Chapter 14 Notes

Atraumatic Care of the Pediatric Patient

! Embracing the concepts of family-centered care or patient- and family-centered
care is essential
! Family-centered care supports the around-the-clock presence and participation of
parents in care
! Hospitalization is often a traumatic experience for a child
ATRAUMATIC CARE OF THE PEDIATRIC PATIENT
As Ruggiero and colleagues (2018) point out, parents are the utilizers of their child’s health care,
and therefore obtaining parental buy-in is important in pediatric nursing to garner parental
understanding. Embracing the concepts of family-centered care or patient- and family-centered
care is essential for the pediatric nurse. Family-centered care supports the around-the-clock
presence and participation of parents in the care for hospitalized children. This approach
provides many bene ts, such as increasing the satisfaction of family and patients, improving
effective communication between health workers and families, a better understanding of
diseases, better coordination in care and the planning of follow-up visits, improving patient
safety, and increasing work satisfaction among health workers.
Parents’ perceptions of the application of atraumatic care for the hospitalization of children has
been widely studied. Hospitalization is often a traumatic experience for a child. Hospitalization
requires children to adapt to various dif cult conditions, such as treatment, health personnel, and
separation from their family, especially parents. Separation from parents often causes signi cant
emotional changes in children in terms of coping with the anxiety they feel due to the fear of
being hospitalized. Hospitalization trauma leads to various reactions in children, such as crying,
panic attack, refusal to eat, hyperactivity, and self-alienation, which make it dif cult for the
health worker to approach them. Parental presence has been shown to help the child cope with
hospitalization.

Growth and Development

! Promoting development through play in care setting
! Children primarily learn through stimulation and play
! Helps children develop:
! Fine motor and gross motor skills
! Hand-eye coordination
! Communication skills
! Social skills
! Problem-solving skills
! Memory development
Growth and Development
Promoting Development Through Play in Care Settings
Pediatric care can occur in a variety of settings including the hospital, clinic, school, or
rehabilitation center. Regardless of location of service, measurement and assessment of pediatric
growth and developmental milestones should be included in routine health screening and
physical assessment. Growth and development occur across varying settings and can be
in uenced by the environment. The nurse must have a sound understanding and knowledge

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 about the concepts of growth and development as this can better support the child and family
moving through the various growth and development stages.
Children primarily learn through stimulation and play. Play helps children develop ne and gross
motor skills, hand-eye coordination, communication skills, social skills, problem-solving skills,
and memory development. Nursing care should focus on providing age-appropriate interventions
as needed depending on the needs of the child and family. For example, toys and stimulation that
are appropriate for school may not be acceptable in the hospital. The nurse can encourage the
family members to bring the child’s favorite things from home to minimize stress and create a
sense of safety for the child as they receive care in different settings. When hospitalization is
required, health restoration is a priority, but consideration of growth and development must be
included in the nursing plan of care.
Other members of the health-care team can collaborate to support the needs of the child during
stressful times, such as before procedures. One example is a child life specialist (CLS), a
master’s-prepared specialist who works with the patient, family, and health-care team to provide
age-appropriate interventions and can be helpful to identify appropriate resources for the child,
regardless of location of service.

Gathering the Child’s Health History

! Establishing a relationship with the patient and family
! Infant or nonverbal child: health history information is obtained from those
who accompany the child to the health-care setting
! Young children need to feel secure before engaging in conversation
! School-age children may choose to be interviewed without the parent in the
room
! Adolescents need to know that certain conversations can take place without
parent’s knowledge
GATHERING THE CHILD’S HEALTH HISTORY
Establishing a Relationship With the Patient and the Family
Assessing a child’s health history can be a daunting task. Children vary in language skills, clarity
of speech, cognitive abilities, and social skills. Some children can verbalize where they hurt
while others may only react by crying. Each child must be approached with these differences in
mind. Any differences that fall out of the realm of what is considered normal growth and
development should be noted by the nurse and other members of the health-care team.
For an infant or a nonverbal child, the nurse begins the health history with an interview of the
parents, grandparents, foster parents, stepparents, nannies, older siblings, and adult guardians
who accompany the child to the health-care setting. After introductions are made, it is important
to clarify the identity of the person who has brought the child in for care.
Young children need to feel secure before engaging in conversation with the nurse. Once the
child feels comfortable with the nurse present, the child may be more apt to contribute to the
interview process. They may be able to add important pieces of information needed for optimum
care.
The school-age child may elect to be interviewed with-out the parent in the room. This allows
them to speak freely of health concerns and to ask questions. The nurse should speak with the
parent separately to determine whether the parent has speci c concerns or issues that may need
to be addressed during the visit.

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 With the adolescent, the nurse may ask the parent to leave the room during discussion of issues
related to social and sexual content. The adolescent needs to know that this conversation can take
place without the parent’s knowledge. This allows the nurse to provide appropriate medical and
nursing care that will ensure the adolescent’s health and safety. Exceptions to maintaining
con dentiality involve instances concerning abuse or a life-threatening situation, which should
be discussed with the adolescent before the health-care encounter.

Family Dynamics
Assessed by observing the behaviors between the child and parent
Questions to consider
Important to establish a good rapport with the parent by asking open questions
Conduct interview in a comfortable room with available seating for the parent
Family Dynamics
Family dynamics are assessed by observing the behaviors between the child and parent.
Questions to consider:
• During a health-care visit, does the parent or caregiver seem appropriately concerned
about the problem?
• Does the parent or caregiver have the information/knowledge or is there a gap identi ed
by the nurse that can be addressed through education of the parents regarding their child's
condition? Is the parent or caregiver a reliable historian?
• Is the parent or caregiver providing comfort to the child if the child is frightened?
• Does the parent or caregiver appear angry about being in the of ce?
• Is the parent or caregiver aware of the needs of the child?
• Does the child look well cared for?

Pediatric History
! Chief complaint
! Use of culturally appropriate care
! Comprehensive health history
! Family medical and social history
! Past medical history
! Immunization
! Developmental milestones
! Patterns of daily activities
! Review of systems
Pediatric History
When clarifying the child’s history, the nurse may use the mnemonic OLD CAT to ask the
appropriate questions. For example, a child complaining of pain would be asked these questions:
Onset: "When did the pain start?"
Location: "Where is the pain?"
Duration: "How long does the pain last?" Character: "Can you tell me on a scale of 1 to 10
how bad it is?" For a younger child, ask the parent, "How much pain do you think the child is
experi- encing?" or use a pain scale that is appropriate for the child's level of development.
Aggravating/Alleviating: "What has made the pain better or worse?"
Timing: "When does the pain start/stop?
Health Assessment

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 HEALTH ASSESSMENT
When examining children, the approach to the physical assessment is based on the child’s age,
cognitive level, and degree of illness. Infants can be examined from head to toe without
dif culty. Some children are fearful of any examiner and are uncooperative. Others seem to
enjoy the experience as something new. As a guideline, an examination starts with the least
invasive actions and concludes with the most distressful actions. For example, it is easier to
examine the posterior lung elds with the caregiver holding the child on their lap early in the
examination while leaving the examination of the ears and mouth for the end of the examination.
! Anthropometric measurements
! Length
! Weight
! Body mass index (BMI)
! Head circumference
Anthropometric Measurements
Before the physical assessment, vital signs and anthropometric measurements (growth
measurements of length, weight, and head circumference) are taken, recorded, and plotted on
appropriate growth charts. Growth charts use percentile curves to demonstrate the percent of a
child’s body measurements. The CDC recommends that the World Health Organization growth
standards be used to monitor for children 0 to 2 years of age, and the CDC growth charts be used
for children older than 2.
Length
Length is measured while an infant is lying supine on a measuring tray or board. If a measuring
board is not available, the nurse holds the head in midline while an assistant holds the hips and
knees extended at on a paper-covered table. Points are marked at the top of the head and the
heels of the feet, the child is moved, and the distance between markings is measured. For the
older child, a stadiometer (a device used to measure a standing height) is used to obtain a
standing height. The child removes their shoes and stands with their back to the stadiometer, with
the back of the heels and shoulders touching the wall.
Weight
The weight of an infant is measured using an infant scale lined with a thin paper cover. After the
scale setting is balanced, the infant’s clothing is removed and the child is weighed in either a
supine or sitting position. The nurse protects the child from an accidental fall by placing a hand
over the infant without direct contact. Older children are weighed on a standing scale. The same
scales should be used to measure height and weight at each visit.
Once weight and height are assessed, body mass index (BMI) can be calculated. The BMI is used
to assess total body fat and nutritional status. In children, the BMI is represented as a percentile,
allowing a comparison to other children of the same age and gender. BMI is assessed at least
once a year at the annual well-child appointment.
Head Circumference
For children 3 years old and younger, head circumference measurements are done at routine
well-child visits. The head’s largest circumference is measured by placing the tape over the lower
forehead, above the pinna of the ears, and over the occipital prominence (Fig. 14-1). This
measurement is recorded in centimeters and displayed as a percentile. As with weight and height,
evidence of growth within the percentiles remains consistent over time, with normal values
according to age and gender re ecting normal development. A deviation either below or above

