects, animals, people, situations)?
            • How do you handle them?
          • Do you think your child’s illness has changed the way he or she thinks about himself or herself (e.g., more shy, embarrassed about appearance, less competitive with friends, stays at home more)?
        • Role/Relationship Pattern
          • Does your child have a favorite nickname?
          • What are the names of other family members or others who live in the home (relatives, friends, pets)?
          • Who usually takes care of your child during the day and night (especially if other than parent, such as babysitter, relative)?
          • What are the parents’ occupations and work schedules?
          • Are there any special family considerations (adoption, foster child, stepparent, divorce, single parent)?
          • Have any major changes in the family occurred lately (death, divorce, separation, birth of a sibling, loss of a job, financial strain, mother beginning a career, other)? Describe child’s reaction.
          • Who are your child’s play companions or social groups (peers, younger or older children, adults, or prefers to be alone)?
          • Do things generally go well for your child in school or with friends?
          • Does your child have “security” objects at home (pacifier, bottle, blanket, stuffed animal or doll)? Did you bring any of these to the hospital?
          • How do you handle discipline problems at home? Are these methods always effective?
          • Does your child have any condition that interferes with communication? If so, what are your suggestions for communicating with your child?
          • Will your child’s hospitalization affect the family’s financial support or care of other family members (e.g., other children)?
          • What concerns do you have about your child’s illness and hospitalization?
          • Who will be staying with your child while hospitalized?
          • How can we contact you or another close family member outside of the hospital?
        • Sexuality/Reproductive Pattern
          • (Answer questions that apply to your child’s age group.)
          • Has your child begun puberty (developing physical sexual characteristics, menstruation)? Have you or your child had any concerns?
          • Does your daughter know how to do breast self-examination?
          • Does your son know how to do testicular self-examination?
          • How have you approached topics of sexuality with your child?
          • Do you think you might need some help with some topics?
          • Has your child’s illness affected the way he or she feels about being a boy or a girl? If so, how?
          • Do you have any concerns with behaviors in your child, such as masturbation, asking many questions or talking about sex, not respecting others’ privacy, or wanting too much privacy?
          • Initiate a conversation about an adolescent’s sexual concerns with open-ended to more direct questions and using the terms “friends” or “partners” rather than “girlfriend” or “boyfriend”:
            • Tell me about your social life.
            • Who are your closest friends? (If one friend is identified, could ask more about that relationship, such as how much time they spend together, how serious they are about each other, if the relationship is going the way the teenager hoped.)
            • Might ask about dating and sexual issues, such as the teenager’s views on sexuality education, “going steady,” “living together,” or premarital sex.
            • Which friends would you like to have visit in the hospital?
        • Coping/Stress Tolerance Pattern
          • (Answer questions that apply to your child’s age group.)
          • What does your child do when tired or upset?
            • If upset, does your child want a special person or object?
            • If so, explain.
              • If your child has temper tantrums, what causes them, and how do you handle them?
          • Whom does your child talk to when worried about something?
          • How does your child usually handle problems or disappointments?
          • Have there been any big changes or problems in your family recently? If so, how have you handled them?
          • Has your child ever had a problem with drugs or alcohol or tried to commit suicide?
          • Do you think your child is “accident prone”? If so, explain.
        • Value/Belief Pattern
          • What is your religion?
          • How is religion or faith important in your child’s life?
          • What religious practices would you like continued in the hospital (e.g., prayers before meals or bedtime; visit by minister, priest, or rabbi; prayer group)?
        • Complementary medicine practices and examples
          • Nutrition, diet, and lifestyle or behavioral health changes:
            •  Macrobiotics, megavitamins, diets, lifestyle modification, health risk reduction and health education, wellness
          • Mind-body control therapies: 
            • Biofeedback, relaxation, prayer therapy, guided imagery, hypnotherapy, music or sound therapy, massage, aromatherapy, education therapy
          • Traditional and ethnomedicine therapies: 
            • Acupuncture, ayurvedic medicine, herbal medicine, homeopathic medicine, American Indian medicine, natural products, traditional Asian medicine

• Communication impairment
  • Autism spectrum disorders (ASD)
    • Neurodevelopmental disorders
    • Etiology—Unknown
    • Clinical manifestations and diagnostic evaluation
      • Deficits in social interactions, communication, and behavior
    • Prognosis
      • Can be improved or overcome
    • Care Management
      • Interprofessional care
      • Family support
      • Severely disabling condition
        • No cure for autism
      • Some improvement with language skills
      • Numerous therapies used
        • Recognize early
        • Attempt behavior modification
        • Provide a structured routine
        • Decrease unacceptable behavior
      • Autism often becomes a family disease
      • Frequently parents express guilt and shame
      • Stress importance of family counseling
      • Autism Society of America is good source of information 
      • Clients should be managed at home or in long-term placement facility

• Visual impairment
  • Common problem during childhood
    • In the United States, prevalence of blindness or serious visual impairment is 30 to 64 per 100,000
    • 5% to 10% of all preschoolers
    • Identified through vision screening programs
  • Etiology
    • Prenatal or postnatal infections
    • Retinopathy of prematurity
    • Types of visual impairment
      • Refractive Errors
        • Myopia
          • Nearsightedness: Ability to see objects clearly at close range but not at a distance
          • Pathophysiology
            • Results from eyeball that is too long, causing images to fall in front of the retina
          • Clinical Manifestations
            • Headaches
            • Dizziness
            • Excessive eye rubbing
            • Head tilt or forward head thrusts
            • Difficulty in reading or doing other close work
            • Clumsiness; walking into objects
            • Blinking more than usual or irritability when doing close work
            • Inability to see objects clearly
            • Poor school performance, especially in subjects that require demonstration, such as arithmetic
          • Treatment
            • Corrected with biconcave lenses that focus rays on retina
            • May be corrected with laser surgery
        • Hyperopia
          • Farsightedness: Ability to see objects at a distance but not at close range
          • Pathophysiology
            • Results from eyeball that is too short, causing image to focus beyond retina
          • Clinical Manifestations
            • Because of accommodative ability, child can usually see objects at all ranges
            • Most children are normally hyperopic until about 7 years of age
          • Treatment
            • When required, corrected with convex lenses that focus rays on retina
            • May be corrected with laser surgery
        • Astigmatism
          • Unequal curvatures in refractive apparatus
          • Pathophysiology
            • Results from unequal curvatures in cornea or lens that cause light rays to bend in different directions
          • Clinical Manifestations
            • Depend on severity of refractive error in each eye
            • Possible clinical manifestations of myopia
          • Treatment
            • Corrected with special lenses that compensate for refractive errors
            • May be corrected with laser surgery
        • Anisometropia
          • Different refractive strength in each eye
          • Pathophysiology
            • May develop amblyopia because weaker eye is used less
          • Clinical Manifestations
            • Depend on severity of refractive error in each eye
            • Possible clinical manifestations of myopia
          • Treatment
            • Treated with corrective lenses, preferably contact lenses, to improve vision in each eye so that they work as a unit
            • May be corrected with laser surgery
        • Amblyopia
          • Lazy eye: Reduced visual acuity in one eye
          • Pathophysiology
            • Results when one eye does not receive sufficient stimulation
            • Each retina receives different images, resulting in diplopia (double vision)
            • Brain accommodates by suppressing less intense image
            • Visual cortex eventually does not respond to visual stimulation, with resultant loss of vision in that eye
          • Clinical Manifestations
            • Poor vision in affected eye
          • Treatment
            • Preventable if treatment of primary visual defect, such as anisometropia or strabismus, begins before 6 years of age
        • Strabismus
          • “Squint” or malalignment of eyes
          • Esotropia: Inward deviation of eye
          • Exotropia: Outward deviation of eye
          • Pathophysiology
            • May result from muscle imbalance or paralysis, poor vision, or congenital defect
            • Because visual axes are not parallel, brain receives two images, and amblyopia can result
          • Clinical Manifestations
            • Squints eyelids together or frowns
            • Difficulty in focusing from one distance to another
            • Inaccurate judgment in picking up objects
            • Inability to see print or moving objects clearly
            • Closing one eye to see
            • Tilting head to one side
            • If combined with refractive errors, may see any of the manifestations listed for refractive errors
            • Diplopia
            • Photophobia
            • Dizziness
            • Headaches
          • Treatment
            • Depends on cause of strabismus
            • May involve occlusion therapy (patching stronger eye) or surgery to increase visual stimulation to weaker eye
            • Early diagnosis essential to prevent vision loss
        • Cataracts
          • Opacity of crystalline lens
          • Pathophysiology
            • Prevents light rays from entering eye and refracting on retina
          • Clinical Manifestations
            • Gradual decrease in ability to see objects clearly
            • Possible loss of peripheral vision
            • Nystagmus (with permanent visual impairment)
            • Gray opacities of lens
            • Strabismus
            • Absence of red reflex
          • Treatment
            • Requires surgery to remove cloudy lens and replace lens (with intraocular lens implant, removable contact lens, prescription glasses)
            • Must be treated early to prevent permanent visual impairment from amblyopia
        • Glaucoma
          • Increased intraocular pressure
          • Pathophysiology
            • Congenital type results from defective development of some component related to flow of aqueous humor
            • Increased pressure on optic nerve causes eventual atrophy and severe permanent visual impairment
          • Clinical Manifestations
            • Loss of peripheral vision—mostly seen in acquired types
            • Possible bumping into objects
            • Perception of halos around objects
            • Possible complaint of pain or discomfort (severe pain, nausea, or vomiting if sudden rise in pressure)
            • Eye redness
            • Excessive tearing (epiphora)
            • Photophobia
            • Spasmodic winking (blepharospasm)
            • Corneal haziness
            • Enlargement of eyeball (buphthalmos)
          • Treatment
            • Requires surgical treatment (goniotomy) to open outflow tracts
            • May require more than one procedure
    • Trauma
      • Penetrating wounds are most often a result of sharp instruments (e.g., sticks, knives, or scissors) or propulsive objects (e.g., firecrackers, guns, arrows, or slingshots). 
      • Nonpenetrating injuries may be a result of foreign objects in the eyes, lacerations, a blow from a blunt object such as a ball (baseball, softball, basketball, racquet sports) or fist, or thermal or chemical burns
      • Treatment is aimed at preventing further ocular damage and is primarily the responsibility of the ophthalmologist
      • It involves 
        • Adequate examination of the injured eye (with the child sedated or anesthetized in severe injuries)
        • Appropriate immediate intervention, such as removal of the foreign body or suturing of the laceration
        • Prevention of complications, such as administration of antibiotics or steroids and complete bed rest to allow the eye to heal and blood to reabsorb
      • Eye injuries
        • Foreign Object
          • Examine eye for presence of a foreign body (evert upper eyelid to examine upper eye).
          • Remove a freely movable object with pointed corner of gauze pad lightly moistened with water.
          • Do not irrigate eye or attempt to remove a penetrating object
          • Caution child against rubbing eye.
        • Chemical Burns
          • Irrigate eye copiously with tap water for 20 minutes.
          • Evert upper eyelid to flush thoroughly.
          • Hold child’s head with eye under a tap of running lukewarm water.
          • Take child to emergency department.
          • Have child rest with eyes closed.
          • Keep room darkened.
        • Ultraviolet Burns
          • If skin is burned, patch both eyes (make certain eyelids are completely closed); secure dressing with Kling bandages wrapped around head rather than with tape.
          • Have child rest with eyes closed.
          • Refer to an ophthalmologist.
        • Hematoma (“Black Eye”)
          • Use a flashlight to check for gross hyphema (hemorrhage into anterior chamber; visible fluid meniscus across iris; more easily seen in light-colored than in brown eyes).
          • Apply ice for first 24 hours to reduce swelling if no hyphema is present.
          • Refer to an ophthalmologist immediately if hyphema is present.
          • Have child rest with eyes closed.
        • Penetrating Injuries
          • Take child to emergency department.
          • Never remove an object that has penetrated eye.
          • Follow strict aseptic technique in examining eye.
          • Observe for:
            • Aqueous or vitreous leaks (fluid leaking from point of penetration)
            • Hyphema
            • Shape and equality of pupils, reaction to light, prolapsed iris (not perfectly circular)
          • Apply a Fox shield if available (not a regular eye patch) and apply patch over unaffected eye to prevent bilateral movement.
          • Maintain bed rest with child in a 30-degree Fowler’s position.
          • Caution child against rubbing eye.
          • Refer to an ophthalmologist.
    • Postnatal infections
      • The most common eye infection is conjunctivitis.
        • Treatment is usually with ophthalmic antibiotics. 
        • Severe infections may require systemic antibiotic therapy. 
        • Steroids are used cautiously because they exacerbate viral infections such as herpes simplex, increasing the risk for damage to the involved structures
      • Care management
        • Assessment involves 
          • Identifying those children who by virtue of their history are at risk
          • Observing for behaviors that indicate a vision loss
          • Screening all children for visual acuity and signs of other ocular disorders such as strabismus.
        • Nursing alert
          • Suspect visual impairment in a child of any age whose pupils do not react to light
          • Promote parent-child attachment
          • Promote child’s optimal development 
          • Development and independence
          • Play and socialization
          • Education
            • Braille
            • Audio books and learning materials
    • Other disorders
      • Sickle cell disease
      • Juvenile rheumatoid arthritis
      • Tay-Sachs disease