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the percentile from the previous visit may signify a problem. The nurse informs the primary care
provider of these ndings.
! Vital signs
! Temperature
! Pulse
! Respirations
! Blood pressure
Vital Signs
Temperature
Vital signs consist of temperature, pulse, respirations, and blood pressure (Table 14-3). A variety
of digital and tympanic thermometers are available. The route used for assessing temperature
depends on the age and developmental level of the child. Newborn temperature is assessed via
the axillary route. The tip of a digital thermometer is placed in the axilla with the arm held
against the side of the body until the temperature registers. Rectal temperatures are not routinely
measured. If a rectal temperature is desired, caution is taken not to insert the thermometer more
than 1⁄2 inch. In older children, tympanic membrane or temporal temperatures are obtained (Fig.
14-2). Because temperatures register within seconds, this route is a convenient one in pediatrics.
The route used is charted when recording the child’s temperature.
Pulse
Assessing the pulse in newborns and children requires concentration. The heart rate is variable
and changes with illness. The apical pulse is counted for a full minute while the infant or child is
quiet. With an uncooperative infant, the femoral arteries are palpated in the inguinal area, or the
brachial arteries in the antecubital fossa.
Respirations
Respirations are to be counted for 1 full minute and can be assessed accurately only when the
infant or child is not crying. A good time to count them is when a child is sleeping or resting
quietly in a parent’s arms. If possible, it is wise to start the vital sign assessment with
respirations. There is a great deal of variability in the respiratory rate in children. Infants and
young children are diaphragmatic breathers. The nurse can visually count the number of
respirations by observing the abdomen as the child breathes.
Blood Pressure
Blood pressure is measured during well-child visits or routine physicals beginning at age 3.
Readings are especially important for children with cardiac, pulmonary, or kidney disease;
dehydration; or complaints of dizziness, regardless of age. For accurate radial blood pressures,
selection of the cuff size is important. Appropriate cuff size is one in which the width of the
bladder is approximately 40% and the length is approximately 80% of the circumference of the
arm. Electronic blood pressure devices with varying cuff sizes are also available.

! General impression
General Impression
As the nurse meets the child and the parents and engages in conversation with them, an
impression begins to form. This subjective feeling about the child encompasses many areas of
assessment. As the nurse conducts the health history and performs the physical assessment,
additional notions regarding the child and family develop. Not only is the uniqueness of the child
portrayed, but a re ection of the child’s family life becomes evident.

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 Take note of the behaviors of the child as they interact with their parents. How does the child
react to questions? What is the child’s speech like? Is the child quiet, pleasant, talkative,
uninterested, or angry? For the younger child, does the child listen to parents, interact in a
meaningful way, or engage in age-appropriate behavior?
Hygiene and nutritional status are also examined. Is the child clean and appropriately dressed for
the season? Body size, skin color, eyes, and the condition of the hair are observed for evidence of
a good overall nutritional state.
! Skin assessment
Skin Assessment
The skin is assessed for color, turgor, and lesions. Skin color re ects ethnicity, diet, disease, and
injury. Variations in tone are a result of genetic composition. Carotenemia, a benign yellowing of
the skin caused by excessive carotene in the blood, may be present in the child with a diet high in
yellow and orange vegetables, or yellowing of the skin and sclerae may indicate a dysfunction of
the liver. Pallor may indicate anemia. Cyanosis may indicate a compromised cardiorespiratory
state. Petechial lesions may indicate an infectious process or a blood disorder. Ecchymotic
lesions may also indicate a blood disorder or signify past accidental or non-accidental injuries.
The nurse can assess the child’s skin turgor for evidence of dehydration by grasping a small area
of skin and pulling up. Once released, the skin should quickly return to its normal position. Skin
that remains in the “tenting” position for several seconds indicates absence of skin turgor or
presence of skin turgor with inadequate hydration.
If a rash is present or if jaundice is suspected, the nurse determines whether the skin blanches or
turns pale by applying pressure to the skin with the thumbs about 1 to 2 inches apart. This
presses the normal pink and darker colors out.
In the presence of jaundice, there is a yellowish underlying color. Petechial lesions do not blanch,
which may indicate a serious bacterial infection in an ill child. The primary healthcare provider
should be noti ed immediately.
The skin examination concludes with the inspection and documentation of the texture of the hair
and the condition of the scalp, palms, and nails. Cradle cap is common in new-borns and infants
and is identi ed by thick, crusty scales over the scalp. The older child is monitored for lice or
ticks.
Normal nails are pink and convex, with white edges extending over the end of the ngers. In
children with cardiac disease, nails are examined for evidence of clubbing. Nail biting is a
nervous habit evidenced by very short nails without the normal white edges.
The palms are examined for the normal exion creases. While most people have three creases, in
a small section of the population the two horizontal creases fuse to form a single horizontal
palmar crease. This is a common nding in many genetic disorders, particularly Down’s
syndrome. If this palmar crease is evident on only one hand, the child may have no genetic
disorders.
! Head assessment
Head Assessment
The head is observed for symmetry and shape. Beyond the newborn period, head shape
abnormalities in the infant may be caused by craniosynostosis, a premature fusing of one or
more of the cranial sutures, or from gravitational in uences caused by the infant’s head being
kept in the same position for an extended period of time. An odd head shape can develop because
of the malleability of the skull bones. The supine sleep position has greatly reduced the incidence
of sudden infant death syndrome. However, infants who are placed in the recommended supine

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 position for sleep are at increased risk for deformational posterior plagiocephaly, or attening,
of the occiput.
The skull is palpated to evaluate fontanelles, sutures, contusions, or other swellings. Fontanelles
are brous membrane-covered areas where two or more skull bones converge. Although there are
six fontanelles, the two most commonly evaluated are the posterior and anterior fontanelles. The
posterior fontanelle closes within 1 to 3 months after birth, while the diamond-shaped anterior
fontanelle (AF) remains open until 12 to 18 months of age.
The AF is the most signi cant fontanelle for evaluation (Fig. 14-3). Assess the fontanelles when
the infant is held in a sitting position. Depression of the AF may indicate dehydration; fullness of
the AF is a potential sign of increased intracranial pressure.
The face is examined for general appearance and the comparison of features to those of the
parents. Unusual features are noted, such as a micrognathia (shortened chin), low-set ears,
attened nasal bridge, enlarged or protruding tongue, allergic shiners (dark, undereye rings), or
a wide and attened philtrum (the vertical groove from the bottom of the nose to the upper lip).
! Neck assessment
Neck Assessment
Lymph nodes of the head and neck are palpated systematically, starting at the preauricular area,
proceeding to the postauricular area, and then to the occipital nodes (Fig. 14-4). Next, the
tonsillar nodes at the angle of the mandible are examined, followed by the submandibular and
submental nodes under the chin, the cervical chain of lymph nodes, and the supraclavicular area.
Size, shape, mobility, and tenderness are documented. It is common for young children to have
palpable, painless, movable nodes up to 1 cm in diameter. Pain upon palpation may be indicative
of an upper airway infection. The trachea is palpated for midline placement and masses. A lateral
deviation of the trachea may be caused by a mass or a collapsed lung. The thyroid gland is
examined for enlargement, nodules, and goiters.
! Eye assessment
Eye Assessment
Observation of the eyes includes assessment of symmetry, shape, and placement in relation to the
nose. In addition, the nurse can assess for symmetry and size of the pupils and their response to
light. The conjunctiva and lids are observed for conjunctivitis, styes, or chalazions (small
discrete swellings of the upper lid that develop when a meibomian oil gland becomes blocked).
The sclerae are inspected for color. The nurse notes erythema, swelling, or discharge from the
eye. Documentation of the presence of discharge includes type (e.g., watery or purulent), color,
amount, and associated symptoms. Treatment depends on the cause, which may be bacterial,
viral, or allergic.
! Visual acuity
VISUAL ACUITY
To ensure optimal eye health in children, testing for ocular alignment and visual acuity should be
examined yearly. Assessment of visual acuity depends on the age of the child. Infants begin to
use a steady gaze to regard faces or objects with interesting patterns. The nurse observes for and
documents this nding during the physical examination. Any difference in visual acuity between
one eye and the other is abnormal and requires a referral to a specialist. In addition, children are
referred for further evaluation if they have a visual acuity reading of less than 20/50 or after
failing a second screening.
! Ocular alignment
OCULAR ALIGNMENT