• Down Syndrome
  • Most common chromosome abnormality 
    • 1 per 691 to 1000 live births
    • Causes unknown; probably multiple
    • Occurs in populations of all races
  • Etiology
    • Nonfamilial trisomy 21 
      • Extra chromosome 21 in 95% of cases
    • Maternal age
      • Age 35: Risk is 1 per 350 births
      • Age 40: Risk is 1 per 100 births
  • Diagnostic Evaluation
    • Clinical manifestations
      • Head and Eyes
        • Separated sagittal suture
        • Brachycephaly
        • Rounded and small skull
        • Flat occiput
        • Enlarged anterior fontanel
        • Oblique palpebral fissures (upward, outward slant)
        • Inner epicanthal folds
        • Speckling of iris (Brushfield spots)
      • Nose and Ears
        • Small nose
        • Depressed nasal bridge (saddle nose)
        • Small ears and narrow canals
        • Short pinna (vertical ear length)
        • Overlapping upper helices
        • Conductive hearing loss
      • Mouth and Neck
        • High, arched, narrow palate
        • Protruding tongue
        • Hypoplastic mandible
        • Delayed teeth eruption and microdontia
        • Abnormal teeth alignment common
        • Periodontal disease
        • Neck skin excess and laxity
        • Short and broad neck
      • Chest and Heart
        • Shortened rib cage
        • Twelfth rib anomalies
        • Pectus excavatum or carinatum
        • Congenital heart defects common (e.g., atrial septal defect, ventricular septal defect)
      • Abdomen and Genitalia
        • Protruding, lax, and flabby abdominal muscles
        • Diastasis recti abdominis
        • Umbilical hernia
        • Small penis
        • Cryptorchidism
        • Bulbous vulva
      • Hands and Feet
        • Broad, short hands and stubby fingers
        • Incurved little finger (clinodactyly)
        • Transverse palmar crease
        • Wide space between big and second toes
        • Plantar crease between big and second toes
        • Broad, short feet and stubby toes
      • Musculoskeletal and Skin
        • Short stature
        • Hyperflexibility and muscle weakness
        • Hypotonia
        • Atlantoaxial instability
        • Dry, cracked, and frequent fissuring
        • Cutis marmorata (mottling)
      • Physical problems
        • Reduced birth weight
        • Learning difficulty (average intelligence quotient [IQ] of 50)
        • Hypothyroidism common
        • Impaired immune function
        • Increased risk for leukemia
        • Early-onset dementia (in one-third)
  • Therapeutic management
    • Available therapies
      • Surgery to correct congenital anomalies
      • Evaluation of hearing and sight
      • Periodic testing of thyroid function
    • Nursing alert
      • Persistent neck pain
      • Loss of established motor skills and bladder or bowel control
      • Changes in sensation
    • Prognosis
      • Life expectancy for those with Down syndrome has improved in recent years but remains lower than for the general population. 
      • Many individuals with Down syndrome survive to 60 years of age and beyond
      • As the prognosis continues to improve for these individuals, it will be important to provide for their long-term health care and social and leisure needs.
    • Care management
      • Supporting child’s family at time of diagnosis
        • Infants with Down syndrome are usually diagnosed at birth
          • Parents should be informed of the diagnosis at this time
          • Parental responses to the child may greatly influence decisions regarding future care. 
            • Some families willingly take the child home 
            • Others consider foster care or adoption. 
          • The nurse must answer questions regarding developmental potential carefully because the responses may influence the parents’ decision. 
          • The nurse should share the available informative sources (e.g., parent groups, professional counseling, and literature) to help the family learn about Down syndrome
      • Preventing of physical problems
        • Parents perceive hypotonicity of muscles and hyperextensibility of joints, almost flaccid extremities resemble the posture of a rag doll to their bodies as evidence of inadequate parenting. 
        • The extended body position promotes heat loss, because more surface area is exposed to the environment. 
        • Encourage the parents to swaddle or wrap the infant snugly in a blanket before picking up the child to provide security and warmth. 
        • The nurse also discusses with parents their feelings concerning attachment to the child, emphasizing that the child’s lack of clinging or molding is a physical characteristic and not a sign of detachment or rejection.
        • Decreased muscle tone compromises respiratory expansion. 
          • The underdeveloped nasal bone causes a chronic problem of inadequate drainage of mucus.
          • The constant stuffy nose forces the child to breathe by mouth, which dries the oropharyngeal membranes, increasing the susceptibility to upper respiratory tract infections.
          • Inadequate drainage resulting in pooling of mucus in the nose also interferes with feeding. 
            • Because the child breathes by mouth, sucking for any length of time is difficult. 
          • When eating solids, the child may gag on the food because of mucus in the oropharynx.
          • Parents are advised to clear the nose before each feeding; give small, frequent feedings; and allow opportunities for rest during mealtime.
        • Parents need to know that the tongue thrust is not an indication of refusal to feed but a physiologic response. 
        • Parents are advised to use a small but long, straight-handled spoon to push the food toward the back and side of the mouth.
        • Dietary intake needs supervision. 
          • Decreased muscle tone affects gastric motility, predisposing the child to constipation. 
          • Dietary measures, such as increased fiber and fluid, promote evacuation.
          • The child’s eating habits may need scrutiny to prevent obesity. 
          • Height and weight measurements should be obtained on a serial basis.
      • Assist in prenatal diagnosis and genetic counseling
        • Offer prenatal testing and genetic counseling to women of advanced maternal age and those who have a family history of the disorder.

The Child with a Chronic or Complex Condition

• Developmental aspects

• Coping mechanisms
  • Children with more positive and accepting attitudes about their chronic illness use a more adaptive coping style characterized by optimism, competence, and compliance.
  • Coping patterns used by children with special needs
    • Develops competence and optimism: 
      • Accentuates the positive aspects of the situation and concentrates more on what he or she has or can do than on what is missing or on what he or she cannot do; is as independent as possible
    • Feels different and withdraws: 
      • Sees self as being different from other children because of the chronic health condition; views being different as negative; sees self as less worthy than others; focuses on things he or she cannot do, and sometimes over-restricts activities needlessly
    • Is irritable, is moody, and acts out: 
      • Uses proactive and self-initiated coping behaviors, although usually counterproductive in that the behaviors are not ego enhancing or socially responsible and do not result in desired outcomes; acts out irritability, which may or may not be associated with condition’s symptoms
    • Complies with treatment: 
      • Takes necessary medications, treatments; adheres to activity restrictions; also uses behaviors that indicate developing independence (e.g., assumes responsibility for taking medication)
    • Seeks support: 
      • Talks with adults, children, physicians, and nurses; develops plans to handle problems as they occur; uses downward comparison (i.e., realizes that others have it worse)
  • Hopefulness
    • Hopefulness is an internal quality that mobilizes humans into goal-directed action that may be satisfying and life sustaining.
  • Health education and self-care
    • Children need information about their condition, the therapeutic plan, and how the disease or the therapy might affect their situation. 
    • Children nearing puberty also need to understand the maturation process and how their chronic illness may alter this event.
• Responses to parental behavior
  • Parental behavior toward the child is one of the most important factors influencing the child’s adjustment. 
  • Children’s perceptions of their mothers’ support and maternal perceptions of the psychosocial impact of the child’s chronic illness on the family were shown to be two of the greatest predictors of children’s psychologic adjustment
• Type of illness or condition
  • The type of illness or condition also influences the child’s emotional response. 
  • Interestingly, children with more severe disorders often cope better than those with milder conditions.
  • Children’s cognitive ability and the timing of onset of abstract thinking in adolescence, an obvious condition may be easier for them to accept because its limitations are concrete.
  • The onset of a disabling condition may generate a state of confusion for children, who may have trouble differentiating between actual bodily functions and their image of their bodies.
  • They may also experience problems in identifying themselves and those extensions of self (e.g., wheelchairs, braces, crutches, other mechanical or prosthetic devices) and may have difficulty in accepting functional aids.

Nursing Care of the family and child with a chronic or complex condition

• Assessment
  • Affecting of factors affecting family adjustment

• Provide support at the time of diagnosis
  • Situations requiring special consideration
    • Congenital Anomaly
      • Tension in the delivery room conveys the sense that something is seriously wrong. Communication is often delayed while the physician is involved with the mother’s care. The way the infant is presented may well set the tone for the early parent-child relationship.
      • Clarify role with physician regarding revealing information to enable immediate parental support.
      • Explain to parents briefly in simple language what the defect is and something concerning the immediate prognosis before showing them the infant. Later more information can be given when they are more ready to “hear” what is said.
      • Be aware of nonverbal communication. Parents watch facial expressions of others for signs of revulsion or rejection.
      • Present infant as something precious.
      • Emphasize well-formed aspects of infant’s body.
      • Allow time and opportunity for parents to express their initial response.
      • Encourage parents to ask questions, and provide honest, straightforward answers without undue optimism or pessimism.
    • Cognitive Impairment
      • Unless cognitive impairment (or mental retardation) is associated with other physical problems, it is often easy for parents to miss clues to its presence or to make defensive excuses regarding the diagnosis.
      • Plan situations that help parents become aware of the problem. 
      • Encourage parents to discuss their observations of child but withhold diagnostic opinions.
      • Focus on what the child can do and appropriate interventions to promote progress (e.g., infant stimulation programs) to involve parents in their child’s care while helping them gain an awareness of the child’s condition.
    • Physical Disability
      • If loss of motor or sensory ability occurs during childhood, the diagnosis is readily apparent. The challenge lies in helping the child and parents over the period of shock and grief and toward the phase of acceptance and reintegration.
      • Institute early rehabilitation (e.g., using a prosthetic limb, learning to read braille, learning to read lips).
      • Be aware that physical rehabilitation usually precedes psychologic adjustment.
      • When the cause of the disability is accidental, avoid implying that parents or child was responsible for the injury, but allow them the opportunity to discuss feelings of blame.
      • Encourage expression of feelings
    • Chronic Illness
      • Realization of the true impact may take months or years. Conflict over parents versus child’s concerns may result in serious problems. When condition is inherited, parents may blame themselves, or child may blame the parents.
      • Help each family member gain an appreciation of the others’ concerns.
      • Discuss hereditary aspect of condition with parents at time of diagnosis to lessen guilt and accusatory feelings.
      • Encourage child to express feelings by using third-person technique (e.g., “Sometimes when a person has an illness that was passed on by the parents, that person feels angry or bitter toward them”).
    • Multiple Disabilities
      • The child or parent may require additional time for the shock phase and may be able to attend to only one diagnosis before hearing significant information regarding other disorders.
      • Acknowledge parents’ understanding and acceptance of all diagnoses, especially when an obvious and more hidden disability coexists.
      • Appreciate the devastating consequences of more than one disability for a child, especially if they interfere with expressive-receptive abilities.
    • Terminal Illness
      • Parents require much support to deal with their own feelings and guidance in how to tell the child the diagnosis. They may want to conceal the diagnosis from the child. They may believe that the child is too young to know, will not be able to cope with the information, or will lose hope and the will to live.
      • Approach the subject of disclosure in a positive way by asking, “How will you tell your child about the diagnosis?” Help parents understand the disadvantages of not telling the child (e.g., deprives child of the opportunity to discuss feelings openly and ask questions, incurs the risk of child learning the truth from outside and sometimes less tactful sources, may lessen child’s trust and confidence in the parents after learning the truth).
      • Guide parents to see the potential problems involved in fostering a conspiracy.
      • Offer parents guidelines for how and what to tell the child about the disease or the possibility of death. Explanations should be tailored to child’s cognitive ability, be based on knowledge child already has, and be honest. Honesty must be tempered with concern for child’s feelings.
      • Assure parents that telling a child the name of the illness and the reason for treatment instills hope, provides support from others, and serves as a foundation for explaining and understanding subsequent events.
      • Acknowledge that being honest is not always easy because the truth may prompt the child to ask other distressing questions, such as “Am I going to die?” However, even this difficult question must be answered.
• Supporting family’s coping methods
  • Parents
    • Developing successful parent-professional partnerships
      • Promote primary nursing; in nonhospital settings, designate a case manager.
      • Acknowledge parents’ overall competence and their unique expertise with their child.
      • Respect parents’ time as having value equal to that of other members of child’s health care team.
      • Explain or define any medical, technical, or discipline-specific terms.
      • Tell families, “I am not sure” or “I don’t know” when appropriate.
      • Facilitate family’s effectiveness in team meetings (e.g., provide parents with same information as other participants).
    • Parents can be encouraged to discuss their feelings toward the child, the impact of this event on their marriage, and associated stresses such as financial burdens. 
    • For most families, regardless of their income or insurance coverage, financial concerns exist. 
    • The costs of caring for a child with special needs can be overwhelming.
    • One or both parents may have to sacrifice job opportunities to remain close to a medical facility or to avoid losing insurance benefits. 
    • Numerous volunteer and community resources are available that provide assistance, rehabilitation, equipment, and funding for a variety of health problems. 
    • National and local disease-oriented organizations may provide needed assistance and support to families that qualify.
  • • Parent-to-parent support
      • Just being with another parent who has shared similar experiences is helpful. 
        • It may not need to be a parent of a child with the same diagnosis, because parents in the process of adjusting to a child with special needs—or finding respite services, educational or rehabilitative services, special equipment vendors, and financial counseling—tread a common path.
      • Another strategy is to ask another parent to talk to the parents. 
        • The nurse should seek out a parent who is a good listener, has a nonjudgmental approach to differences in families, and possesses good advocacy and problem-solving skills.
      • Parent groups are rich resources for information. 
        • Nurses can assist in starting a group by identifying one or two parents as leaders; sharing with them the names, telephone numbers, and addresses of other families who have expressed both an interest and a willingness to release their phone number and address; and guiding them in how to initiate a first meeting.
    • Advocate for empowerment
      • Nurses can advocate for methods that foster opportunities for parent empowerment.
        • Nurses can suggest reimbursement for travel and child care plus stipends to enable parents’ voices to be heard at meetings and conferences.
  • The child
    • Through ongoing contacts with the child, the nurse 
      • Observes the child’s responses to the disorder, ability to function, and adaptive behaviors within the environment and with significant others
      • Explores the child’s own understanding of his or her illness or condition 
      • Provides support while the child learns to cope with his or her feelings
    • Children are encouraged to express their concerns rather than allowing others to express them for them because open discussions may reduce anxiety
    • Encouraging expression of emotion
      • Describe the behavior: 
        • “You seem angry at everyone.”
      • Give evidence of understanding: 
        • “Being angry is only natural.”
      • Give evidence of caring: 
        • “It must be difficult to endure so many painful procedures.”
      • Help focus on feelings: 
        • “Maybe you wonder why this happened to you.”
    • Promoting normalization
      • Preparation: 
        • Prepare child in advance for changes that may occur from the chronic or complex condition.
          • Tell the child in advance the possible side effects of drug therapy.
      • Participation: 
        • Include child in as many decisions as possible, especially those relating to his or her care regimen.
          • The child is responsible for taking medications or scheduling home treatments.
      • Sharing: 
        • Allow both family members and child’s peers to be a part of the care regimen whenever possible.
          • Give the child his or her medication when the other siblings receive their vitamins.
        • The parent cooks the same menu for the whole family.
        • If the child is invited to another’s home, the parent advises the family of the child’s dietary restrictions.
      • Control: 
        • Identify areas where child can be in control so that feelings of uncertainty, passivity, and helplessness are decreased.
          • The child identifies activities that are appropriate to his or her energy level and chooses to rest when fatigued.
      • Expectation: 
        • Apply the same family rules to the child with a complex chronic illness as to the well siblings or peers.
          • The child is disciplined, is expected to fulfill household responsibilities, and attends school in accordance with abilities.
  • Siblings
    • The presence of a child with special needs in a family may result in parents paying less attention to the other children. 
    • Siblings may respond by developing negative attitudes toward the child or by expressing anger in different forms. 
    • The nurse can help by using anticipatory guidance, questioning the parents about what they believe is the best way to have siblings respond to the child, and guiding them through ways to meet their other children’s needs for attention.
    • Siblings may also experience embarrassment associated with having a brother or sister with a chronic or complex condition.
    • Parents are then faced with the difficulty of responding to this embarrassment in an understanding and appropriate manner without punishing the siblings for how they feel. Parents are encouraged to talk with the siblings about how they view their affected sibling. 
      • Siblings of a child with developmental disabilities may express fears about their ability to bear normal children.
      • Many siblings benefit from sharing their concerns with other young people who are experiencing a similar situation. 
      • Support groups for siblings can help decrease isolation, promote expression of feelings, and provide examples of effective coping skills.
• Educating about the disorder and general health care
  • Activities of daily living
    • Possible differences in nutritional requirements
    • Common problems are undernutrition resulting from food being 
      • Inappropriately restricted or loss of appetite
      • Vomiting or motor deficits that interfere with feeding
      • Overnutrition
        • Due to caloric intake in excess of energy expenditure because of boredom and lack of stimulation in other areas
  • Safe transportation
    • Modification regarding car safety
  • Primary health care
    • All the usual health care
    • Communication in an emergency
• Promote Normal Development
  • Early childhood
    • Basic trust, separation from parents, beginning independence
      • Characteristics of parental overprotection
        • Sacrifices self and rest of family for the child
        • Continually helps the child, even when the child is capable
        • Is inconsistent with regard to discipline or uses no discipline; frequently applies different rules to the siblings
        • Is dictatorial and arbitrary, making decisions without considering
        • the child’s wishes, such as keeping the child from attending school
        • Hovers and offers suggestions; calls attention to every activity; overdoes praise
        • Protects the child from every possible discomfort
        • Restricts play, often because of fear that the child will be injured
        • Denies the child opportunities for growing up and assuming responsibility, such as learning to give own medications or perform treatments
        • Does not understand the child’s capabilities, and sets goals too high or too low
        • Monopolizes the child’s time, such as sleeping with the child, permitting few friends, or refusing participation in social or educational activities
  • School age
    • Industry/activity
      • Preparation for entry into or resumption of school is best accomplished through a team approach with the parents, child, teacher, school nurse, and primary nurse in the hospital. Ideally, this planning should begin before hospital discharge, provided that the child is well enough to resume usual activities.
      • They need preparation before entering or resuming school. 
        • Having a tutor in the hospital or home as soon as children are physically able helps them realize that school will continue and gives them time to consider this prospect
      • Children need the opportunity to interact with healthy peers and to engage in activities with groups or clubs composed of similarly affected agemates.
  • Adolescence
    • Developing independence/autonomy
      • Redefining autonomy in terms of individuals’ capacities to take responsibility for their own behavior, to make decisions regarding their own lives, and to maintain supportive social relationships.
• Establish realistic future goals
  • Cultivate realistic vocations for the child with chronic illness or disabilities
  • Prolonged survival leads to new decisions and problems
    • Independent living
    • Marriage, employment, insurance coverage
    • Reproductive decisions