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 A common method for assessing ocular alignment is the Hirschberg corneal light re ex test, in
which a light is shone directly into the child’s eyes and the position of the corneal light re ection
in both eyes is noted. The re ection should fall in the same location on the cornea of each eye.
Displacement of the corneal light re ection in one eye is indicative of strabismus.
The second screening test is the cover-uncover test, in which the child is asked to focus on a
distant object across the room. The nurse covers the rst eye while watching the second eye for
movement. The cover is then removed from the rst eye, which is observed for any movement. If
no movement is detected, ocular alignment is intact. The examination is repeated on the opposite
eye.
The red re ex is tested by viewing the pupil through an ophthalmoscope from a distance of 10
inches. If the pupil appears red, the nding is normal. A white retinal re ex may indicate
cataracts, retinoblastoma, or chorioretinitis.
! Ear Assessment
Ear Assessment
The external ears are examined for size, shape, placement, pain, and presence of drainage from
the ear canal. The pinna of the ear should be above the imaginary horizontal line drawn from the
medial and lateral canthi toward the occiput. Various congenital anomalies are associated with
low-set ears; for example, a congenital anomaly such as Down’s syndrome is associated with
low-set and/or misshapen ears. In another example, because ears and the kidneys are developed
during the same time in utero, ear anomalies are also associated with renal abnormalities.
To assess for pain, and potential otitis externa (infection of the outer ear), the nurse moves the
pinna of the ear up and down. If the child complains of pain when pressure is applied to the
tragus, the canal is examined for evidence of otitis externa. Cerumen (ear wax) may be seen on
the external ear or in the external canal with an otoscope. Purulent drainage may indicate a
foreign body in the external ear canal or a ruptured tympanic membrane. Any clear drainage
noted from the ear, particularly after head trauma or with cranial infections, should be reported to
the health-care provider immediately because this uid may indicate a cerebrospinal uid leak.
Visual loss of these landmarks may occur because of erythema, fullness behind the tympanic
membrane, in ammation, purulent exudate, or uid. Because of the anatomical structure of their
ears, infants and young children are prone to developing otitis media. The eustachian tubes are
shorter and more horizontally positioned than those of adults, enabling viruses and bacteria to
travel to the middle ear. Infants who are breastfed, do not attend day care, and are fed in an
upright position have decreased rates of otitis media.
Early detection of hearing loss is important to prevent delayed hearing, speech, and language
development. Hearing loss may affect both the academic success and psychosocial development
of the child. Because hearing loss in childhood is associated with middle ear disease, it is
recommended that children with positive results from of ce screening examinations be referred
to an audiologist for further evaluation and treatment.
General Assessment
! Systematic order of exam
! Least invasive to most invasive
! Reserve head to toe order for the older child
! Consider developmental age versus chronological age
! Be honest!
! Take note of cleanliness and clothing
! Is the child clean/dirty? Is the child appropriately dressed?

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 ! Signs of neglect versus physical abuse versus sexual abuse

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Measurements
! Weights
! Use standing scale when child can safely stand steady without assistance
! Lengths/Heights
! 0-2 years measure length
! > 2 years measure height
! Head Circumference
! Measure up to 36 months
Anthropometric Measurements
Before the physical assessment, vital signs and anthropometric measurements (growth
measurements of length, weight, and head circumference) are taken, recorded, and plotted on
appropriate growth charts. Growth charts use percentile curves to demonstrate the percent of a
child’s body measurements. The CDC recommends that the World Health Organization growth
standards be used to monitor for children 0 to 2 years of age, and the CDC growth charts be used
for children older than 2.
Weight
The weight of an infant is measured using an infant scale lined with a thin paper cover. After the
scale setting is balanced, the infant’s clothing is removed and the child is weighed in either a
supine or sitting position. The nurse protects the child from an accidental fall by placing a hand
over the infant without direct contact. Older children are weighed on a standing scale. The same
scales should be used to measure height and weight at each visit.
Once weight and height are assessed, body mass index (BMI) can be calculated. The BMI is used
to assess total body fat and nutritional status. In children, the BMI is represented as a percentile,
allowing a comparison to other children of the same age and gender. BMI is assessed at least
once a year at the annual well-child appointment.
Length
Length is measured while an infant is lying supine on a measuring tray or board. If a measuring
board is not available, the nurse holds the head in midline while an assistant holds the hips and
knees extended at on a paper-covered table. Points are marked at the top of the head and the
heels of the feet, the child is moved, and the distance between markings is measured. For the
older child, a stadiometer (a device used to measure a standing height) is used to obtain a
standing height. The child removes their shoes and stands with their back to the stadiometer, with
the back of the heels and shoulders touching the wall.
Head Circumference
For children 3 years old and younger, head circumference measurements are done at routine
well-child visits. The head’s largest circumference is measured by placing the tape over the lower
forehead, above the pinna of the ears, and over the occipital prominence (Fig. 14-1). This
measurement is recorded in centimeters and displayed as a percentile. As with weight and height,
evidence of growth within the percentiles remains consistent over time, with normal values
according to age and gender re ecting normal development. A deviation either below or above
the percentile from the previous visit may signify a problem. The nurse informs the primary care
provider of these ndings.

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 Skin
! Note birthmarks
! Mongolian spots
! Ecchymosis is a common nding in children
! Learning to walk
! Movements not as coordinated
! Forehead, knees, shins, lower arms
! Be alert to areas of balding on an infant
Skin Assessment
The skin is assessed for color, turgor, and lesions. Skin color re ects ethnicity, diet, disease, and
injury. Variations in tone are a result of genetic composition. Carotenemia, a benign yellowing of
the skin caused by excessive carotene in the blood, may be present in the child with a diet high in
yellow and orange vegetables, or yellowing of the skin and sclerae may indicate a dysfunction of
the liver. Pallor may indicate anemia. Cyanosis may indicate a compromised cardiorespiratory
state. Petechial lesions may indicate an infectious process or a blood disorder. Ecchymotic
lesions may also indicate a blood disorder or signify past accidental or non-accidental injuries.
The nurse can assess the child’s skin turgor for evidence of dehydration by grasping a small area
of skin and pulling up. Once released, the skin should quickly return to its normal position. Skin
that remains in the “tenting” position for several seconds indicates absence of skin turgor or
presence of skin turgor with inadequate hydration.
If a rash is present or if jaundice is suspected, the nurse determines whether the skin blanches or
turns pale by applying pressure to the skin with the thumbs about 1 to 2 inches apart. This
presses the normal pink and darker colors out.
In the presence of jaundice, there is a yellowish underlying color. Petechial lesions do not blanch,
which may indicate a serious bacterial infection in an ill child. The primary healthcare provider
should be noti ed immediately.
The skin examination concludes with the inspection and documentation of the texture of the hair
and the condition of the scalp, palms, and nails. Cradle cap is common in new-borns and infants
and is identi ed by thick, crusty scales over the scalp. The older child is monitored for lice or
ticks.
Normal nails are pink and convex, with white edges extending over the end of the ngers. In
children with cardiac disease, nails are examined for evidence of clubbing. Nail biting is a
nervous habit evidenced by very short nails without the normal white edges.
The palms are examined for the normal exion creases. While most people have three creases, in
a small section of the population the two horizontal creases fuse to form a single horizontal
palmar crease. This is a common nding in many genetic disorders, particularly Down’s
syndrome. If this palmar crease is evident on only one hand, the child may have no genetic
disorders.

HEENT
! HEAD
! Suture lines
! There should not be any separation
! Fontanelles
! Posterior closes by 3 months of age

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 ! Anterior closes by 18 months of age

! EYES
! Symmetry of size and shape
! Pupil size, shape, reactivity
! Visual acuity testing at 3 years if able to understand/follow directions
(choose the age appropriate eye chart)
! Test with and without glasses
! EARS
! Look for symmetrical size and placement
! When inspecting tympanic membrane:
! Pull pinna down and back under 3 years
! Pull pinna up and back older than 3 years
^^^^

Thorax & Lungs

Nose vs. mouth breathers
Chest vs. belly breathers
• Abdominal/diaphragmatic breathing less than 7 years of age
• Older children are thoracic breathers
Throat/Mouth Assessment
The examination of the throat and mouth is saved for last in younger, less cooperative children.
The nurse may ask the child to see “all of the tongue.” Eliciting the sound “eeehh” attens the
tongue better than “aaahh,” and visualization of the posterior pharynx is possible without the use
of the tongue blade. The palate, uvula, tonsils, and mucous membranes are observed and
assessed for color, exudate, and odor. The lips are observed for shape, symmetry, color, dry-ness,
ssures at the corners of the mouth indicative of vitamin B2 (ribo avin) de ciency, and clefts.
The teeth are inspected for number present, condition, color, alignment, and caries. Tooth
eruptions occur at varying rates. Generally, when counting teeth on visual examination, the nurse
can expect one tooth per month after 6 months of age until all 20 deciduous teeth are in place.
The gingival tissue is inspected for color and condition. The gingival tissue is the same color as
the surrounding mucous membranes and should not be hypertrophied or show evidence of
bleeding.
Lung Assessment
Lung sounds are best auscultated with the child in a sitting position. The nurse instructs the child
to take slow deep breaths through an open mouth. Using a stethoscope with an appropriately
sized pediatric diaphragm, the nurse systematically auscultates the ve lobes of the lungs,
anteriorly and posteriorly, beginning with the apices and then moving side to side to compare
bilateral lung sounds. In an infant, auscultation of lung sounds is best done early in the
examination, while the child is quiet.
Direct observation of a child’s breathing can help determine inadequate oxygenation status. For
example, a child with tachypnea (a rapid respiratory rate is 80 to 120 breaths/ minute), shallow
breathing, and use of accessory muscles means respiratory distress. Conversely, the child with
slow breathing means the child does not have the energy for adequate oxygenation. Quiet breath
sounds with an increased work of breathing means that air is not entering the lung elds. An
alteration in depth, hyperpnea (too deep), is associated with fever, and hypopnea (too shallow)
is associated with central nervous system depression.