Principles of palliative care

• Principles of palliative care
  • The World health Organization amended the definitive of palliative care for children to include the following:
    • Palliative care for children is the active total care of the child’s body, mind, and spirit and involves giving support to the family.
    • It begins when illness is diagnosed and continues regardless of whether or not a child receives treatment directed at the disease.
    • Health care providers must evaluate and alleviate the child’s physical, psychologic, and social distress.
    • Effective palliative care requires a broad multidisciplinary approach that includes the family and makes use of available community resources; it can be successfully implemented even if resources are limited.
    • It can be provided in tertiary care facilities, in community health centers, and even in children’s homes.
  • Pain and symptom management
• Decision-making at end of life
  • Ethical considerations
  • Physicians, health care team
  • Parents
  • The dying child
    • Children’s understanding of and reactions to death

• Treatment options for terminally ill children
  • Hospital
    • Families may choose to remain in the hospital to receive care if the child’s illness or condition is unstable and home care is not an option or the family is uncomfortable with providing care at home.
    • Families are encouraged to bring familiar items from the child’s room at home.
      • There should be a consistent and coordinated care plan for the comfort of the child and family.
  • Home care
    • Home care is often the option chosen by physicians and families because of the traditional view that a child must be considered to have a life expectancy of less than 6 months to be referred to hospice care.
  • Hospice
    • Parents should be offered the option of caring for their child at home during the final phases of an illness with the assistance of a hospice organization
    • Hospice is a community health care organization that specializes in the care of dying patients by combining the hospice philosophy with the principles of palliative care
    • Families may continue to see their primary care physicians as they choose
    • Hospice care is based on several important concepts that significantly set it apart from hospital care:
      • Family members are usually the principal caregivers and are supported by a team of professional and volunteer staff.
      • The priority of care is comfort. The child’s physical, psychosocial, and spiritual needs are considered. Pain and symptom control are primary concerns, and no extraordinary efforts are used to attempt a cure or prolong life.
      • The family’s needs are as important as those of the patient.
      • Hospice is concerned with the family’s post-death adjustment, and care may continue for 1 year or longer.

Nursing care of the child and family at end of life

• Regardless of where the child is cared for during the terminal stage of illness, both the child and the family usually experience fear of
  • Pain and suffering
  • Dying alone (child) or not being present when the child dies (parent)
  • Actual death
• Fear of pain and suffering
  • Pain and symptom management
    • Ethical principle of double effect
      • An action that has one good (intended) and one bad (unintended but foreseeable) effects is permissible if the following conditions are met:
        • The action itself must be good or indifferent. Only the good consequences of the action must be sincerely intended.
        • The good effect must not be produced by the bad effect.
        • There must be a compelling or proportionate reason for permitting the foreseeable bad effect to occur.
  • Parents’ and siblings’ need for education and support
    • This empowers parents and provides a sense of control over the child’s comfort and well-being, reducing their fear that their child will be in pain or suffering as he or she is dying.
      • Better bereavement outcomes (e.g., adaptive coping, family cohesion, and less anxiety, stress, and depression) have been reported by parents who were actively involved in the care of their child
    • Nurses can assist the family by helping the parents identify ways to involve siblings in the caring process, perhaps by bringing some supplies or a favorite toy, game, or food item. 
      • Parents should also be encouraged to schedule time focusing on the siblings.
      • Helping parents identify a trusted friend or family member who can sit with the ill child for a short period will allow them to attend to their own needs or those of their other children.
• Fear of dying alone or of not being present when the child dies
  • When a child is being cared for at home, the burden of care on parents and family members can be great. 
    • Often, as the child’s condition declines, family members begin the “death vigil.” 
    • Rarely is a child left alone for any length of time. 
  • This can be exhausting for family members, and nurses can assist the family by helping them arrange shifts so that friends or family members can be present with the child and allow others to rest. 
  • If the family has limited resources, community organizations, such as hospice or churches, often have volunteers who are willing to visit and sit with children. 
  • It is important that whoever is sitting with the child be aware of when the parent(s) would like to be notified to return to the child’s bedside
  • When a child is dying in the hospital, the parents should be always given full access to the child.
  • If the parents need to leave, they should be provided with a pager or other means of immediate communication and alerted if staff members note any change in the child that may indicate imminent death. 
  • Nurses should advocate for parents’ presence in intensive care and emergency departments and attend to the parents’ needs for food, drinks, comfortable chairs, blankets, and pillows.
• Fear of actual death
  • Home deaths
    • Physical signs of approaching death
      • Loss of sensation and movement in the lower extremities, progressing toward the upper body
      • Sensation of heat, although the body feels cool
      • Loss of senses:
        • Tactile sensation decreasing
        • Sensitivity to light
        • Hearing the last sense to fail
      • Confusion, loss of consciousness, slurred speech
      • Muscle weakness
      • Loss of bowel and bladder control
      • Decreased appetite and thirst
      • Difficulty swallowing
      • Change in respiratory pattern:
        • Cheyne-Stokes respirations (waxing and waning of depth of breathing with regular periods of apnea)
        • “Death rattle” (noisy chest sounds from accumulation of pulmonary and pharyngeal secretions)
      • Weak, slow pulse; decreased blood pressure
  • Hospital deaths
    • Children dying in the hospital who are receiving supportive care interventions experience a similar process. 
    • Death resulting from accident or trauma or acute illness in settings such as the emergency department or intensive care unit, often requires the active withdrawal of some form of life-supporting intervention, such as a ventilator or bypass machine.
    • These situations often raise difficult ethical issues, and parents are often less prepared for the actual moment of death.
    • Nurses can assist these parents by providing detailed information about what will happen as supportive equipment is withdrawn, ensuring that appropriate pain medications are administered to prevent pain during the dying process and allowing the parents time before the start of the withdrawal to be with and speak to their child.
    • It is important that the nurse attempt to control the environment around the family at this time by providing privacy, asking if they would like to play music, softening lights and monitor noises, and arranging for any religious or cultural rituals that the family may want performed.

Organ or tissue donation and autopsy

• Meaningfulness of acting to benefit another human being
• Common questions asked by families
• Sensitive approach
• Organ donation: Legislated in many states
• Unexplained or violent death
  • Autopsy may be required by law

• Grief and Mourning
  • Grief: A process
  • Highly individualized
    • Parental grief
      • Along with experience the primary loss of their child, many secondary losses are felt, such as 
        • The loss of part of oneself
        • Hopes and dreams for the child’s future
        • The family unit
        • Prior social and emotional community supports
        • Often spousal support.
      • Studies with bereaved parents have shown that grieving does not end with the severing of the bond with the deceased child but rather involves a continuing bond between the parent and the deceased child
      • Parental resolution of grief is a process of integrating the dead child into daily life in which the pain of losing a child is never completely gone but lessens
      • A child’s death can also challenge the marital relationship in several ways. 
      • Maternal and paternal reactions often differ
    • Sibling grief
      • Children grieve differently than adults
        • Their understanding and reactions to death depend on their age and developmental level.
        • Children grieve for a longer duration, revisiting their grief as they grow and develop new understandings of death. 
          • They do not grieve 100% of the time. 
          • They grieve in spurts and can be emotional and sad in one instance and then, just as quickly, off and playing.
          • Children express their grief through play and behavior.
          • Children can be exquisitely attuned to their parents’ grief and will try to protect them by not asking questions or by trying not to upset them. 
          • This can set the stage for the sibling to try to become the “perfect child.”
        • Children exhibit many of the grief reactions of adults, including physical sensations and illnesses, anger, guilt, sadness, loneliness, withdrawal, acting out, sleep disturbances, isolation, and search for meaning. 
      • Nurses should be attentive for signs that siblings are struggling with their grief and provide guidance to parents when possible.
  • Supporting grieving families
    • General
      • Stay with the family; sit quietly if they prefer not to talk; cry with them if desired.
      • Accept the family’s grief reactions; avoid judgmental statements (e.g., “You should be feeling better by now”).
      • Avoid offering rationalizations for the child’s death (e.g., “Your child isn’t suffering anymore”).
      • Avoid artificial consolation (e.g., “I know how you feel,” or “You are still young enough to have another baby”).
      • Deal openly with feelings such as guilt, anger, and loss of self-esteem.
      • Focus on feelings by using a feeling word in the statement (e.g., “You’re still feeling all the pain of losing a child”).
      • Refer the family to an appropriate self-help group or for professional help if needed.
    • At the time of death
      • Reassure the family that everything possible is being done for the child if they want lifesaving interventions.
      • Do everything possible to ensure the child’s comfort, especially relieving pain.
      • Provide the child and family with the opportunity to review special experiences or memories in their lives.
      • Express personal feelings of loss or frustration (e.g., “We will miss him so much,” “We tried everything; we feel so sorry that we couldn’t save her”).
      • Provide information that the family requests and be honest.
      • Respect the emotional needs of family members, such as siblings, who may need brief respites from the dying child.
      • Make every effort to arrange for family members, especially the parents, to be with the child now of death if they want to be present.
      • Allow the family to stay with the dead child for as long as they wish and to rock, hold, or bathe the child.
      • Provide practical help when possible, such as collecting the child’s belongings.
      • Arrange for spiritual support based on the family’s religious beliefs; pray with the family if no one else can stay with them.
    • Post Death
      • Attend the funeral or visitation if there was a special closeness with the family.
      • Initiate and maintain contact (e.g., sending cards, telephoning, inviting them back to the unit, making a home visit).
      • Refer to the dead child by name; discuss shared memories with the family.
      • Discourage the use of drugs and alcohol as a method of escaping grief.
      • Encourage all family members to communicate their feelings rather than remaining silent to avoid upsetting another member.
      • Emphasize that grieving is a painful process that often takes years to resolve.