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 The child’s posture can also indicate adequate or inadequate oxygenation. The child in
respiratory distress sits in a tripod position sitting upright, leaning forward on out-stretched arms
with the jaw thrust forward. This position helps maximize opening of the airway and use of
accessory muscles of respiration. Because a child with respiratory dif culties is often anxious, it
is important to allow them to assume the position of comfort, which is usually the position that is
easiest for the child to breathe.
BREATH SOUNDS
Normal breath sounds can be classi ed as bronchial, bronchovesicular, or vesicular. Adventitious
sounds of these three classi cations are described as crackles, wheezes, and rhonchi,
respectively. Bronchial breath sounds are loud, high-pitched, and heard only over the trachea.
The inspiratory and expiratory sounds are equal in length. Bronchovesicular breath sounds are of
intermediate intensity and pitch, with equal inspiratory and expiratory phases. These sounds are
best heard between the scapulae and over the mainstem bronchi. If bronchial or bronchovesicular
sounds are heard elsewhere, it is indicative of an area of consolidation. Vesicular breath sounds
are heard throughout the lung elds. These soft and low-pitched sounds have a longer inspiratory
phase than an expiratory one. Decreased or absent breath sounds indicate a serious condition
such as asthma, atelectasis, emphysema, pneumothorax, or acute respiratory distress syndrome
(ARDS).
Chest Assessment
The nurse inspects the chest for size, shape, symmetry, respiratory effort, and breast
development. In infants, the anteroposterior diameter is fairly equal to the lateral diameter. By
age 2, the lateral diameter is greater than the anteroposterior diameter. Equal anteroposterior and
lateral diameter after the age 2 may indicate chronic lung disease. A chest that is larger on the left
than on the right may indicate an enlarged heart or a collapsed right lung. Pectus carinatum
(protrusion of the chest) and pectus excavatum (abnormal depression of the lower portion of the
sternum) are abnormal chest shapes caused by sternal deviations.
With any increased work of breathing, retractions are observed. When the trachea or the smaller
airways of the lungs experience air ow restriction, the pressure within the chest is reduced. As a
result, the intercostal muscles are drawn inward in an attempt to assist in breathing. This drawing
inward is visible as intercostal retractions. Retractions may also be seen in the substernal,
subcostal, and suprasternal notch regions.
Normal breast development begins in girls between 10 and 14 years of age. Boys also undergo
breast changes, and many show evidence of breast development. For the female, breast
development is documented using the Tanner Staging of Development of Secondary Sex
Characteristics (Table 14-4). Breast assessment is important at every well-child visit for early
detection of precocious puberty. Girls must be taught breast self-examination when breast tissue
begins to develop.
Retractions
^^^^

Heart
! Apical pulse location changes with growth
! < 7 years 4th intercostal space medial to the left midclavicular line
! > 7 years, 5th intercostal space at the left midclavicular line
! Normal sounds
! S1 heard best at the apex (tricuspid, mitral areas)

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 ! S2 heard best at the base (aortic, pulmonic areas)
! S3 is a normal nding in children
^^^^

Abdomen
! Infants to 6 years breathe with diaphragm
! Infants and toddlers = Rounded abdomens
! Children and adolescents = Flat abdomens
! Umbilical hernias are common in infants and African-American children
^^^^
Tanner's Scale: Understand the
Genitalia progression - from Laarveld
????

Musculoskeletal Bowley
! Observe shape of extremities
! Genu Varum (A) - normal until age 2/3
! Genu Valgum (B) – normal from 2 – 7 years of age
! Assess for hip dysplasia
! Symmetrical gluteal folds Knock-Knees
! Assess for scoliosis
! Unilateral rib hump
????

Neuromuscular
! Infant re exes
! Cerebellar function
! Assess on children and adolescents
! Finger to nose, heel to shin, Romberg
????
Nursing Care of the Child with a Disability
! Emotional Concerns: raising a child with a disability is distressing because of the
disruption of the normal routine
! Developmental Concerns: many congenital problems are repaired surgically either
shortly after birth or once the child is physically developed and strong enough to
withstand the rigors of surgery
! Physical Concerns: can pose various physical concerns as often, abnormalities
a ect several body systems
! Caregiver Fatigue: caring for a child with a signi cant disability takes its toll on the
entire family.
THE CHILD WHO HAS A DISABILITY
Disabilities may be congenital or genetically based or develop from illness, injury, or disease
progression (Table 14-7). Regardless of the cause, families of children with disabilities are beset
with emotional upset and confusion about the reality of not having the child they expected (i.e.,
one without a disability). In addition, the family is often distressed about the child’s pain and
their experiences with surgery, treatments, procedures, and repeated clinic appointments. The

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 child is apt to have ongoing physical, occupational, or speech therapy, and parents often need to
perform physically painful procedures at home to promote their child’s development. Other
ongoing treatments and procedures include respiratory therapy, gavage feedings, medication
administration, using assistive devices, planning special diets, taking care of elimination needs,
and implementing special techniques to maintain the musculoskeletal system. Understanding the
child with a disability includes knowing about emotional, developmental, and physical concerns
as well as comprehending caregiver fatigue and the concept of resiliency.
Understanding the Child With a Disability
Emotional Concerns
Raising a child with a disability is distressing because of the disruption of the normal routine, the
conveyance of continuous “bad news” or prognostics, the recon rmation of future emotional and
physical concerns, and the awareness of nancial implications of diagnosis and treatment. These
nancial concerns include medical care that is not covered by insurance or government-
sponsored health-care programs as well as expenses incurred for child care or respite care. Often,
a parent is required to stop working and become a full-time caregiver, resulting in further
economic distress. The nurse can help the family access community resources that can provide
ongoing emotional support.
Developmental Concerns
Many congenital problems are repaired surgically either shortly after birth or once the child is
physically developed and strong enough to withstand the rigors of surgery. Parents and the child
need constant support from health-care personnel to sustain a loving environment for the child
with a disability who may be undergoing the same growth and development changes as any other
child of the same age. However, because of constant medical and surgical interventions, the child
may demonstrate signs of regression.
Physical Concerns
Caring for a child with a disability can pose various physical concerns. For example, children
with severe congenital heart problems face a lifetime of corrective procedures to augment initial
surgeries or pharmacological therapies that consume time, energy, and nances. In addition, both
parent and child need to learn physical self-care techniques, such as diabetes or anticoagulation
monitoring. Often, abnormalities affect several body systems so visits must be made to several
different medical specialists who may require multiple pharmacotherapeutic regimens. Through-
out all this, families must learn to care for the physical needs of the child.
Caregiver Fatigue
Caring for a child with a signi cant disability takes its toll on the entire family. Respite care
agencies were developed in response to the needs of parents of extremely disabled children to
give short-term relief from the 24-hour surveillance and care often required in cases of severe
disability. As medical advancements have increased the life expectancy of disabled children, so
too have the number of disabled children or premature births resulted in larger numbers of
children and families requiring long-term medical care and social systems to support their needs

Decreasing Hospital Stress

! Play therapy: has been shown to help to ease the stress of hospitalization and
decrease the child’s fear and anxiety. It may provide children with a means for
dealing with their concerns and feelings.
! Guided Imagery: the mind helps the body maintain a relaxed state with the help of
all ve senses.

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! Role Modeling: the child learns certain behaviors by observing the behavior of
others.
DECREASING THE STRESS OF HOSPITALIZATION
Hospitalization of a child places stress on both the child and family. Family visitation and the
family-centered care have dramatically helped children and families cope with the stress of a
hospitalization. Despite the availability of parental rooming-in, the parent may also be coping
with other children at home or the need to work, which could lead to separation from the child
even though family visitation is encouraged. It is important to remember that the ill child
depends on their parents as the primary source of coping and comfort. To help a child of any age
adapt to the stress of hospitalization, the pediatric nurse can suggest rooming-in to the parents,
where they stay in the room both during the day and through the night (Table 14-8).
The nurse can also use creativity in helping the child to gain control over the environment by
encouraging them to bring items from home to familiarize the room and make it personal. They
might also encourage the child to draw a picture or design that can be hung up in the hospital
room or ask them to watch a movie or select a game that they would like to play.
Therapeutic Play
Therapeutic play, otherwise known as play therapy or medical play, is used with children who
have had or will have a stressful medical experience. Therapeutic play has been shown to help to
ease the stress of hospitalization and decrease the child’s fear and anxiety. It may provide
children with a means for dealing with their concerns and feelings.
Some facilities have a child life therapist to assist with therapeutic play and offer age-appropriate
toys or distraction such as music or games. Therapeutic play also may help the child to cope
with, and master, stressful experiences (Fig. 14-8). Pediatric nurses are encouraged to
incorporate therapeutic play in their everyday care of the child. By using play techniques and
activities in all settings, including the emergency and outpatient departments, children bene t
even from watching other children at play.
Therapeutic play can be used to prepare a child who requires an injection. The nurse or child life
therapist encourages the child to play with equipment such as a needleless syringe lled with
water, a doll, and an alcohol prep pad. After the injection, the nurse can then provide a bandage
and a sticker for a reward. Another example is an older child simulating the medical procedure
(administering IV antibiotics), a therapeutic play technique that the nurse uses to discuss the
process with the child, clarifying what is going to happen and allowing them to release anxiety
and decrease fears of the imminent situation.
Guided Imagery
Another way to help a child cope with the stress of hospitalization is the use of guided imagery.
This relaxation technique, which can be used by people of all ages, aims to ease stress and
promote a sense of peace and harmony during a dif cult time. With this technique, the mind
helps the body maintain a relaxed state with the help of all ve senses.
Role Modeling
Role modeling can help decrease fears and anxieties as well as teach coping skills. During this
process, the child learns certain behaviors by observing the behavior of others. Role models can
be the people who are involved in the child’s life, such as parents, grandparents, siblings, or
teachers as well as peers and entertainment and sports gures. Role models who are similar in
age, sex, race, and attitudes and who have a caring demeanor are more likely to be imitated. For
example, a child might view a video about another child and their experience preparing for

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 hospitalization and surgery. Seeing another child going through a similar experience may help
them cope with the anxiety and stress of the impending procedure.

Preparing Children for Procedures

PREPARING CHILDREN FOR PROCEDURES
Explaining Procedures
As a child grows and develops cognitively, their understanding of experiences and response to
the events naturally changes. To an adolescent, a venipuncture may be an annoyance, but to a
toddler, it may be a frightening experience that is stressful to both the child and parent.
Developmental characteristics dictate how to approach the child and what to say to the child.
What the nurse conveys to the patient and the parents can diminish the anxiety and fearfulness
associated with common procedures.

Infant
! Describe the procedure to the parents, explaining what will happen and how long it
will take. Encourage the parent to stop you at any point if they have a question.
! Remind parents that infants often cry for reasons other than discomfort but be
honest about any discomfort the infant may experience with the procedure.
! Identify what restraints may be used and give an explanation as to why they are
needed.
! Allow parents to decide whether they would like to be present for the procedure.
Parents may prefer to leave the room and return immediately following the
procedure to comfort their child.
Preparing an Infant for a Procedure
• Describe the procedure to the parents, explaining what will happen and how long
it will take. Encourage the parent to stop you at any point if they have a question.
• Remind parents that infants often cry for reasons other than discomfort but be
honest about any discomfort the infant may experience with the procedure.
• Identify what restraints may be used and give an explanation as to why they are
needed.
• Allow parents to decide whether they would like to be present for the procedure.
Parents may prefer to leave the room and return immediately following the procedure
to comfort their child.

Toddler
! Describe the procedure to the parents, explaining what will happen and how long it
will take.
! Use play to demonstrate the procedure to the toddler; encourage them to
demonstrate or practice with a doll or teddy bear.
! Use simple, concrete language to describe the procedure and how it might feel to
the toddler. Limit preparation to 5 to 10 minutes because of the child’s short
attention span.
! Identify what restraints may be used and explain why they are needed.
! Allow parents to decide whether they would like to be present for the procedure.
Parents may prefer to leave the room and return immediately after the procedure to

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 comfort their child. Allow the parents to stroke their child or speak soothingly to
their child if they remain in the room.
Preparing a Toddler for a Procedure
• Describe the procedure to the parents, explaining what will happen and
how long it will take.
• Use play to demonstrate the procedure to the toddler; encourage them to
demonstrate or practice with a doll or teddy bear.
• Use simple, concrete language to describe the procedure and how it might
feel to the toddler. Limit preparation to 5 to 10 minutes because of the child’s
short attention span.
• Identify what restraints may be used and explain why they are needed.
• Allow parents to decide whether they would like to be present for the
procedure. Parents may prefer to leave the room and return immediately after
the procedure to comfort their child. Allow the parents to stroke their child or
speak soothingly to their child if they remain in the room.
Preschooler
! Explain the procedure in terminology the child can understand.
! Begin preparation immediately before the procedure so the child will not worry for
hours or days.
! Use play to demonstrate the procedure to the child; encourage them to
demonstrate or practice with a doll or teddy bear.
! Set limits for the child so they are aware of expectations. For example, tell them
they can yell and scream as much as they want but must hold very still.
! Give legitimate choices to the child whenever possible.
! Allow parents to decide whether they would like to be present for the procedure.
Parents may prefer to leave the room and return immediately after the procedure to
comfort their child.
! Allow the parents to stroke their child or speak soothingly to their child if they
remain in the room.
! Use distraction techniques such as deep breathing, singing, or squeezing a
parent’s or nurse’s hand.
Preparing a Preschooler for a Procedure
• Explain the procedure in terminology the child can understand.
• Begin preparation immediately before the procedure so the child will not worry for
hours or days.
• Use play to demonstrate the procedure to the child; encourage them to demonstrate or
practice with a doll or teddy bear.
• Set limits for the child so they are aware of expectations. For example, tell them they
can yell and scream as much as they want but must hold very still
• Give legitimate choices to the child whenever possible.
• Allow parents to decide whether they would like to be present for the procedure.
Parents may prefer to leave the room and return immediately after the procedure to
comfort their child.
• Allow the parents to stroke their child or speak soothingly to their child if they remain
in the room.

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 • Use distraction techniques such as deep breathing, singing, or squeezing a parent’s or

nurse’s hand.
Schoolage
! Explain procedure in terminology the child can understand.
! Preparation can begin in advance of procedure because they have a good
concept of time
! May use play to demonstrate the procedure and if possible, have the child
demonstrate on and practice positioning with a doll or teddy bear.
! Allow the child to touch and explore equipment to be used and involve the child in
simple tasks during the procedure when possible.
! Set limits for the child so they are aware of expectations.
! For example, tell them they can yell and scream as much as they want but
must hold very still.
! Give choices whenever possible.
! Allow parents and child to decide together whether parents will stay for the
procedure.
! Allow the parents to stroke their child or speak soothingly to their child if
they remain in the room.
! Teach techniques like deep breathing, counting, reciting a silly rhyme, or anything
else that might help distract and relax the child during the procedure.
Preparing a School-Age Child for a Procedure
• Explain the procedure in terminology that the child can understand. Children
in this stage of development have a better concept of time than younger
children do, so preparation can begin in advance of the procedure.
• For the younger school-age child, use play to demonstrate the procedure and if
possible, have the child demonstrate on and practice positioning with a doll or
teddy bear.
• Allow the child to touch and explore equipment to be used in the procedure
and involve the child in simple tasks during the procedure when possible.
• Set limits for the child so they are aware of expectations. For example, tell
them they can yell and scream as much as they want but must hold very still.
• Teach the child techniques such as deep breathing, counting, reciting a silly
rhyme, or anything else that might help distract and relax the child during the
procedure.
• Give legitimate choices to the child whenever possible.
• Allow parents and the child to decide together whether parents will be present
for the procedure. Some school-age children may be modest about exposing
body parts in front of family members. Allow the parents to stroke their child
or speak soothingly to their child if they remain in the room.
Adolescent
Describe the procedure, explaining exactly what will happen and how long it will take.
Encourage the adolescent to stop you at any point if they have a question.
Be honest. Describe potential risks and pain associated with the procedure, but don’t
dwell on it.
Allow the adolescent to take as active a role as possible.

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 Practicing positioning or demonstrating the equipment before the procedure

helps give the adolescent a sense of control.
Provide a peer video of the procedure if possible.
If possible, let them make decisions like when the procedure should take place.
Allow the adolescent the option of having a parent present.
O er tips for distraction such as deep breathing, relaxation, counting, or squeezing an
object or parent’s hand.
Preparing an Adolescent for a Procedure
• Describe the procedure, explaining exactly what will happen and how long it will take.
Encourage the adolescent to stop you at any point if they have a question.
• Be honest. Describe potential risks and pain associated with the procedure, but don’t dwell on
it.
• Allow the adolescent to take as active a role as possible in the procedure. Practicing
positioning or demonstrating the equipment before the procedure helps give the adolescent a
sense of control.
• Provide a peer video of the procedure if possible
• If possible, allow the adolescent to make decisions such as when the procedure should take
place
• Allow the adolescent the option of having a parent present
• Offer tips for distraction such as deep breathing, relaxation, counting, or squeezing an object
or parent’s hand.

Informed Consent
Providing the patient with the necessary knowledge to make a decision regarding
health care and the bene ts and risks of treatment or the refusal of treatment.
In most of the United States and Canadian provinces, the age of legal consent is 18.
An exception is made for the adolescent younger than 18 who is married, a parent,
self-supporting, or a member of the military.
Assent: children are not able to give true informed consent until they turn 18. So,
before taking part in a clinical trial, they are asked for their assent. Assent means that
they agree to take part.
Informed Consent
Informed consent involves providing the patient with the necessary knowledge to make a
decision regarding health care. Informed consent implies that the person understands the bene ts
and risks of treatment or the refusal of treatment. The person must also be legally able to give
consent by virtue of their age. In most of the United States and Canadian provinces, the age of
legal consent is 18. An exception is made for the adolescent younger than 18 who is married, a
parent, self-supporting, or a member of the military. Informed consent can be obtained from
these emancipated minors. In some jurisdictions, the age of consent varies for girls aged 14 years
and older for contraception advice and gynecological procedures. For most children, the parent
or legal guardian is the person who gives consent for their care.
Written informed consent is required before diagnostic procedures, medical treatments, or
surgical procedures. It is also required before immunizations or any treatment with inherent risks.