Impact of Cognitive or Sensory Impairment on the Child and Family

• Cognitive Impairment
  • Is a general term that encompasses any type of mental difficulty or deficiency
  • Used synonymously with “intellectual disability”
  • Diagnosis
    • Made after a period of suspicion by family or health professionals
    • In some instances, made at birth
• Intellectual disability
  • Three components
    • Intellectual functioning
      • Subaverage intellectual function: IQ of 70 to 75 or below
    • Functional strengths and weaknesses
      • Impairment in 2 of 10 adaptive skills
    • Younger than age 18 at the time of diagnoses
• Diagnosis and classification
  • Early signs suggestive of cognitive impairment
    • Dysmorphic syndromes (e.g., Down syndrome, fragile X syndrome [FXS])
    • Irritability or non-responsiveness to environment
    • Major organ system dysfunction (e.g., feeding or breathing difficulties)
    • Gross motor delay
    • Fine motor delay
    • Language difficulties or delay
    • Behavior difficulties
• Etiology
  • Infection and intoxication, such as congenital rubella, syphilis, maternal drug consumption (e.g., fetal alcohol syndrome), chronic lead ingestion, or kernicterus
  • Trauma or physical agent (e.g., injury to the brain experienced during the prenatal, perinatal, or postnatal period)
  • Inadequate nutrition and metabolic disorders, such as phenylketonuria or congenital hypothyroidism
  • Gross postnatal brain disease, such as neurofibromatosis and tuberous sclerosis
  • Unknown prenatal influence, including cerebral and cranial malformations, such as microcephaly and hydrocephalus
  • Chromosomal abnormalities resulting from radiation; viruses; chemicals; parental age; and genetic mutations, such as Down syndrome and FXS
  • Gestational disorders, including prematurity, low birth weight, and post-maturity
  • Psychiatric disorders that have their onset during the child’s developmental period up to 18 years of age, such as autism spectrum disorders (ASDs)
  • Environmental influences, including evidence of a deprived environment associated with a history of intellectual disability among parents and siblings

• Nursing care of children with impaired cognitive function
  • Educate child and family
    • Early intervention
      • A systematic program of therapy, exercises, and activities designed to address developmental delays in children with disabilities to help achieve their full potentials
      • The child’s education should begin as soon as possible, because it has been shown that increased and early intervention exposure relates directly to greater improvements in cognitive development
  • Teach child self-care skills
    • Before beginning a self-feeding program, the nurse performs a task analysis.
    • After a task analysis, the child is observed in a particular situation, such as eating, to determine what skills are possessed and the child’s developmental readiness to learn the task. 
    • Family members are included in this process, because their “readiness” is as important as the child’s. 
    • Numerous self-help aids are available to facilitate independence and can help eliminate some of the difficulties of learning, such as using a plate with suction cups to prevent accidental spills
  • Promote child’s optimal development
    • It requires appropriate guidance for establishing acceptable social behavior and personal feelings of self-esteem, worth, and security.
      • They must arise from the genuine love and caring that exist among family members
    • Ensuring the child’s physical well-being
      • Any congenital defects, such as cardiac, gastrointestinal, or orthopedic anomalies, should be repaired. 
      • Plastic surgery may be considered when the child’s appearance can be substantially improved. 
      • Dental health is significant, and orthodontic and restorative procedures may improve facial appearance immensely.
  • Encourage play and exercise
    • The nurse will need to guide parents toward selection of suitable play and exercise activities
    • The type of play is based on the child’s developmental age, although the need for sensorimotor play may be prolonged
    • Parents should use every opportunity to expose the child to as many different sounds, sights, and sensations as possible. 
    • Appropriate toys include musical mobiles, stuffed toys, floating toys, a rocking chair or horse, a swing, bells, and rattles. 
    • The child should be taken on outings, such as trips to the grocery store or shopping center.
  • Provide means of communication
    • Some children may need tongue exercises to correct the tongue thrust or gentle reminders to keep the lips closed.
    • Nonverbal communication may be appropriate for some of these children, and various devices are available
    • For children with physical limitations, several adaptations or types of communication devices are available to facilitate selection of the appropriate picture or word
  • Establish discipline
    • Control measures are based primarily on teaching a specific behavior rather than on understanding the reasons behind it.
    • Stressing moral lessons is of little value to a child who lacks the cognitive skills to learn from self-criticism or evaluation of previous mistakes. 
    • Behavior modification, especially reinforcement of desired actions, and use of time-out procedures are appropriate forms of behavior control.
  • Encourage socialization
    • Opportunities for social interaction and infant stimulation programs should began at an early age
      • Parents should be encouraged early to teach their child socially acceptable behavior: waving goodbye, saying “hello” and “thank you,” responding to his or her name, greeting visitors, and sitting modestly. 
      • The teaching of socially acceptable sexual behavior is especially important to minimize sexual exploitation. 
      • Parents also need to expose the child to strangers so that he or she can practice manners, because there is no automatic transfer of learning from one situation to another.
  • Provide information on sexuality
    • This may pose a level of difficulty to the parents
      • Possibility of pregnancy
      • Future plans to marry
      • Ability to be independent
    • The nurse should help in this area by providing parents with information about sexuality education that is geared to the child’s developmental level.
      • Adolescent girls need a simple explanation of menstruation and instructions on personal hygiene during the menstrual cycle
      • Practical sexual information regarding anatomy, physical development, and conception
        • Because they are easy to persuade and lack judgment, they need a well-defined, concrete code of conduct with specific instructions for handling certain situations.
  • Help families adjust to future care
    • Older parents may not be able to continue care responsibilities after they reach retirement or older age. 
    • The decision regarding residential placement is a difficult one for families, and the availability of such facilities varies widely. 
    • The nurse’s role includes assisting parents in investigating and evaluating programs and helping parents adjust to the decision for placement
  • Care for the child during hospitalization
    • To prevent engaging in this nontherapeutic approach, nurses must use the mutual participation model in planning the child’s care.
    • Parents should stay with their child but not be made to feel as if the responsibility is totally theirs.
    • The nurse also assesses the child’s functional level of eating and playing; ability to express needs verbally; progress in toilet training; and relationship with objects, toys, and other children. 
    • The child is encouraged to be as independent as possible in the hospital.
  • Assist in measures to prevent cognitive impairment
    • Counseling and education can reduce or eliminate such factors (e.g., poor nutrition, cigarette smoking, chemical abuse), which increase the risk for prematurity and intrauterine growth restriction.
    • Interventions are directed toward improving maternal health by educating women regarding the dangers of chemicals, including 
      • Prenatal alcohol exposure, which affects organogenesis, craniofacial development, and cognitive ability.
      • Adequate prenatal care
      • Optimal medical care of high-risk newborns
      • Rubella immunization
      • Genetic counseling
      • Prenatal screening, especially in terms of Down syndrome or FXS. 
    • The use of folic acid supplements prevents neural tube defects during pregnancy and during the childbearing years; and the use of newborn screening for treatable inborn errors of metabolism (e.g., congenital hypothyroidism, phenylketonuria, and galactosemia) are early appropriate therapies to prevent developmental disabilities in children.

• Appropriate routes
  • Oral
    • Nursing actions
      • Route is preferred due to convenience, cost, and ability to maintain steady blood levels
      • Take 1 to 2 hr to reach peak analgesic effects. Oral medications are not suited for children experiencing pain that requires rapid relief or pain that is fluctuating in nature
  • Topical/transdermal
    • Nursing actions
      • Lidocaine and prilocaine is available in a cream or gel
        • Used for any procedure in which the skin will be punctured (IV insertion, biopsy) 60 min prior to a superficial puncture
        • Place an occlusive dressing over the cream after application
        • Prior to procedure, removing the dressing and clean the skin. Indication of an adequate response is reddened or blanched skin
        • Demonstrate to the child that the skin is not sensitive by tapping or scratching lightly
        • Instruct parents to apply medication at home prior to the procedure
      • Fentanyl
        • Use for children older than 12 years of age
        • Use to provide continuous pain control. Onset of 12 to 24 hr and a duration of 72 hr
        • Use an immediate-release opioid for breakthrough pain
        • Treat respiratory depression with naloxone
  • Intravenous
    • Nursing actions
      • Bolus
        • Rapid pain control in approximately 5 min
        • Use for medications (morphine, hydromorphone)
        • Continuous: provides steady blood levels
      • Patient-controlled analgesia (PCA)
        • Self-administration of pain medication
        • Can be basal, bolus, or combination
        • Has lockout to prevent overdosing
      • Family-controlled analgesia
        • Same concept as PCA
        • Parent or caregiver manages the child’s pain
  • Nonpharmacological measures
    • Distractions
      • Tell jokes or a story to the child
      • Involve parent and child in identifying strong distractors.
      • Involve child in play; use radio, smartphone, tablet, or computer game; have child sing or use rhythmic breathing.
      • Have child take a deep breath and blow it out until told to stop.
      • Have child blow bubbles to “blow the hurt away.”
      • Have child concentrate on yelling or saying “ouch,” with instructions to “yell as loud or soft as you feel it hurt; that way I know what’s happening.”
      • Have child look through kaleidoscope (type with glitter suspended in fluid-filled tube) and encourage him or her to concentrate by asking, “Do you see the different designs?”
      • Use humor, such as watching cartoons, telling jokes or funny
      • stories, or acting silly with child.
      • Have child read, play games, or visit with friends.
    • Relaxation
      • Infant or young child
        • Hold or rock the infant or young child
          • Rock in a wide, rhythmic arc in a rocking chair, or sway back and forth, rather than bouncing child.
        • Assist older children into a comfortable position, well-supported position, such as vertically against the chest and shoulder
        • Assist with breathing techniques

• Repeat one or two words softly, such as “Mommy’s here.”

• Slightly older child
  • Ask child to take a deep breath and “go limp as a rag doll” while exhaling slowly; then ask child to yawn (demonstrate if needed)
  • Help child assume a comfortable position (e.g., pillow under neck and knees).
  • Begin progressive relaxation: starting with the toes, systematically instruct child to let each body part “go limp” or “feel heavy.” If child has difficulty relaxing, instruct child to tense or tighten each body part and then relax it.
  • Allow child to keep eyes open, since children may respond better if eyes are open rather than closed during relaxation.

• Guided imagery
  • Assist the child in an imaginary experience
    • Including as many senses as possible (e.g., “feel the cool breezes,” “see the beautiful colors,” “hear the pleasant music”).
  • Have the child describe the details and write down or record scripts
  • Encourage child to concentrate only on the pleasurable event during the painful time; enhance the image by recalling specific details by reading the script or playing the tape.
  • Combine with relaxation and rhythmic breathing
• Positive self-talk
  • Have the child say positive things during a procedure or painful episode
    • “I will be feeling better soon,” or “When I go home, I will feel better, and we will eat ice cream”).
• Thought Stopping
  • Identify positive facts about the painful event (e.g., “It does not last long”).
  • Identify reassuring information (e.g., “If I think about something else, it does not hurt as much”).
  • Condense positive and reassuring facts into a set of brief statements, and have child memorize them (e.g., “Short procedure, good veins, little hurt, nice nurse, go home”).
  • Have child repeat the memorized statements whenever thinking about or experiencing the painful event.
• Behavioral contracting
  • Informal: May be used with children as young as 4 or 5 years of age:
    • Use stickers or token as a reward
    • Give time limits for the child to cooperate
      • Give a child who is uncooperative or procrastinating during a procedure a limited time (measured by a visible timer) to complete the procedure.
      • Proceed as needed if child is unable to comply
    • Reinforce cooperation with a reward
  • Formal: Use written contract, which includes the following:
    • Realistic (seems possible) goal or desired behavior
    • Measurable behavior (e.g., agrees not to hit anyone during procedures)
    • Contract written, dated, and signed by all people nvolved in any of the agreements
    • Identified rewards or consequences that are reinforcing
    • Goals that can be evaluated
    • Commitment and compromise requirements for both parties (e.g., while timer is used, nurse will not nag or prod child to complete procedure)
• Containment
  • Swaddle the infant
  • Place rolled blankets around the child 
  • Maintain proper positioning
• Nonnutritive sucking
  • Offer pacifier with sucrose before, during, and after painful procedure
  • Offer nonnutritive sucking during episodes of pain
• Kangaroo care
  • Skin-to-skin contact between infants and parents
• Complementary and alternative medicine
  • Classifications of CAM are grouped into five classes
    • Biologically based: foods, special diets, herbal or plant preparations, vitamins, other supplements
    • Manipulative treatments: chiropractic, osteopathy, massage
    • Energy based: Reiki, bioelectric or magnetic treatments, pulsed fields, alternating and direct currents
    • Mind-body techniques: mental healing, expressive treatments, spiritual healing, hypnosis, relaxation
    • Alternative medical systems: homeopathy; naturopathy; ayurveda; traditional Chinese medicine, including acupuncture and moxibustion

• Pharmacologic management
  • The World Health Organization states that the principles for pharmacologic pain management should include the following:
    • Using a two-step strategy
    • Dosing at regular intervals
    • Using the appropriate route of administration
    • Adapting treatment to the individual child
  • Nonopioids
    • They include acetaminophens and NSAIDs are suitable for mild to moderate pain
    • Nonsteroidal Anti-inflammatory Drugs for Children

• Opioids
  • Needed for moderate to several pain
  • Morphine remains the standard agents used for comparison to other opioid agents
  • When morphine is not a suitable opioid, it can be substituted by drugs as:
    • Hydromorphone hydrochloride (Dilaudid) and fentanyl citrate (Sublimaze)
    • Codeine
      • Oral opiate analgesic, is a weak opioid and has well-known safety and efficacy problems related to genetic variability in biotransformation
• Coanalgesic drugs
  • It may be used alone or with opioids to control pain symptoms and opioid side effects
  • Drugs frequently used to relieve anxiety, cause sedation, and provide amnesia are diazepam (Valium) and midazolam (Versed)
    • However, these drugs are not analgesics and should be used to enhance the effects of analgesics, not as a substitute for analgesics.
  • Other adjuvants include tricyclic antidepressants (e.g., amitriptyline, imipramine) and antiepileptics (e.g., gabapentin, carbamazepine, clonazepam)
  • Other medications commonly prescribed include stool softeners and laxatives for constipation, antiemetics for nausea and vomiting, diphenhydramine for itching, steroids for inflammation and bone pain, and dextroamphetamine and caffeine for possible increased pain and sedation

• Routes and Methods of Analgesic Drug Administration
  • Oral
    • Oral route preferred because of convenience, cost, and relatively
    • steady blood levels
    • Higher dosages of oral form of opioids required for equivalent
    • parenteral analgesia
    • Peak drug effect occurring after 1 to 2 hours for most analgesics
    • Delay in onset a disadvantage when rapid control of severe or 
    • fluctuating pain is desired
  • Sublingual, Buccal, or Transmucosal
    • Tablet or liquid placed between cheek and gum (buccal) or under tongue (sublingual)
    • Highly desirable because more rapid onset than oral route
      • Produces less first-pass effect through liver than oral route, which normally reduces analgesia from oral opioids (unless sublingual or buccal form is swallowed, which occurs often in children)
    • Few drugs commercially available in this form 
    • Many drugs can be compounded into sublingual troche or lozenge.*
      • Actiq: Oral transmucosal fentanyl citrate in hard confection base on a plastic holder; indicated only for management of breakthrough cancer pain in patients with malignancies who are already receiving and are tolerant to opioid therapy, but can be used for preoperative or preprocedural sedation and analgesia
  • Intravenous (Bolus)
    • Preferred for rapid control of severe pain
    • Provides most rapid onset of effect, usually in about 5 minutes
    • Advantage for acute pain, procedural pain, and breakthrough pain
    • Needs to be repeated hourly for continuous pain control
    • Drugs with short half-life (morphine, fentanyl, hydromorphone) preferable to avoid toxic accumulation of drug
  • Intravenous (Continuous)
    • Preferred over bolus and intramuscular (IM) injection for
    • maintaining control of pain
    • Provides steady blood levels
    • Easy to titrate dosage
  • Subcutaneous (Continuous)
    • Used when oral and intravenous (IV) routes not available
    • Provides equivalent blood levels to continuous IV infusion
    • Suggested initial bolus dose to equal 2-hour IV dose; total 24-hour dose usually requires concentrated opioid solution to minimize infused volume; use smallest-gauge needle that accommodates infusion rate
  • Patient-Controlled Analgesia
    • Generally refers to self-administration of drugs, regardless of route
    • Typically uses programmable infusion pump (IV, epidural, subcutaneous [SC]) that permits self-administration of boluses of medication at preset dose and time interval (lockout interval is time between doses)
    • Patient-controlled analgesia (PCA) bolus administration often combined with initial bolus and continuous (basal or background) infusion of opioid
    • Optimum lockout interval not known but must be at least as long as time needed for onset of drug
      • Should effectively control pain during movement or procedures
      • Longer lockout provides larger dose
  • Family-Controlled Analgesia
    • One family member (usually a parent) or other caregiver designated as child’s primary pain manager with responsibility for pressing PCA button
    • Guidelines for selecting a primary pain manager for family controlled analgesia:
      • Spends a significant amount of time with the patient
      • Is willing to assume responsibility of being primary pain manager
      • Is willing to accept and respect patient’s reports of pain (if able to provide) as best indicator of how much pain the patient is experiencing; knows how to use and interpret a pain rating scale
      • Understands the purpose and goals of patient’s pain management plan
      • Understands concept of maintaining a steady analgesic blood level
      • Recognizes signs of pain and side effects and adverse reactions to opioid
  • Nurse-Activated Analgesia
    • Child’s primary nurse designated as primary pain manager and is only person who presses PCA button during that nurse’s shift
    • Guidelines for selecting primary pain manager for family-controlled analgesia also applicable to nurse-activated analgesia
    • May be used in addition to basal rate to treat breakthrough pain with bolus doses; patient assessed every 30 minutes for need for bolus dose
    • May be used without a basal rate as a means of maintaining analgesia with around-the-clock bolus doses
  • Intramuscular
    • Note: Not recommended for pain control; not current standard of care
      • Painful administration (hated by children)
      • Tissue and nerve damage caused by some drugs
      • Wide fluctuation in absorption of drug from muscle
      • Faster absorption from deltoid than from gluteal sites
      • Shorter duration and more expensive than oral drugs
      • Time-consuming for staff and unnecessary delay for child
  • Intranasal
    • Available commercially as butorphanol (Stadol NS); approved for those older than 18 years of age
    • Should not be used in patient receiving morphine-like drugs because butorphanol is partial antagonist that will reduce analgesia and may cause withdrawal
  • Intradermal
    • Used primarily for skin anesthesia (e.g., before lumbar puncture, bone marrow aspiration, arterial puncture, skin biopsy)
    • Local anesthetics (e.g., lidocaine) cause stinging, burning sensation
    • Duration of stinging dependent on type of “caine” used
    • To avoid stinging sensation associated with lidocaine:
      • Buffer the solution by adding 1 part sodium bicarbonate (1 mEq/mL) to 9 to 10 parts 1% or 2% lidocaine with or without epinephrine
    • Normal saline with preservative, benzyl alcohol, anesthetizes venipuncture site
    • Same dose used as for buffered lidocaine
  • Topical or Transdermal
    • EMLA (eutectic mixture of local anesthetics [lidocaine and prilocaine]) cream and anesthetic disk or LMX4 (4% liposomal lidocaine cream)
      • Eliminates or reduces pain from most procedures involving skin puncture
      • Must be placed on intact skin over puncture site and covered by occlusive dressing or applied as anesthetic disc for 1 hour or more before procedure
    • Lidocaine-tetracaine (Synera, S-Caine)
      • Apply for 20 to 30 minutes
      • Do not apply to broken skin
    • LAT (lidocaine-adrenaline-tetracaine), tetracaine-phenylephrine (tetraphen)
      • Provides skin anesthesia about 15 minutes after application on nonintact skin
      • Gel (preferable) or liquid placed on wounds for suturing
      • Adrenaline not for use on end arterioles (fingers, toes, tip of nose, penis, earlobes) because of vasoconstriction
    • Transdermal fentanyl (Duragesic)
      • Available as patch for continuous pain control
      • Safety and efficacy not established in children younger than 12 years of age
      • Not appropriate for initial relief of acute pain because of long interval to peak effect (12 to 24 hours); for rapid onset of pain relief, give an immediate-release opioid
      • Orders for “rescue doses” of an immediate-release opioid recommended for breakthrough pain, a flare of severe pain that breaks through the medication being administered at regular intervals for persistent pain
      • Has duration of up to 72 hours for prolonged pain relief
      • If respiratory depression occurs, possible need for several doses of naloxone
    • Vapo-coolant
      • Use of prescription spray coolant, such as Fluori-Methane or ethyl chloride (Pain-Ease); applied to the skin for 10 to 15 seconds immediately before the needle puncture; anesthesia lasts about 15 seconds
      • Some children dislike cold; may be more comfortable to spray coolant on a cotton ball and then apply this to the skin
      • Application of ice to the skin for 30 seconds found to be ineffective
  • Rectal
    • Alternative to oral or parenteral routes
    • Variable absorption rate
    • Generally disliked by children
    • Many drugs able to be compounded into rectal suppositories
  • Regional Nerve Block
    • Use of long-acting local anesthetic (bupivacaine or ropivacaine) injected into nerves to block pain at site
    • Provides prolonged analgesia postoperatively, such as after inguinal herniorrhaphy
    • May be used to provide local anesthesia for surgery, such as dorsal penile nerve block for circumcision or for reduction of fractures
  • Inhalation
    • Use of anesthetics, such as nitrous oxide, to produce partial or complete analgesia for painful procedures
    • Side effects (e.g., headache) possible from occupational exposure to high levels of nitrous oxide
  • Epidural or Intrathecal
    • Involves catheter placed into epidural, caudal, or intrathecal space for continuous infusion or single or intermittent administration of opioid with or without a long-acting local anesthetic (e.g., bupivacaine, ropivacaine)
    • Analgesia primarily from drug’s direct effect on opioid receptors in spinal cord
    • Respiratory depression rare but may have slow and delayed onset; can be prevented by checking level of sedation and respiratory rate and depth hourly for initial 24 hours and decreasing dose when excessive sedation is detected
    • Nausea, itching, and urinary retention common dose-related side effects from the epidural opioid
    • Mild hypotension, urinary retention, and temporary motor or sensory deficits common unwanted effects of epidural local anesthetic
    • Catheter for urinary retention inserted during surgery to decrease trauma to child; if inserted when child is awake, anesthetize urethra with lidocaine
  • Patient-Controlled Analgesia
    • Patient controls the amount and frequency of the analgesic, which is typically delivered through a special infusion device. 
    • Children who are physically able to “push a button” (i.e., 5 to 6 years of age) and who can understand the concept of pushing a button to obtain pain relief can use PCA
    • PCA infusion devices typically allow for three methods or modes of drug administration to be used alone or in combination:
      • Patient-administered boluses that can be infused only according to the preset amount and lockout interval (time between doses).
        • More frequent attempts at self-administration may mean the patient needs the dose and time adjusted for better pain control.
      • Nurse-administered boluses that are typically used to give an initial loading dose to increase blood levels rapidly and to relieve breakthrough pain (pain not relieved with the usual programmed dose).
      • Continuous basal rate infusion that delivers a constant amount of analgesic and prevents pain from returning during those times, such as sleep, when the patient cannot control the infusion.
  • Epidural Analgesia
    • Although an epidural catheter can be inserted at any vertebral level, it is usually placed into the epidural space of the spinal column at the lumbar or caudal level
    • The thoracic level is usually reserved for older children or adolescents who have had an upper abdominal or thoracic procedure, such as a lung transplant. 
    • An opioid (usually fentanyl, hydromorphone, or preservative-free morphine, which is often combined with a long-acting local anesthetic, such as bupivacaine or ropivacaine) is instilled via single or intermittent bolus, continuous infusion, or patient-controlled epidural analgesia. 
    • Analgesia results from the drug’s effect on opiate receptors in the dorsal horn of the spinal cord, rather than the brain. 
    • As a result, respiratory depression is rare, but if it occurs, it develops slowly, typically 6 to 8 hours after administration.
    • Careful monitoring of sedation level and respiratory status is critical to prevent opioid-induced respiratory depression.
    • Assessment of pain and the skin condition around the catheter site are important aspects of nursing care.
  • Transmucosal and Transdermal Analgesia
    • Oral transmucosal fentanyl (Oralet) and intranasal fentanyl provides nontraumatic preoperative and preprocedural analgesia and sedation. 
    • Fentanyl is also available as a transdermal patch (Duragesic). 
    • Duragesic is contraindicated for acute pain management, but it may be used for older children and adolescents who have cancer pain or sickle cell pain or for patients who are opioid tolerant.
    • One of the most significant improvements in the ability to provide atraumatic care to children undergoing procedures is the anesthetic cream
• Side effects of Opioids
  • General
    • Constipation (possibly severe)
    • Respiratory depression
    • Sedation
    • Nausea and vomiting
    • Agitation, euphoria
    • Mental clouding
    • Hallucinations
    • Orthostatic hypotension
    • Pruritus
    • Urticaria
    • Sweating
    • Miosis (may be sign of toxicity)
    • Anaphylaxis (rare)
  • Signs of Tolerance
    • Decreasing pain relief
    • Decreasing duration of pain relief
  • Signs of Withdrawal Syndrome in Patients With Physical Dependence
    • Initial Signs of Withdrawal
      • Lacrimation
      • Rhinorrhea
      • Yawning
      • Sweating
    • Later Signs of Withdrawal
      • Restlessness
      • Irritability
      • Tremors
      • Anorexia
      • Dilated pupils
      • Gooseflesh
      • Nausea, vomiting
  • Managing Opioid-Induced Respiratory Depression
    • If Respirations Are Depressed
      • Assess sedation level.
      • Reduce Infusion by 25% When Possible.
      • Stimulate patient (shake shoulder gently, call by name, ask to breathe).
      • Administer oxygen.
    • If Patient Cannot Be Aroused or Is Apneic
      • Initiate resuscitation efforts as appropriate.
      • Administer naloxone (Narcan):
        • For children weighing less than 40 kg (88 lbs), dilute 0.1 mg naloxone in 10 mL sterile saline to make 10 mcg/mL solution, and give 0.5 mcg/kg.
        • For children weighing more than 40 kg (88 lbs), dilute 0.4-mg ampule in 10 mL sterile saline and give 0.5 mL.
      • Administer bolus by slow intravenous (IV) push every 2 minutes until effect is obtained.
      • Closely monitor patient. Naloxone’s duration of antagonist action may be shorter than that of the opioid, requiring repeated doses of naloxone.
• Fear of Opioid Addiction
  • One of the reasons for the unfounded but prevalent fear of addiction from opioids used to relieve pain is a misunderstanding of the differences between physical dependence, tolerance, and addiction.
    • Physical dependence 
      • Is a physiologic state in which abrupt cessation of the opioid, or administration of an opioid antagonist, results in a withdrawal syndrome. 
      • Physical dependence on opioids is an expected occurrence in all individuals who continuously use opioids for therapeutic or nontherapeutic purposes. It does not, in and of itself, imply addiction.
    • Tolerance 
      • Is a form of neuroadaptation to the effects of chronically administered opioids (or other medications) that is indicated by the need for increasing or more frequent doses of the medication to achieve the initial effects of the drug. 
      • A person may develop tolerance both to the analgesic effects of opioids and to some of the unwanted side effects, such as respiratory depression, sedation, or nausea. Tolerance is variable in occurrence, but it does not, in and of itself, imply addiction.
    • Addiction 
      • Is characterized by a persistent pattern of dysfunctional opioid use that may involve any or all of the following:
        • Adverse consequences associated with the use of opioids
        • Loss of control over the use of opioids
        • Preoccupation with obtaining opioids, despite the presence of adequate analgesia