Special Considerations
^^^^

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 Pain Assessment
Pain Assessment and Management
Ongoing assessment is essential for the child experiencing pain. Proper pain assessment requires
identi cation of the type of pain (source and location) the child is experiencing, the origins of
either physiological or psychological pain, the severity of the pain, and the behavioral patterns
associated with the pain.
Pain assessment tools are invaluable for obtaining a child’s perception and for the younger or
disabled child as well as the parent’s view of pain levels. There are several statistically reliable
pain scales available for use with children of different ages and stages of cognitive development.
The most commonly used pain scales are the numeric scale, the Wong Faces Scale, the FLACC,
and CHEOPS pain scales (Fig. 14-6 and Table 14-5). Accurate pain assessment also requires an
understanding of multiple factors, not the least of which is cognitive development, education of
the child and family regarding the pain assessment tool being used, and consistency in
application of the chosen tool.
Assessment of the severity of pediatric pain is based upon the child’s cognitive ability. Self-
reporting is the “gold standard” and is used in children who are able to understand and report
their pain severity along a continuum, such as a visual analog scale.
To ascertain if a child can cognitively understand the numeric scale, the nurse can ask a child
which of two numbers is larger. If the child is able to understand the question and answer
correctly, the visual analog scale is appropriate. For most children, this occurs around age 7. The
Wong-Baker FACES scale is often used for children ages 4 to 7 who can distinguish between a
happy and sad face.
In infants and children who cannot self-report, the nurse can use behavioral observational scales
such as the FLACC tool (Face, Legs, Activity, Cry, Consolability). Pain assessment in nonverbal
children with neurological impairment is challenging because they are unable to self-report. For
this population, the FLACC has been approved as an appropriate tool.
The nurse should familiarize the child and family with an appropriate pain scale during
hospitalization or a clinic visit, when the child is injured or ill, or for a medical procedure or
surgery. The nurse understands that it is important to use the same pain scale according to age,
developmental stage, and cognitive function level. In addition to the pain scales, the nurse asks
about intensity, duration, and location of the pain; the effects of movement on the severity of
pain; any aggravating and alleviating factors; and, if appropriate, previous interventions that
alleviated the pain. It is useful to know what experiences the child has had with pain, including
previous surgeries, illnesses, or congenital conditions. A child’s ability to manage pain is
sometimes related to the child’s position in the family or their experience of illnesses in other
close family members. Pain has many descriptors: mild, moderate, severe, chronic, stabbing,
burning, pricking, aching, throbbing, or dull. Pain is also expressed nonverbally with facial
expressions, guarding, and muscle tension.
Mild pain is a slight discomfort. Its management may include minor analgesics along with
comfort measures or distraction. However, engaging in a distraction does not mean that the child
has no pain. It is simply a coping mechanism that diverts a child’s attention from the pain for a
nite period of time. Pharmacological intervention for mild pain starts with analgesics such as
children’s acetaminophen (Tylenol) or children’s ibuprofen (Advil or Motrin) and is administered
on a scheduled or as-needed basis.

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 Although moderate pain may also be relieved by using distraction, the child experiences much
stronger unpleasant sensations. Using a child’s vivid imagination is very effective in pain
management, as long as it is used in conjunction with regularly timed analgesic administration,
including milder opioids such as codeine in varying combinations of acetaminophen (Children’s
Tylenol).
Severe pain causes pallor, sweating, piloerection (elevation of the hair above the skin), dilated
pupils, increased respiration and blood pressure, and muscle tension. However, if pain has been
prolonged, the child’s body may have become accustomed to it, in which case marked increases
in vital signs may not be noted. Again, that does not mean that the child is not experiencing pain.
When brief, intense pain subsides, the child’s body may respond with a lower blood pressure or
pulse rate.

Pain Management
! Anticipate painful procedures and plan accordingly
! Consider appropriate route for type of pain to treat to determine timing of treatment
! topical
! oral
! injection
! IV

Management of severe pain, often associated with surgical interventions, usually calls for strong
analgesics like morphine sulfate (Astramorph). The maximum allowable dosage according to the
child’s weight in kilograms may be started in the recovery room and followed by regular dosing,
within the allowable limit for the speci c child, to ensure adequate pain coverage.
Acute pain occurs 24 to 48 hours after trauma or surgery. It is initially experienced as severe pain
and gradually subsides over time. With orthopedic trauma, a short period of autoanesthesia can
occur that belies the extent of the injury. Because narcotics do not relieve all the pain following
surgery, they can be accompanied with some success by comfort measures, such as holding a
hand or encouraging the child “to send their pain to you by squeezing your hand tightly.”
Chronic pain in children is any pain lasting more than 3 months. It can result in fear of reinjury,
anorexia, weight loss, changes in sleep patterns, guarded movements, a rigid facial expression,
and an overall diminishment of the child’s joy of living. Management of chronic pain involves
careful observation of which pain relief measures work best for a particular child. Decreasing
pain to acceptable levels allows the child to carry on with as many age-appropriate activities as
possible given the circumstances of their illness or condition. Table 14-6 shows a comparison of
acute and chronic pain.

Management of Infant Pain

! Sucrose
! Activates opioid pathways, resulting in release of endogenous opioids
! Used in infants up to one year
! Utilize prior to any needle stick procedures
! Administer on paci er 2 minutes prior to procedure
! heel sticks, Immunizations, IV insertion, Venipuncture
! may be repeated for procedures longer than 5 minutes
! Contraindications:

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 ! Sucrose intolerance – Congenital sucrase-isomaltase de ciency

(CSID)
! Fructose intolerance
! Glucose-galactose malabsorption
????

Specimen Collections
! Urine Sample
Urine Sample Collection
To collect a urine sample, children may require either catheterization or a clean-catch specimen.
A catheterized specimen is obtained using sterile technique. Bladder catheterization can be a
traumatic experience for both the child and the parents. Distraction techniques can be helpful in
decreasing anxiety and fear. A lubricant with 2% lidocaine may be used to eliminate the
discomfort of catheterization. If a clean-catch specimen is requested, the nurse places a urine
collection bag around the perineal area after cleaning the perineum and surrounding skin (Fig.
14-13). The infant is diapered and the bag monitored for urinary output. The urine must be
removed from the bag and sent to the laboratory within 30 minutes of voiding.
! Stool Sample
Stool Sample Collection
Stool samples are frequently obtained for ova and parasites (O&P), to determine the causative
agent for a diarrheal condition, or to check for the presence of occult blood. If the child is toilet-
trained, they can use the potty chair or the toilet with a collection hat under the seat. In a
nonpotty-trained child, stool from the diaper is collected. Samples are transferred into a
collection cup using tongue blades. O&P samples are sent to the laboratory as soon as possible.
When laboratory services are not provided 24 hours a day, the sample should be refrigerated as
soon as possible.
! Blood Sample
Blood Sample Collection
Having blood drawn can be a traumatic event. Preparation and support during the procedure
alleviates some of the fear and pain associated with venipuncture. Trauma can be alleviated by
using distraction techniques with the child before the venipuncture. Application of EMLA cream,
a topical analgesic containing lidocaine and prilocaine, anesthetizes the skin before any painful
procedure. The cream is applied to the site, covered with a transparent dressing for 1 hour, and
removed before the venipuncture.
! Throat Culture
Throat Culture Collection
A rapid strep test or a throat culture can be used to diagnose group A streptococci as the cause of
sore throat. If the rapid strep test is positive, an antibiotic is prescribed. If the rapid strep test is
negative, a culture to grow the bacteria is done to con rm the results. A throat culture is more
accurate than the rapid strep test, but it may take several days to obtain results. Most children do
not tolerate throat cultures very well. For younger children, it may help to place the child on the
parent’s lap facing forward and have the parent place one arm across the child’s chest and over
their arms, and one hand on the child’s forehead. The child is now suf ciently restrained to
obtain a specimen safely. The nurse uses a tongue blade to push the tongue downward and swabs
the posterior pharynx with two sterile cotton-tipped applicators (Fig. 14-14).
! Cerebrospinal Fluid collection

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 Cerebrospinal Fluid Collection

A lumbar puncture (LP) is a necessary procedure to rule out sepsis or meningitis. It can also be
scheduled as a procedure for children undergoing treatment for cancer. The nurse prepares the
child for an LP by telling the family and the child the reason for the procedure and teaching
distraction methods to the child. Practicing the position required for the procedure can be helpful
with the older child. An hour before the LP, EMLA cream can be applied to the skin at the
designated site. This makes the procedure less painful. With the lumbar puncture, a needle is
inserted into the subarachnoid space at the level of L4 or L5 to withdraw cerebrospinal uid
(CSF) for analysis. An infant is seated upright with the head bent forward. An older child must
lie on their side with the head exed, hips and knees exed, and the back arched while being
rmly held to make sure they do not move. CSF samples are sent for culture, glucose, red blood
cells, and protein.
After the LP, vital signs are taken. The child is encouraged to lay at for 1 hour and drink uids.
The child may complain of a headache or pain at the site of the LP. Frequent neurological
assessment is performed to note changes in status. Complications such as nerve trauma,
infection, bleeding, or pressure effects are rare.