Complications

• Chronic and Recurrent Pain Assessment
  • Pain that persists for 3 months or longer than the expected period of healing
    • Complex regional pain syndrome
    • Chronic daily headache
    • Multidirectional rating scale
      • Physical functioning
      • Emotional functioning
      • Social functioning
      • School functioning
• Pain assessment in specific populations
  • Pain in neonates
    • Manifestations of Acute Pain in the Neonate
      • Physiological responses
        • Vital signs: Observe for variations
          • Increased heart rate
          • Increased blood pressure
          • Rapid, shallow respirations
        • Oxygenation
          • Decreased transcutaneous oxygen saturation (TcPO2)
          • Decreased arterial oxygen saturation (SaO2)
        • Skin: Observe color and character
          • Pallor or flushing
          • Diaphoresis
          • Palmar sweating
        • Other observations
          • Increased muscle tone
          • Dilated pupils
          • Decreased vagal nerve tone
          • Increased intracranial pressure
          • Laboratory evidence of metabolic or endocrine changes: Hyperglycemia, lowered pH, elevated corticosteroids
      • Behavioral Responses
        • Vocalizations: Observe quality, timing, and duration
          • Crying
          • Whimpering
          • Groaning
        • Facial expression: Observe characteristics, timing, orientation of eyes and mouth
          • Grimaces
          • Brow furrowed
          • Chin quivering
          • Eyes tightly closed
          • Mouth open and squarish
        • Body movements and posture: Observe type, quality, and amount of movement or lack of movement; relationship to other factors
          • Limb withdrawal
          • Thrashing
          • Rigidity
          • Flaccidity
          • Fist clenching
        • Changes in state: Observe sleep, appetite, activity level
          • Changes in sleep-wake cycles
          • Changes in feeding behavior
          • Changes in activity level
          • Fussiness, irritability
          • Listlessness
  • Children with communication and cognitive impairment
    • Children who have significant difficulties in communicating with others about their pain include those who have significant neurologic impairments are at a greater risk for undertreatment of pain
      • Cerebral palsy 
      • Cognitive impairment
      • Metabolic disorders
      • Autism
      • Severe brain injury
      • Communication barriers (e.g., critically ill children who are on ventilators or heavily sedated or have neuromuscular disorders, loss of hearing, or loss of vision)
    • They often experience spasticity, contractures, injury, infection, and orthopedic surgical treatment that may be painful. 
    • Behaviors include moaning, inconsistent patterns of play and sleep, changes in facial expression, and other physical problems that may mask expression of pain and be difficult to interpret.
    • Pain scales
      • Observational scales and interview questionnaires for pain may not be as reliable for pain assessment as self-report scales in children of Hispanic origin
      • Children of Asian descent, who may learn to read Chinese characters vertically downward and from right to left, may have difficulty using horizontally oriented scales.
  • Cultural differences
    • Expression of pain can be greatly affected by communication barriers
    • Cultural background may influence the validity and reliability of pain assessment tools developed in a single cultural context.
  • Children with chronic illness and complex pain
    • Questionnaires and pain assessment scales do not always provide the most meaningful means of assessing pain in children, particularly for those with complex pain  
    • Some children cannot relate to a face or a number that describes their pain
    • Other children, such as those with cancer, are experiencing multiple symptoms and may find it difficult to isolate the pain from other symptoms.
    • In addition to asking the child or parent when the pain started and how long the pain lasts, the nurse can assess variations and rhythms by asking whether the pain is better or worse at certain times of the day or night.
    • If the child has had pain for a while, the child or parent may know which medications and doses are helpful.
    • The nurse may ask the child or parent to keep a diary of activities, positions, and other events that may increase or decrease the pain
      • A diary can help families identify triggers that may cause pain and interventions that work.
• Complementary pain medicine
  • Classification of complementary and alternative medicine
    • Biologically based
    • Manipulative treatments
    • Energy based
    • Mind-body techniques
    • Alternative medical systems
• Nursing Actions
  • Assess pain thoroughly and adequately
  • Administer medications in a timely manner
  • Evaluate and monitor the child’s response to treatments
  • Titrate analgesic medications to achieve optimal dosing
  • Make recommendations for alternate medications if needed
• Consequences of untreated Pain in Infants
  • Acute Consequences
    • Periventricular-intraventricular hemorrhage
    • Increased chemical and hormone release
    • Breakdown of fat and carbohydrate stores
    • Prolonged hyperglycemia
    • Higher morbidity for neonatal intensive care unit patients
    • Memory of painful events
    • Hypersensitivity to pain
    • Prolonged response to pain
    • Inappropriate innervation of the spinal cord
    • Inappropriate response to nonnoxious stimuli
    • Lower pain threshold
  • Potential Long-Term Consequences
    • Higher somatic complaints of unknown origin
    • Greater physiologic and behavioral responses to pain
    • Increased prevalence of neurologic deficits
    • Psychosocial problems
    • Neurobehavioral disorders
    • Cognitive deficits
    • Learning disorders
    • Poor motor performance
    • Behavioral problems
    • Attention deficits
    • Poor adaptive behavior
    • Inability to cope with novel situations
    • Problems with impulsivity and social control
    • Learning deficits
    • Emotional temperament changes in infancy or childhood
    • Accentuated hormonal stress responses in adult life
  • Common Pain States in Children
    • Levels of Sedation
      • Minimal Sedation (Anxiolysis)
        • Patient responds to verbal commands.
        • Cognitive function may be impaired.
        • Respiratory and cardiovascular systems are unaffected.
      • Moderate Sedation (Previously Conscious Sedation)
        • Patient responds to verbal commands but may not respond to light tactile stimulation.
        • Cognitive function is impaired.
        • Respiratory function is adequate; cardiovascular system is unaffected.
      • Deep Sedation
        • Patient cannot be easily aroused except with repeated or painful stimuli.
        • Ability to maintain airway may be impaired.
        • Spontaneous ventilation may be impaired; cardiovascular function is maintained.
      • General Anesthesia
        • Loss of consciousness, patient cannot be aroused with painful stimuli.
        • Airway cannot be maintained adequately, and ventilation is impaired.
        • Cardiovascular function may be impaired.
    • Painful and invasive procedures
      • Procedural sedation and analgesia
    • Postoperative pain 
      • Associated with surgery
      • Combination of medications
    • Burn pain
      • Multiple components
      • Difficult and challenging to control
    • Recurrent headaches
      • Tension, dental braces, weakness of eye muscles, sinusitis, epilepsy, sleep apnea, injury
    • Recurrent abdominal pain
      • Common in children
    • Pain associated with sickle cell disease
      • ED visits for opioid treatment
    • Cancer pain in children
      • Most prevalent symptom is pain
    • Pain and sedation in end-of-life care
      • Comfort can be relief with a combination of opioids and adjuvant analgesics

Impact of Chronic Illness, Disability, or End-of-Life Care for the Child and Family

• Scope of the problem
  • Increasing viability of preterm infants
  • Portability of life-sustaining technology
  • Life-extending treatments
  • Rise in the numbers of children with complex and chronic diseases
• Chronic Conditions of Childhood

• Trends in care
  • Developmental focus
    • This instead of focusing on the chronological age or diagnosis emphasizes the child’s abilities and strengths rather than disabilities
    • Attention is directed to normalizing experiences the child’s abilities and strengths rather than disabilities.
    • It also considers family development
      • The life cycle of the family unit reflects changing ages and needs of family members, as well as changing external demands. 
      • A family member’s serious illness can cause significant stress or crisis at any stage of the family life cycle. 
      • Just as with individual development, family development may be interrupted or even regress to an earlier level of functioning. 
      • Nurses can use the concept of family development to plan meaningful interventions and evaluate care.
  • Family-centered care
    • This considers the family as the constant in the child’s life is especially evident in the care of children with special needs
    • As parents learn about the child’s health care needs, they often become experts in delivering care.
    • Health care providers, including nurses, are adjuncts to the child’s care and need to form partnerships with parents.
    • Effective communication and negotiation between parents and nurses are essential to forming trusting and effective partnerships and finding the best ways to meet the needs of the child and family
      • Family—Health care provider communication
      • Establishing a therapeutic relationship
        • Has been shown to predict improved health-related outcomes
        • To build successful therapeutic relationships with families, it is necessary for nurses to recognize parents’ expertise with regard to their child’s condition and needs. 
        • Health care environments for children with serious illnesses are fraught with obstacles that serve as barriers to successful therapeutic relationships with families. 
        • Individual discussions, especially with the case manager, primary nurse, clinical nurse specialist, or nurse practitioner, help establish a consistent and flexible care plan that can prevent conflicts or deal with these conflicts before they disrupt care.
      • The role of culture
        • For some ethnic and minority populations, cultural understandings of illness, the structure of family life, social roles for individuals with disabilities, and other factors related to the perception of children may differ from those of mainstream American culture.
        • Cultural attributes such as values and beliefs regarding an illness or chronic condition and its causation, social roles for people who are ill or disabled, family structure, the role of children, childrearing practices, self versus group orientation, spirituality, and time orientation also affect a family’s response to an illness or chronic condition in a child
  • Shared decision-making
    • This result from open, honest, culturally sensitive communication and the establishment of a therapeutic relationship among the family and health care providers.
      • Facilitating shared decision making
        • Continually assess the impact of the child’s illness and treatment on the family.
        • Provide honest, accurate information regarding the trajectory of the disease, anticipated complications, and prognostic information.
        • Discuss what the family desires for the child’s quality of life.
        • Avoid personal opinion or judgment of the family’s questions and decisions.
        • Be aware of nurses’ personal and cultural assumptions and the ways these assumptions impact communication, decision making, and judgment.
  • “Normalization”
    • This efforts family members make to create a normal family life, their perceptions of the consequences of these efforts, and the meanings they attribute to their management efforts
    • For chronically ill children, such efforts may include attending school, pursuing hobbies and recreational interests, and achieving employment and a level of independence. 
    • For their families, it may entail adapting the family routine to accommodate the ill or disabled child’s health and physical needs
    • Nurses can assist families in normalizing their lives by assessing the family’s everyday life, social support systems, coping strategies, family cohesiveness, and family and community resources.
    • Goal of home care is:
      • Normalize the life of the child, including those with technologically complex care, in a family and community context and setting.
      • Minimize the disruptive impact of the child’s condition on the family.
      • Foster the child’s maximum growth and development.

• The Familly of the Child with a Chronic or Complex Condition
  • Adaptive tasks of Parents having children with chronic conditions
    • Accept the child’s condition.
    • Manage the child’s condition on a day-to-day basis.
    • Meet the child’s normal developmental needs.
    • Meet the developmental needs of other family members.
    • Cope with ongoing stress and periodic crises.
    • Assist family members to manage their feelings.
    • Educate others about the child’s condition.
    • Establish a support system.
  • Impact of the child’s chronic illness
    • Parents
      • In addition to the stress of grieving for the loss of hope for a perfect child, parents are affected by whether or not they receive positive feedback from interactions with their child. 
      • Many parents feel satisfaction and fulfillment from the parenting role. 
      • For others, parenting may be a series of unrewarding experiences that contribute to feelings of inadequacy and failure
      • Anticipated Parental Stress Points
        • Diagnosis of the condition: 
          • Parents require considerable education while dealing with an emotional response.
        • Developmental milestones: 
          • Times that children normally achieve walking, talking, and self-care are delayed or impossible for the child.
        • Start of schooling: 
          • Particularly stressful are situations in which appropriate schooling will not be in a regular class placement.
        • Reaching the ultimate attainment: 
          • Parents must handle situations such as realizing that ambulation will be impossible or that the child will not learn to read.
        • Adolescence: 
          • Issues such as sexuality and independence become prominent.
        • Future placement: 
          • Decisions about placement must be made when the child becomes an adult or when the parents can no longer care for the child.
        • Death of the child
      • Parental roles
        • Parenting a child with a complex chronic condition requires attending to the routine aspects of parenting with the added responsibility of 
          • Performing complex technical care
          • Symptom management
          • Advocating for their child
          • Seeking and coordinating health and social services for their ill or disabled child
        • These added responsibilities must then be balanced with the needs of other family members, extended family and friends, and personal health and obligations to minimize consequences to the overall functioning of the family
        • The nurse can assist parents in avoiding role conflicts by providing anticipatory guidance early on. 
        • Teaching should address stressors often identified as having an impact on the marriage
          • The burden of care at home assumed by primarily one parent
          • The financial burden
          • The fear of the child dying
          • Pressure from relatives
          • The hereditary nature of the disease
          • Fear of pregnancy.
      • Mother-Father Differences
        • Mothers are often the primary caregiver and are more likely than fathers to give up their jobs to care for their children, often resulting in social isolation
          • Often have greater needs for social support and positive appraisal of the situation than fathers.
        • Fathers of children with disabilities struggle with issues that may be distinct from those of the mothers may think that their role as protector is challenged, 
          • This is because they do not know how to help and cannot protect their family from the seemingly overwhelming recurring problems. 
          • The extensive stresses in the family can leave fathers feeling depressed, weak, guilty, powerless, isolated, embarrassed, and angry. 
          • Fearful that they will lose control or be viewed as weak or ineffectual, however, fathers often hide their feelings and display an outward confidence that may lead others to believe that everything is fine. 
          • Fathers worry about what the future holds for their children, their ability to manage the increasing financial burden, and the daily disruptions of the entire family
      • Single-Parent Families
        • As the only parent of a child who may require extensive, sophisticated, and lifelong care, the single parent may feel an enormous burden. 
        • Available financial and emotional resources may already be stretched to the limit. 
        • A special effort should be made to assist the single parent in finding financial and support services that can ease the burden of care.
        • Nurses can also assist the single parent in identifying helping roles that may be acceptable to relatives and friends.
    • Siblings
      • Most evidence shows a negative effect on siblings of children with chronic illnesses compared with siblings of healthy children
      • Siblings of children with chronic illnesses report psychosocial problems more often than their peers
      • Several factors increase the risk of negative effects for siblings of ill children. 
      • Responsibility for caregiving, differential treatment by parents, and limitations in family resources and recreational time are often the experiences of siblings of ill or disabled children
      • Supporting siblings of children with special needs
        • Promote healthy sibling relationships
          • Value each child individually and avoid comparisons. 
            • Remind each child of his or her positive qualities and contribution to other family members.
          • Help siblings see the differences and similarities between themselves and the child with special needs. 
            • Create a climate in which children can achieve successes without feeling guilty.
          • Teach siblings ways to interact with the child.
          • Seek to be fair in terms of discipline, attention, and resources; require the affected child to do as much for himself or herself as possible.
          • Let siblings settle their own differences; intervene only to prevent siblings from hurting one another.
          • Legitimize reasonable anger. 
            • Even children with special needs behave badly sometimes.
          • Respect a sibling’s reluctance to be with or to include the child with special needs in activities.
        • Help siblings cope
          • Listen to siblings to let them know that their thoughts and suggestions are valued.
          • Praise siblings when they have been patient, have sacrificed, or have been particularly helpful. 
            • Do not expect siblings to always act in this manner.
          • Acknowledge the personal strengths siblings have and their ability to cope with stress successfully.
          • Provide age-appropriate information about the child’s condition and update it when appropriate.
          • Let teachers know what is happening so that they can be understanding and helpful.
          • Recognize special stress times for siblings, and plan to minimize negative effects.
          • Schedule special time with siblings; have a friend or family member substitute when parent is unavailable.
          • Encourage siblings to join or help establish a sibling support group.
          • Use the services of professionals when needed. If parent feels that such a service is necessary, it should be provided in as vigorous a manner as a service for the child with special needs.
        • Involve siblings
          • Seek out ways to realistically include siblings in the care and treatment of the child with special needs.
          • Limit caregiving responsibilities, and give recognition when siblings perform them.
          • Develop a library of children’s books on special needs.
          • Invite siblings to attend meetings to develop plans for the child with special needs (e.g., individualized educational program [IEP], individualized family service plan [IFSP]).
          • Discuss future plans with siblings.
          • Solicit their ideas on treatment and service needs.
          • Have siblings visit professionals who work with the child.
          • Help siblings develop competencies to teach the child new skills.
          • Provide opportunities for siblings to advocate for the child.
          • Allow siblings to set their own pace for learning and involvement.
  • Assessing coping behaviors
    • Approach behaviors
      • Asks for information regarding diagnosis and child’s present condition
      • Seeks help and support from others
      • Anticipates future problems; actively seeks guidance and answers
      • Endows the chronic illness or complex condition with meaning
      • Shares burden of disorder with others
      • Plans realistically for the future
      • Acknowledges and accepts child’s awareness of diagnosis and prognosis
      • Expresses feelings (e.g., sorrow, depression, and anger) and realizes reason for the emotional reaction
      • Realistically perceives child’s condition; adjusts to changes
      • Recognizes own growth through passage of time, such as earlier denial and nonacceptance of diagnosis
      • Verbalizes possible loss of child
    • Avoidance Behaviors
      • Fails to recognize seriousness of child’s condition despite physical evidence
      • Refuses to agree to treatment
      • Intellectualizes about the illness but in areas unrelated to child’s condition
      • Is angry and hostile to members of the staff regardless of their attitude or behavior
      • Avoids staff, family members, or child
      • Entertains unrealistic future plans for child with little emphasis on the present
      • Is unable to adjust to or accept a change in progression of disease
      • Continually looks for new cures with no perspective toward possible benefit
      • Refuses to acknowledge child’s understanding of disease and prognosis
      • Uses magical thinking and fantasy; may seek “occult” help
      • Places complete faith in religion to point of relinquishing own responsibility
      • Withdraws from outside world; refuses help
      • Punishes self because of guilt and blame
      • Makes no change in lifestyle to meet needs of other family members
      • Resorts to excessive use of alcohol or drugs to avoid problems
      • Verbalizes suicidal intent
      • Is unable to discuss possible loss of child or previous experiences with death
  • Assisting family members in managing their feelings
    • Shock and Denial
      • Shock and denial can last from days to months, sometimes even longer. 
      • Examples of denial that may be exhibited at the time of diagnosis include the following:
        • Physician shopping
        • Attributing the symptoms of the actual illness to a minor condition
        • Refusing to believe the diagnostic tests
        • Delaying consent for treatment
        • Acting happy and optimistic despite the revealed diagnosis
        • Refusing to tell or talk to anyone about the condition
        • Insisting that no one is telling the truth, regardless of others’ attempts to do so
        • Denying the reason for admission
        • Asking no questions about the diagnosis, treatment, or prognosis
    • Adjustment
      • This stage may be accompanied by several responses, which are normal parts of the adaptation process. 
      • Probably the most universal of these feelings are guilt and self-accusation.
      • Guilt 
        • Guilt is often greatest when the cause of the disorder is directly traceable to the parent, as in genetic diseases or accidental injury. 
        • However, it can occur even without any scientific or realistic basis for parental responsibility. 
        • Frequently, the guilt stems from a false assumption that the child’s condition is a result of personal failure or wrongdoing, such as not doing something correctly during pregnancy or the birth.
        • Some parents are convinced that they are being punished for some previous misdeed. 
        • Others may see the illness as a trial sent by God to test their religious strength and faith.
        • Children may interpret their serious illness as retribution for past misbehavior. 
        • The nurse should be particularly sensitive to the child who passively accepts all painful procedures. 
        • This child may believe that such acts are inflicted as deserved punishment.
      • Anger
        • Anger directed inward may be evident as self-reproaching or punitive behavior, such as neglecting one’s health and verbally degrading oneself. 
        • Anger directed outward may be manifested in either open arguments or withdrawal from communication and may be evident in the person’s relationship with any number of individuals, such as the spouse, the child, and siblings. 
        • Passive anger toward the ill child may be evident in decreased visiting, refusal to believe how sick the child is, or an inability to provide comfort.
        • Children are apt to respond with anger as well, and this includes the affected child and the well siblings
        • Children are aware of the loss engendered by their illness or complex condition and may react angrily to the restrictions imposed or the feelings of being different.
        • Siblings may also feel anger and resentment toward the ill child and parents for the loss of routine and parental attention. 
        • It is difficult for older children and almost impossible for younger children to comprehend the plight of the affected child. 
        • Their perception is of a brother or sister who has the undivided attention of their parents, is showered with cards and gifts, and is the focus of everyone’s concern.
      • During the period of adjustment, four types of parental reactions to the child influence the child’s eventual response to the disorder:
        • Overprotection: 
          • The parents fear letting the child achieve any new skill, avoid all discipline, and cater to every desire to prevent frustration.
        • Rejection: 
          • The parents detach themselves emotionally from the child but usually provide adequate physical care or constantly nag and scold the child
        • Denial: 
          • The parents act as if the disorder does not exist or attempt to have the child overcompensate for it.
        • Gradual acceptance: 
          • The parents place necessary and realistic restrictions on the child, encourage self-care activities, and promote reasonable physical and social abilities.
    • Reintegration and Acknowledgment
      • This adjustment phase also involves social reintegration in which the family broadens its activities to include relationships outside of the home with the child as an acceptable and participating member of the group.
    • Establishing a support system
      • Nursing goal is to assess which families are at risk for succumbing to the effects of the crisis.
      • Several variables influence the resolution of a crisis 
        • Available support system
        • Perception of the event
        • Coping mechanisms
        • Reactions to the child
        • Available resources
        • Concurrent stresses within the family
      • By receiving emotional support and guidance early, there is an increased likelihood that they will also cope successfully.
      • Concept of functional burden
        • Impact of the child with special needs
          • The child’s need for medical and nursing care
          • The child’s fixed deficits
          • The child’s age-appropriate dependency in activities of daily living
          • The disruptions in the family routine caused by the care
          • The psychologic burden of the prognosis on the family
        • Family Resources and Ability to Cope
          • The family’s physical resources
          • The family’s emotional resources
          • The family’s educational resources
          • The family’s social supports and available help
          • The competing demands for family members’ time and energy

Physical Assessment

• Anthropometric Measurements
  • Height, weight, and circumference
    • Weigh the child, taking two measurements and averaging them
  • Calculate BMI
    • BMI= weight (kg)height (m)2
  • BMI under the 5th percentile indicated the child is underweight
  • BMI over the 85th percentile correlates with overweight
  • Measure the infant’s head circumference (up to age 2 to 3 years)
• Examination techniques
  • Inspection
    • Purposeful observation of the child’s physical features and behaviors during the entire physical examination
    • Physical feature characteristics include size, shape, color, movement, position, and location.
    • Adequate lighting is essential
    • Detection of odors is also a part of inspection
  • Palpation
    • Use of touch to identify characteristics of the skin, internal organs, and masses.
    • Characteristics include texture, moistness, tenderness, temperature, position, shape, consistency, and mobility of masses and organs
    • The palmar surface of the fingers and the fingertips pads are used for determining position, size, consistency, and masses
    • The ulnar surface of the hand is best for detecting vibrations
  • Auscultation
    • Listening to sounds produced by the airway, lungs, stomach, heart, and blood vessels to identify their characteristics
    • Auscultation is usually performed with a stethoscope to enhance the sounds heard in the chest and abdomen
    • Speech is also assessed during auscultation
  • Percussion
    • Striking the surface of the body, either directly or indirectly, to set up vibrations that reveal the density of underlying tissues and borders of internal organs in the chest and abdomen
    • As the density of the tissue increases, the percussion tone become quieter
    • The tone over air is the loudest, and the tone over solid areas is soft
• Physiological and growth measurements
  • Temperature by age

• Temperature measurement in pediatrics
  • Ask the Question
    • PICOT Question: In infants and children, what is the most accurate method for measuring temperature in febrile children?
  • Search for the Evidence
    • Search Strategies
      • Clinical research studies related to this issue were identified by searching for English publications within the past 15 years for infant and child populations; comparisons with gold standard: rectal thermometry.
    • Databases Used
      • PubMed, Cochrane Collaboration, MD Consult, Joanna Briggs Institute, National Guideline Clearinghouse (AHRQ), TRIP Database Plus, PedsCCM, BestBETs
  • Critical Appraisal of the Evidence
    • Rectal temperature: 
      • Rectal measurement remains the clinical gold standard for the precise diagnosis of fever in infants and children compared with other methods.
      • However, this procedure is more invasive and is contraindicated for infants younger than 1 month of age due to risk for rectal perforation
      • Children with recent rectal surgery, diarrhea, or anorectal lesions, or who are receiving chemotherapy (cancer treatment usually affects the mucosa and causes neutropenia) should not undergo rectal thermometry.
    • Oral temperature (OT): 
      • OT indicates rapid changes in core body temperature, but accuracy may be an issue compared with the rectal site.
      • OTs are considered the standard for temperature measurement, but they are contraindicated in children who have an altered level of consciousness, are receiving oxygen, are mouth breathing, are experiencing mucositis, had recent oral surgery or trauma, or are younger than 5 years of age
      • Limitations of OTs include the effects of ambient room temperature and recent oral intake
    • Axillary temperature: 
      • This is inconsistent and insensitive in infants and children older than 1 month of age
      • A systematic review of 20 studies concluded that axillary thermometers showed variation in findings and are not a good method for accurate temperature assessment 
      • In neonates with fever, the axillary temperature should not be used interchangeably with rectal measurement. 
      • It can be used as a screening tool for fever in young infants
    • Ear (aural) temperature: 
      • This is not a precise measurement of body temperature. A meta-analysis of 101 studies comparing tympanic membrane temperatures with rectal temperatures in children concluded that the tympanic method demonstrated a wide range of variability, limiting its application in a pediatric setting
      • Other published reviews continue to find poor sensitivity using infrared ear thermometry.
      • Diagnosis of fever without a focus should not be made based on tympanic thermometry, because it is not an accurate measure of core temperature
    • Temporal artery temperature (TAT): 
      • TAT is not predictable for fever in young children but can be used as a screening tool for detecting fever less than 38° C (100.4° F) in children 3 months to 4 years of age

• Pulse Rate
  • Grading of Pulses

• Newborn: 110 to 160/min (depending on activity)
• 1 week to 3 months:107 to 180/min (depending on activity)
• 2 to 10 years: 70 to 110/min (depending on activity)
• 10 years and older: 50 to 90/min (depending on activity)

• Respirations
  • Count the respiratory rate in children in the same manner as for adult patients
  • However, in infants, observe abdominal movements, because respirations are primary diaphragmatic
    • Newborn to 1 year: 30 to 35/min
    • 1 to 2 years: 25 to 30/min
    • 6 to 12 years: 19 to 21/min
    • 12 years and older: 16 to 19/min
• Blood pressure
  • Should be measured annually in children 3 years of age through adolescence and in children with symptoms of hypertension, children in emergency departments and intensive care units, and high-risk infants.
  • Orthostatic Hypotension
    • Also called postural hypotension or orthostatic intolerance
    • Manifests as syncope (fainting), vertigo (dizziness), or lightheadedness and is caused by decreased blood flow to the brain (cerebral hypoperfusion)
    • Normally blood flow to the brain is maintained at a constant level by several compensating mechanisms that regulate systemic BP.
    • When one assumes a sitting or standing position from a supine or recumbent position, peripheral capillary vasoconstriction occurs, and blood that was pooling in the lower vasculature is returned to the heart for redistribution to the head and remainder of the body.
    • Leading to vertigo or syncope
    • One of the most common causes of OH is hypovolemia
      • May be induced by medications, such as diuretics, vasodilator medications, and prolonged immobility or bed rest.
    • Other causes of OH include: 
      • Dehydration
      • Diarrhea
      • Emesis
      • Fluid loss from sweating and exertion
      • Alcohol intake
      • Dysrhythmias
      • Diabetes mellitus
      • Sepsis
      • Hemorrhage
  • Width of cuff should cover 40% of the arm and 80-100% of the upper arm without overlapping 

• General Appearance
  • Appears undistressed, clean, well-kept, and without body odors
  • Muscle tone: Erect head posture is expected in infants after 4 months of age
  • Make eye contact when addressed (expect infants)
  • Follows simple commands as age-appropriate
  • Uses speech, language, and motor skills spontaneously
• Skin
  • Assess skin for color, texture, temperature, moisture, turgor, lesions, acne, and rashes. 
  • Examination of the skin and its accessory organs primarily involves inspection and palpation. 
  • Touch allows the nurse to assess the texture, turgor, and temperature of the skin. 
  • The normal color in light-skinned children varies from a milky white and rose to a deeply hued pink. 
  • Dark-skinned children, such as those of Native American, Hispanic, or African descent, have inherited various brown, red, yellow, olive green, and bluish tones in their skin. 
  • Asian persons have skin that is normally of a yellow tone. Several variations in skin color can occur, some of which warrant further investigation
  • Difference in color changes of racial group