Enteral Feedings
! When a child is unable to take adequate nutrition by mouth, an alternate feeding
method is used to maintain and promote growth in the child.
! Orogastric and Nasogastric Feeding Tubes: The tube is inserted and then removed
at the end of the bolus feed.
! Gastrostomy Feeding Tube: enteral tube feedings over a longer period of time, such
as with oral feeding aversions or neurological dysfunction, a GT is an alternative to
the nasogastric tube (Figure 14-15, page 483).
! Ostomies: ostomy is a surgical opening from either the small or large bowel to the
surface of the abdomen to allow for fecal elimination
Enteral Tube Feedings
When a child is unable to take adequate nutrition by mouth, an alternate feeding method is used
to maintain and promote growth in the child. The type of feeding method selected depends on the
child’s medical condition. Children can be nourished through an oroor nasogastric feeding tube
or a GT. Feedings may be administered as a bolus or a continuous infusion. Bolus feedings are
given at relatively the same rate as an oral feeding would normally be taken and are the preferred
method to deliver formula in children who cannot tolerate oral feedings. Formula given as a
continuous infusion is placed on a feeding pump and regulated to be administered over a
predetermined number of hours. Continuous infusions are often preferred in children with
serious cardiac defects to decrease the work-load of the heart while providing enteral nutrition.
To allow underweight infants or children to gain weight, a continuous feeding may be given
during hours of sleep to boost calorie intake without interfering with a normal daily feeding/
eating schedule.
Orogastric and Nasogastric Feeding Tubes
For newborn infants requiring gavage feedings, the orogastric route is preferred because
newborns are obligate nose breathers. The tube is inserted and then removed at the end of the
bolus feed. If the tube is to be left in place, the nasogastric route should be considered.
Nasogastric tube feedings are preferred over total parenteral nutrition because they preserve the
stomach’s mucosa, allow the digestive process to continue, and are cost-effective.

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 The time taken to administer a gavage feeding can be used in the same way as in a regular
feeding. Place the infant comfortably in the mother’s arms with the head elevated. Provide the
infant with a paci er to help simulate an actual feeding. Nonnutritive sucking has been shown to
increase weight gain and decrease crying and to allow for the normal muscular development of
the mouth and tongue.
Once placement of the tube is con rmed and the child is in position, the nurse administers a
bolus feeding of room-temperature formula via gravity through an appropriately sized syringe
attached to the feeding tube. The formula- lled syringe is held less than 12 inches above the
infant. When the feeding is complete, the tubing is ushed with tap water to prevent clogging of
the lumen, the syringe is removed, and the feeding port is capped. To decrease the chance of
regurgitation, the infant is burped after the bolus is infused. Follow hospital guidelines for
nasogastric gavage feedings. The nurse must remember that the amount of water should be only
the amount required to successfully ush the length of tubing; excess water may result in
overfeeding.
Gastrostomy Feeding Tubes
When a child requires enteral tube feedings over a longer period of time, such as with oral
feeding aversions or neurological dysfunction, a GT is an alternative to the nasogastric tube. A
GT is inserted through the abdominal wall into the stomach. The GT is secured internally and
externally with a variety of bumpers depending on the manufacturer of the GT. Some physicians
also secure the GT in place with external sutures for the rst 7 to 10 days postoperatively.
After the initial insertion, the GT is left open to gravity drainage for 12 to 24 hours and the
wound site observed for signs of infection. Stoma care and assessment are important nursing
interventions because of the potential for leakage of gastric secretions onto the periostomal skin.
Guidelines for feeding the child through a GT are similar to nasogastric tube feedings. Figure
14-15 shows two of the many types of GTs available.

Restraining a child
! Parents and the child need to be informed as to why a restraint is necessary.
! Once restraint is applied, the condition of the skin and circulation of the a ected
extremity must be checked and documented
! The extremity is checked every 15 minutes for 1 hour after initial application
and then every 1 to 2 hours to ensure the child’s safety.
! Types of restraints:
! Mummy, elbow, mitten
Restraining the Child
Physical Restraint
Restraining a child may be a necessary intervention to ensure a child’s safety during a procedure
or to prevent injury to an operative site. Parents and the child need to be informed as to why a
restraint is necessary. Once the restraint is applied, the child must be checked and documentation
made as to the condition of the skin and circulation of the affected extremity. The extremity is
checked every 15 minutes for 1 hour after initial application and then every 1 to 2 hours to
ensure the child’s safety.
Common types of restraints used for children are the elbow restraint and the papoose restraint.
The elbow restraint prevents the child from exing the elbow, therefore preventing the child’s
hands from reaching the head (Fig. 14-17). They prevent the child from pulling out an IV line in
a scalp vein or other peripheral line. If the child is recovering from cleft lip repair, the elbow

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 restraint prevents the child from touching the incision area. Most children tolerate this type of
restraint without problems related to skin integrity or circulatory compromise. Elbow restraints
should be removed one at a time every hour to allow for exercise of the arm. The child must be
supervised when the restraints are removed.
The papoose restraint is a total body restraint similar to an infant swaddle. The papoose restraint
temporarily immobilizes an infant or small child for an examination or procedure that involves
the head, neck, or throat (Fig. 14-18). This is ideal to keep the child safe during venipuncture,
throat examination, insertion of a nasogastric tube, or administration of ophthalmic, otic, or oral
medications.
Pharmacological Restraint
In addition to physical restraints, pharmacological restraints can be used with children during
diagnostic and therapeutic procedures. Sedation of children is administered to allow the safe
completion of a procedure. Chloral hydrate (Aquachloral) is a nonbarbiturate sedative-hypnotic
drug commonly used in children to produce sedation. The drug decreases anxiety and induces
sleep without respiratory depression or suppression of the cough re ex.

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 1. Which of the following is a key principle of family-centered care in pediatric nursing
a) Limiting parental involvement to daytime hours
b) Encouraging parents to visit only during procedures
c) Supporting around-the-clock presence of parents
d) Minimizing parental input in decision-making

2. What is the primary goal of atraumatic care in pediatric nursing

a) To perform medical interventions as quickly as possible
b) To prevent or minimize physical and psychological stress in children
c) To minimize parental involvement in the child’s care
d) To ensure children comply with all medical procedures

3. During hospitalization, a child is crying and refusing to eat. What is the most appropriate
action the nurse should take
a) Restrain the child and force-feed them
b) Call a child life specialist to engage the child in therapeutic play
c) Isolate the child until they calm down
d) Administer sedative medication

4. Which technique is recommended to minimize stress during a medical procedure for a

preschool-aged child
a) Encourage deep breathing and counting
b) Provide detailed explanations using medical jargon
c) Avoid allowing parents to be present
d) Limit explanation to less than 2 minutes

5. A nurse is preparing to assess the growth and development of a school-age child. Which tool
should the nurse use
a) Stadiometer
b) Growth chart for head circumference
c) Length measuring board
d) Apgar scale

6. What is the bene t of incorporating therapeutic play in pediatric nursing care

a) It decreases the need for medication
b) It enhances ne motor skills
c) It helps the child cope with hospitalization and procedures
d) It reduces the need for parental presence

7. Which of the following interventions best supports atraumatic care during venipuncture for a
toddler
a) Use a large needle to minimize procedure time
b) Allow the child to observe the procedure closely
c) Involve the parents in comforting the child
d) Explain the procedure to the child in detail

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 8. At what age is it appropriate to measure a child’s head circumference during routine visits
a) Birth to 24 months
b) Birth to 36 months
c) 24 to 48 months
d) 36 to 48 months

9. A nurse is performing a health assessment on an infant. Which area of assessment should the
nurse save for last
a) Heart and lung auscultation
b) Measuring head circumference
c) Checking the posterior fontanel
d) Examination of the mouth and ears

10. Which of the following is a priority when gathering a pediatric health history from a
nonverbal child
a) Use of age-appropriate toys to communicate
b) Obtaining information from the caregiver or guardian
c) Focusing only on past medical history
d) Allowing the child to lead the interview

11. For an adolescent, which health history topic should be discussed con dentially without the
parent’s presence
a) Family history of chronic illness
b) Immunization status
c) Concerns about sexual health
d) Dietary preferences

12. Which developmental milestone is typically achieved by a 2-year-old child

a) Writing their name
b) Riding a tricycle
c) Walking up stairs with assistance
d) Recognizing colors

13. A nurse is assessing a 4-month-old infant. Which nding should the nurse expect
a) Sitting without support
b) Crawling
c) Rolling from back to front
d) Babbling simple sounds

14. In which setting is a child life specialist most likely to play a crucial role
a) Pediatric rehabilitation center
b) Adult emergency room
c) Outpatient dermatology clinic
d) Geriatric ward

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 15. A nurse is assessing the pulse of a newborn. Which site is most appropriate for measuring an
apical pulse
a) At the wrist
b) On the brachial artery
c) At the 4th intercostal space, left midclavicular line
d) On the femoral artery

16. What is the most effective way to manage mild pain in a 7-year-old child
a) Administering morphine
b) Applying EMLA cream
c) Using distraction techniques and acetaminophen
d) Restricting the child’s movements

17. **Which statement by a parent indicates the need for further teaching about atraumatic care
a) “I will bring my child’s favorite blanket to the hospital.”
b) “I should remain calm during my child’s procedure.”
c) “I will avoid asking questions to avoid upsetting my child.”
d) “It is important to stay with my child as much as possible.”

18. During a health visit, a nurse observes a 9-month-old infant who does not respond to their
name. What is the appropriate next step
a) Refer the infant for a hearing assessment
b) Teach the parents to say the infant’s name more clearly
c) Consider this normal for the age
d) Reassess during the next health visit

19. Which of the following tools is appropriate for assessing pain in a 4-year-old child
a) Visual analog scale
b) Wong-Baker FACES scale
c) Numeric rating scale
d) FLACC scale

20. A nurse is assessing skin turgor in a 6-year-old child. What is the expected nding if the child
is well-hydrated
a) The skin remains tented for a few seconds
b) The skin returns to its normal position immediately
c) The skin has a yellowish undertone
d) The skin blanches when pressed

21. A pediatric nurse is preparing a toddler for a lumbar puncture. Which of the following is an
appropriate intervention
a) Offer the child choices to make them feel in control
b) Provide a detailed explanation of the procedure
c) Allow the child to watch the needle being inserted
d) Use therapeutic play to demonstrate the procedure

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 22. Which of the following ndings during a physical assessment of a 2-year-old would require
immediate intervention
a) Babinski re ex present
b) Rounded abdomen
c) Subcostal retractions
d) Symmetrical gluteal folds

23. A 5-year-old child is being prepared for surgery. What is the best way to explain the
procedure to the child
a) Use medical terminology to sound professional
b) Tell the child the procedure won’t hurt at all
c) Use simple, concrete language and allow questions
d) Avoid discussing the procedure to reduce anxiety

24. Which of the following is an expected nding when assessing the anterior fontanelle of a
healthy 10-month-old infant
a) Sunken fontanelle
b) Bulging fontanelle
c) Closed fontanelle
d) Open fontanelle

25. In preparing a preschool child for a blood draw, which technique would best reduce their
anxiety
a) Providing a detailed step-by-step explanation
b) Letting the child choose which arm to use
c) Telling the child that the procedure won’t hurt
d) Encouraging the child to observe the blood collection

26. A nurse is assessing the respiratory rate of a sleeping infant. Which nding is within the
normal range for a 6-month-old
a) 12 breaths per minute
b) 22 breaths per minute
c) 40 breaths per minute
d) 55 breaths per minute

27. Which of the following factors is most important in assessing the development of a 3-year-
old child
a) Ability to dress independently
b) Parent’s report of toilet training success
c) The child’s weight percentile
d) The number of words the child speaks

28. A nurse is educating a parent about the signs of dehydration in their infant. Which sign
should the parent report immediately
a) Fontanelle that appears full and tense
b) Frequent wet diapers

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 c) The infant is crying with tears
d) A sudden increase in appetite

29. At what age is it recommended to begin annual blood pressure measurements for children
a) At birth
b) 1 year old
c) 3 years old
d) 5 years old

30. Which of the following behaviors demonstrates that a 6-year-old child is in Erikson’s stage of
industry vs. inferiority
a) Insisting on dressing without help
b) Expressing the desire to do well in school
c) Imitating parental behaviors
d) Having frequent tantrums

31. A nurse is caring for a toddler who is fearful of an IV placement. Which approach is best to
minimize their fear?
a) Apply an EMLA cream to numb the site before placement
b) Use a large needle to nish the procedure quickly
c) Tell the child the procedure will not hurt at all
d) Restrain the child to prevent movement

32. When assessing the ears of a child under 3 years old, how should the nurse position the ear
a) Pull the pinna up and back
b) Pull the pinna down and back
c) Gently press on the tragus
d) Insert the otoscope without touching the ear

33. Which of the following interventions would be most appropriate for a child diagnosed with
respiratory distress
a) Monitor the child’s vital signs every hour
b) Encourage the child to sit in a tripod position
c) Administer an oral bronchodilator
d) Ask the child to lie at for comfort

34. A 9-month-old infant presents with pallor and petechiae. What is the nurse’s priority action
a) Assess the infant for signs of dehydration
b) Notify the healthcare provider immediately
c) Teach the parents about dietary changes
d) Encourage the infant to breastfeed more often

35. A nurse is preparing to administer a liquid medication to a 1-year-old. Which is the best
technique
a) Use a syringe to slowly squirt the medication into the cheek pouch
b) Mix the medication into the child’s formula bottle

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 c) Ask the child to drink the medication from a small cup

d) Administer the medication with a spoon

36. Which method is most appropriate for administering oxygen to a 2-month-old infant with
bronchiolitis
a) Nasal cannula
b) Simple face mask
c) Non-rebreather mask
d) Endotracheal intubation

37. A nurse is monitoring a child receiving a gastrostomy tube (GT) feeding. What is the most
important intervention during the feeding
a) Position the child supine to prevent regurgitation
b) Flush the tube with cold water after the feeding
c) Hold the child upright during the feeding
d) Administer the feeding as quickly as possible

38. Which physical assessment nding is typical of a healthy newborn

a) Heart rate of 90 beats per minute
b) Abdominal breathing
c) Closed posterior fontanel
d) Cyanosis of the hands and feet

39. What is the nurse's priority when caring for a child who has just undergone lumbar puncture
a) Encourage the child to lie at for 1 hour
b) Monitor the child’s temperature every 4 hours
c) Allow the child to ambulate immediately
d) Apply pressure to the puncture site for 2 minutes

40. A nurse is assessing an 18-month-old with suspected meningitis. What would the nurse
expect to nd during the physical exam
a) Positive Babinski re ex
b) Tense, bulging fontanel
c) Enlarged head circumference
d) Absence of re exes

41. Which of the following is the most appropriate way to assess a 5-year-old child’s visual
acuity
a) Use the Snellen chart
b) Use the Hirschberg corneal light re ex test
c) Use the cover-uncover test
d) Use the E chart

42. What is the nurse’s best approach when preparing a toddler for a procedure
a) Use complex language to explain the procedure
b) Give a detailed explanation of what will happen

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 c) Use simple, concrete language and allow the child to play with equipment
d) Tell the child that their parent will not leave the room

43. A child presents with a white retinal re ex during an eye assessment. Which condition should
the nurse suspect
a) Cataracts
b) Conjunctivitis
c) Strabismus
d) Myopia

44. When assessing the vital signs of a 1-year-old, which method is most appropriate for taking
their temperature
a) Oral
b) Tympanic
c) Rectal
d) Axillary

45. A nurse is educating the parents of a child with asthma on how to monitor for early signs of
respiratory distress. Which sign should the parents report immediately
a) Increased respiratory rate
b) Nasal aring and retractions
c) Wheezing after exercise
d) A dry, persistent cough

46. A nurse is teaching a group of parents about the risks of otitis media in children. Which factor
increases the risk for this condition
a) Breastfeeding
b) Attending daycare
c) Upper respiratory infection treated with antibiotics
d) Sleeping in a supine position

47. A 7-year-old child with congenital heart disease is receiving care. Which of the following
should the nurse assess for during a physical exam
a) Clubbing of the nails
b) Increased urinary output
c) Absence of bowel sounds
d) Decreased pulse in upper extremities

48. What is the priority nursing intervention for a 10-month-old experiencing respiratory
distress
a) Encourage deep breathing exercises
b) Administer an antipyretic
c) Position the infant in high Fowler’s position
d) Suction the airway

49. Which assessment nding in a school-age child warrants further investigation

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 a) S3 heart sound
b) Symmetrical chest expansion
c) Wheezing on auscultation
d) Respiratory rate of 20 breaths per minute

50. A nurse is preparing to perform a catheterization on a pediatric patient. Which intervention

best minimizes discomfort during the procedure
a) Apply EMLA cream 1 hour before the procedure
b) Perform the procedure without explaining it
c) Use a clean, non-sterile catheter
d) Insert the catheter quickly to minimize discomfort

Answers

1. c) Supporting around-the-clock presence of parent

2. b) To prevent or minimize physical and psychological stress in childre
3. b) Call a child life specialist to engage the child in therapeutic pla
4. a) Encourage deep breathing and countin
5. a) Stadiomete
6. c) It helps the child cope with hospitalization and procedure
7. c) Involve the parents in comforting the chil
8. b) Birth to 36 month
9. d) Examination of the mouth and ear
10. b) Obtaining information from the caregiver or guardia
11. c) Concerns about sexual healt
12. c) Walking up stairs with assistanc
13. d) Babbling simple sound
14. a) Pediatric rehabilitation cente
15. c) At the 4th intercostal space, left midclavicular lin
16. c) Using distraction techniques and acetaminophe
17. c) “I will avoid asking questions to avoid upsetting my child.
18. a) Refer the infant for a hearing assessmen
19. b) Wong-Baker FACES scal
20. b) The skin returns to its normal position immediatel
21. d) Use therapeutic play to demonstrate the procedur
22. c) Subcostal retraction
23. c) Use simple, concrete language and allow question
24. d) Open fontane
25. b) Letting the child choose which arm to us
26. c) 40 breaths per minut
27. d) The number of words the child speak
28. a) Fontanelle that appears full and tens
29. c) 3 years ol
30. b) Expressing the desire to do well in schoo
31. a) Apply an EMLA cream to numb the site before placemen
32. b) Pull the pinna down and bac

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 33. b) Encourage the child to sit in a tripod positio

34. b) Notify the healthcare provider immediatel
35. a) Use a syringe to slowly squirt the medication into the cheek pouc
36. a) Nasal cannul
37. c) Hold the child upright during the feedin
38. b) Abdominal breathin
39. a) Encourage the child to lie at for 1 hou
40. b) Tense, bulging fontane
41. d) Use the E char
42. c) Use simple, concrete language and allow the child to play with equipmen
43. a) Cataract
44. d) Axillar
45. b) Nasal aring and retraction
46. b) Attending daycar
47. a) Clubbing of the nail
48. c) Position the infant in high Fowler’s positio
49. c) Wheezing on auscultatio
50. a) Apply EMLA cream 1 hour before the procedure

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