• Hair and scalp
  • Hair should be evenly distributed, smooth, and strong
    • Manifestations of nutritional deficiencies include hair that is stringy, dull, brittle, and dry
    • Hair loss or balding spots on infants can indicate the child is spending too much time in the same position
  • Scalp should be clean and absent from any scaliness, infestations, and trauma.
  • Assess children approaching adolescence for the presence of secondary hair growth
• Head and Neck
  • Head
    • The shape of the head should be symmetric
    • Fontanels should be flat.
      • The posterior fontanel usually closes by 8 weeks of age
      • The anterior fontanel usually closes between 12 and 18 months of age
  • Face
    • Symmetric appearance and movement
    • Proportional features
  • Neck
    • Short in infants
    • No palpable masses
    • Midline trachea
    • Full range of motion present whether assessed actively or passively
  • Eyes
    • Eyebrows
      • Symmetrical and evenly distributed from the inner to the outer canthus
    • Eyelids
      • Close completely and open to allow the lower border and most of the upper portion of the iris to be seen
    • Eyelashes
      • Curve outward and be evenly distributed with no inflammation around any of the hair follicles
    • Conjunctiva
      • Palpebral fissures and conjunctiva are pink
      • Bulbar conjunctiva are transparent
    • Lacrimal apparatus
      • Without excessive tearing, redness, or discharge
    • Sclera
      • Should be white
    • Corneas
      • Should be unclear
    • Pupils
      • Should be:
        • Round
        • Equal in size
        • Reactive to light
        • Accommodating
    • Irises
      • Round with the permanent color manifesting around 6 to 12 months of age
    • Visual acuity
      • Can be difficult to assess in children younger than 3 years of age
      • Visual acuity in infants can be assessed by holding an an object in front of the eyes and checking to see whether the infant is able to fix on the object and follow it
      • Use he tumbling E or HOTV test to check visual acuity of children who are unable to read letters and numbers
      • Older children should be tested using a Snellen chart or symbol charts
    • Peripheral visual fields
      • Should be:
        • Upwards 50°
        • Downward 70°
        • Nasally 60°
        • Temporally 90°
    • Extraocular movements
      • Might not be symmetric in newborns
      • Corneal light reflex should be symmetric
      • Cover/uncover test should demonstrate equal movement of the eyes
      • Six cardinal fields of gaze should demonstrate no nystagmus
    • Color Vision
      • Should be assessed using the Ishihara color test or the Hardy-Rand-Rittler test
      • The child should be able to correctly identify shapes, symbols, or numbers
    • Internal exam
      • Red reflex should be present in infants
      • Arteries, veins, optic discs, and maculae can be visualized in order children and adolescents
• Ears
  • During the tympanic membrane exam:
    • In infants – Pull pinna down and back
    • In children older than 3 – Pull pinna up and back
    • The ear canal should be pink with fine hairs
    • The tympanic membrane should be pearly pink, or gray
    • The light reflex should be visible
  • Alignment
    • The top of the auricles should meet in an imaginary horizontal line that extends from the outer canthus of the eye
  • External ear
    • The external ear should be free of lesions and nontender
    • The ear canal should be free of foreign bodies or discharge 
    • Cerumen is an expected finding
  • Hearing
    • Newborns
      • Have intact acoustic blink reflexes to sudden sounds
    • Infants
      • Turn towards sound
    • Older children
      • Can be screened by whispering a word from behind to see whether they can identify the word
• Nose
  • The position should be midline
  • Patency should be present for each nostril without excessive flaring
  • Smell can be assessed in older children
  • Internal structure
    • The spectrum is midline and intact
    • The mucosa is deep pink in light-skinned clients and various shades of brown or gray in dark-skinned clients
    • The mucosa should be moist without evidence of discharge
• Mouth and throat
  • Lips
    • Darker pigmented than facial skin
    • Smooth, soft, moist, and symmetrical
  • Gums
    • Coral pink in light-skinned clients, and various shades of brown or gray in dark-skinned clients
    • Tight against the teeth
  • Mucous membranes
    • Without lesions
    • Moist, smooth, and glistening
    • Pink in light-skinned clients and various shades of brown or gray in dark-skinned clients
  • Tongue
    • Infants can have white coating on their tongues from milk that can easily removed
    • Oral candidiasis coating is not easily removed
    • Children and adolescents should have pink, symmetric tongues that they are able to move beyond their lips
  • Teeth
    • Infants should have six to eight teeth by 1 year of age
    • Children and adolescents should have teeth that are white and smooth, and begin replacing the 20 deciduous teeth with 32 permanent teeth
  • Hard and soft palates
    • Intact, firm, and concave
  • Uvula
    • Intact and moves with vocalization
  • Tonsils
    • Infants: Might not be able to visualize
    • Children: Barely visible to prominent, same color as surrounding mucosa
  • Voice
    • Infants: Strong cry
    • Children and adolescents: Clear and articulate
  • Atraumatic Care
    • Encouraging Opening the Mouth for examination
      • Perform the examination in front of a mirror.
      • Let the child first examine someone else’s mouth, such as the parent, the nurse, or a puppet, and then examine the child’s mouth.
      • Instruct the child to tilt the head back slightly, breathe deeply through the mouth, and hold the breath; this action lowers the tongue to the floor of the mouth without the use of a tongue blade.
      • Lightly brushing the palate with a cotton swab also may open the mouth for assessment.
• Chest and Lungs
  • Chest shape
    • Infants: Shape is almost circular with anteroposterior diameter equaling the transverse or lateral diameter
    • Children and adolescents: The transverse diameter to anteroposterior diameter changes to 2:1
  • Rib and sternum
    • More soft and flexible in infants; symmetric and smooth, with no protrusions or bulges
  • Movement 
    • Symmetric, no retractions
    •  Infants: Irregular rhythms are common
    • Children younger than 7 years: More abdominal movement is seen during respirations
  • Breath sounds
    • Inspiration is longer and louder than expiration
    • Vesicular, or soft, swishing sounds, are heard over most of the lungs
  • Breasts
    • Newborn: Breasts can be enlarged during the first few days
    • Children and adolescents: nipples and areolas are darker pigmented and symmetric.
      • Females: Breasts typically develop between 10 to 14 years of age. The breasts should appear asymmetric have no masses and be palpable.
      • Males can develop gynecomastia, which is unilateral or bilateral breast enlargement that occur during puberty
  • Classification of Normal Breath Sounds
    • Vesicular Breath Sounds
      • Heard over the entire surface of the lungs with the exception of the upper intrascapular area and area beneath the manubrium.
      • Inspiration is louder, longer, and higher pitched than expiration.
      • The sound is a soft, swishing noise.
    • Bronchovesicular Breath Sounds
      • Heard over the manubrium and in the upper intrascapular regions where the trachea and bronchi bifurcate.
      • Inspiration is louder and higher pitched than in vesicular breathing.
    • Bronchial Breath Sounds
      • Heard only over trachea near suprasternal notch.
      • The inspiratory phase is short, and the expiratory phase is long.
  • Effective Auscultation
    • Make certain the child is relaxed and not crying, talking, or laughing. Record if the child is crying.
    • Check that the room is comfortable and quiet.
    • Warm the stethoscope before placing it against the child’s skin.
    • Apply firm pressure on the chest piece but not enough to prevent vibrations and transmission of sound.
    • Avoid placing the stethoscope over hair or clothing, moving it against the skin, breathing on the tubing, or sliding fingers over the chest piece, which may cause sounds that falsely resemble pathologic findings.
    • Use a symmetric and orderly approach to compare sounds.
  • Atraumatic Care
    • Encouraging Deep Breaths
      • Ask the child to “blow out” the light on an otoscope or pocket flashlight; discreetly turn off the light on the last try so the child feels successful.
      • Place a cotton ball in the child’s palm; ask the child to blow the ball into the air and have parent catch it.
      • Place a small tissue on the top of a pencil and ask the child to blow the tissue off.
      • Have child blow a pinwheel, a party horn, or bubbles.
  • Various Pattern of Respiration
    • Tachypnea: Increased rate
    • Bradypnea: Decreased rate
    • Dyspnea: Distress during breathing
    • Apnea: Cessation of breathing
    • Hyperpnea: Increased depth
    • Hypoventilation: Decreased depth (shallow) and irregular rhythm
    • Hyperventilation: Increased rate and depth
    • Kussmaul respiration: Hyperventilation, gasping and labored respiration; usually seen in diabetic coma or other states of respiratory acidosis
    • Cheyne-Stokes respiration: Gradually increasing rate and depth with periods of apnea
    • Biot respiration: Periods of hyperpnea alternating with apnea (similar to Cheyne-Stokes except that depth remains constant)
    • Seesaw (paradoxic) respirations: Chest falls on inspiration and rises on expiration
    • Agonal: Last gasping breaths before death
  • Description of selected adventitious sounds and their cause

• Circulatory System
  • Heart
    • Inspection
      • Precordial activity
      • Shape and symmetry
        • Heave: an obvious lifting of the chest wall during contraction, may indicate an enlarged heart
    • Palpation
      • Apical impulse
      • Thrills
    • Auscultation
      • Rate and rhythm

• Heart sounds
  • Auscultation should be done in both sitting and reclining position
  • S1 and S2 heart sounds should be clear and crisp. S1 is louder near the base of the heart. Physiological splitting of S2 and S3 heart sounds are expected findings in some children. Sinus arrhythmias that are associated with respirations are common

• Heat Murmurs
  • Intensity, location, radiation, timing, quality
  • Venous hum
    • Caused by turbulent blood flow through the jugular veins
  • Types:
    • Innocent: No anatomic or physiologic abnormality exists.
    • Functional: No anatomic cardiac defect exists, but a physiologic abnormality (such as, anemia) is present.
    • Organic: A cardiac defect with or without a physiologic abnormality exists.

• Pulses
  • Infants: Brachial, temporal, and femoral pulses should be palpable, full, and localized
  • Children and adolescents: Pulse locations and expected findings are the same as those in adults

• Abdomen
  • Without tenderness, no guarding. Peristaltic waves can be visible in thinner children.
  • Shape: Symmetric and without protrusions are around the umbilicus
    • Infants and toddlers have rounded abdomens
    • Children and adolescents should have flat abdomens
  • Bowel sounds should be heard every 5 to 30 seconds
  • The sections are named:
    • Left upper quadrant
    • Left lower quadrant
    • Right upper quadrant
    • Right lower quadrant
  • Atraumatic Care
    • Promoting relaxation during abdominal palpation
      • Position the child comfortably, such as in a semi reclining position in the parent’s lap, with knees flexed.
      • Warm your hands before touching the skin.
      • Use distraction, such as telling stories or talking to the child.
      • Teach the child to use deep breathing and to concentrate on an object.
      • Give an infant a bottle or pacifier.
      • Begin with light, superficial palpation, and gradually progress to deeper palpation.
      • Palpate any tender or painful areas last.
      • Have the child hold the parent’s hand and squeeze it if palpation is uncomfortable.
      • Use the non-palpating hand to comfort the child, such as placing the free hand on the child’s shoulder while palpating the abdomen.
      • To minimize the sensation of tickling during palpation:
        • Have the child “help” with palpation by placing a hand over the palpating hand.
        • Have the child place a hand on the abdomen with the fingers spread wide apart and palpate between his or her fingers.
• Genitalia
  • Anus
    • Surrounding skin should be intact with sphincter tightening noted if the anus is touched. 
    • Routine rectal exams are not done with the pediatric population
  • Male:
    • Hair distribution is diamond shaped after puberty in adolescent males. 
    • No public hair is noted in infants and small children
      • Penis
        • Should appear straight
        • Urethral meatus should be at the tip of the penis.
        • Foreskin might not be retractable in infants and small children
        • Enlargement of the penis occurs during adolescence
        • The penis can look disproportionately small in males who are obese because of skin folds partially covering the base
      • Scrotum
        • Hangs separately from the penis
        • The skin on the scrotum has a rugose appearance and is loose
        • The left testicle hangs slightly lower than the right
        • The inguinal canal should be absent of swelling
        • During puberty, the testes and scrotum enlarge with darker scrotal skin
  • Female
    • Hair distribution over the mons pubis should be documented in terms of amount and location during puberty.
    • Hair should appear in an inverted triangle.
    • No pubic hair should be noted in infants or small children
      • Labia
        • Symmetric, without lesions, moist on the inner aspects
      • Clitoris
        • Small, without bruising or edema
      • Urethral meatus
        • Slit-like in appearance with no discharge
      • Vaginal orifice
        • The hymen can be absent, or it can completely or partially cover the vaginal opening prior to sexual intercourse
• Musculoskeletal system
  • Length, position, and size of extremities are symmetric
  • Joints
    • Stable and symmetric with full range of motion and no crepitus or redness
  • Spine
    • Infants
      • Spines should be without dimples or tufts of hair. 
      • They should be midline with an overall C-shaped lateral curve
    • Toddlers
      • Appears squat with short legs and protuberant abdomen
    • Preschoolers
      • Appear more erect than toddlers
    • Children
      • Should develop the cervical, thoracic, and lumbar curvatures like that of adults
    • Adolescents
      • Should remain midline (no scoliosis noted)
  • Gait
    • Toddlers and younger children
      • A bowlegged or knock-knee appearance is a common finding
      • Feet should face forward while walking
    • Older children and adolescents
      • A steady gait should be noted with even war on the soles of shoes
• Neurological system
  • Tests for cerebellar function
    • Finger-to-nose test: 
      • With the child’s arm extended, ask the child to touch the nose with the index finger with the eyes open and then closed.
    • Heel-to-shin test: 
      • Have the child stand and run the heel of one foot down the shin or anterior aspect of the tibia of the other leg, both with the eyes opened and then closed.
    • Romberg test: 
      • Have the child stand with the eyes closed and heels together; falling or leaning to one side is abnormal and is called the Romberg sign.
  • Infant reflexes

• Cranial Nerves
  • I—Olfactory Nerve
    • Olfactory mucosa of nasal cavity (Smell)
      • With eyes closed, have child identify odors, such as coffee, alcohol from a swab, or other smells; test each nostril separately.
  • II—Optic Nerve
    • Rods and cones of retina, optic nerve (Vision)
      • Check for perception of light, visual acuity, peripheral vision, color vision, and normal optic disc.
  • III—Oculomotor Nerve
    • Extraocular muscles of eye:
      • Superior rectus: moves eyeball up and in
      • Inferior rectus: moves eyeball down and in
      • Medial rectus: moves eyeball nasally
      • Inferior oblique: moves eyeball up and out
        • Have child follow an object (toy) or light in six cardinal positions of gaze
    • Pupil constriction and accommodation
      • Perform PERRLA (Pupils Equal, Round, React to Light, and Accommodation).
    • Eyelid closing Check for proper placement of eyelid.
  • IV—Trochlear Nerve
    • Superior oblique (SO) muscle: moves eye down and out
      • Have child look down and in
  • V—Trigeminal Nerve
    • Muscles of mastication 
      • Have child bite down hard and open jaw; test symmetry and strength.
    • Sensory: face, scalp, nasal and buccal mucosa
      • With child’s eyes closed, see if child can detect light touch in mandibular and maxillary regions.
      • Test corneal and blink reflex by touching cornea lightly with a whisk of cotton ball twisted into a point (approach from side so the child does not blink before cornea is touched).
  • VI—Abducens Nerve
    • Lateral rectus (LR) muscle: moves eye temporally
      • Have child look toward temporal side
  • VII—Facial Nerve
    • Muscles for facial expression 
      • Have child smile, make funny face, or show teeth to see symmetry of expression.
    • Anterior two-thirds of tongue (sensory)
      • Have child identify sweet or salty solution; place each taste on anterior section and sides of protruding tongue; if child retracts tongue, solution will dissolve toward posterior part of tongue.
  • VIII—Auditory, Acoustic, or Vestibulocochlear Nerve
    • Internal ear
    • Hearing and balance
      • Test hearing; note any loss of equilibrium or presence of vertigo.
  • IX—Glossopharyngeal Nerve
    • Pharynx, tongue 
      • Stimulate posterior pharynx with a tongue blade; child should gag.
    • Posterior third of tongue (Sensory)
      • Test sense of sour or bitter taste on posterior segment of tongue.
  • X—Vagus Nerve
    • Muscles of larynx, pharynx, some organs of gastrointestinal system, sensory fibers of root of tongue, heart, and lung
      • Note hoarseness of voice, gag reflex, and ability to swallow.
      • Check that uvula is in midline; when stimulated with tongue blade, it should deviate upward and to stimulated side.
  • XI—Accessory Nerve
    • Sternocleidomastoid and trapezius muscles of shoulder
      • Have child shrug shoulders while applying mild pressure; with examiner’s palms placed laterally on child’s cheeks, have child turn head against opposing pressure on either side; note symmetry and strength.
  • XII—Hypoglossal Nerve
    • Muscles of tongue 
      • Have child move tongue in all directions; have child protrude tongue as far as possible; note any midline deviation.
      • Test strength by placing tongue blade on one side of tongue and having child move it away.
• Expected findings