14.5 Applying the Nursing Process to Caring for an Ill or Hospitalized Pediatric Client

This section will generally apply the nursing process to caring for an ill child. Specific assessments, nursing diagnoses, and interventions for specific childhood disorders are discussed in more detail in the “Respiratory Childhood Disorders” and “Other Childhood Disorders” chapters.

Assessment

When caring for the ill child, a comprehensive nursing assessment should include these aspects^[1]:

• History: A client history should include the chief complaint, current symptoms, allergies, medical and surgical history, family history, current medications, cultural and religious beliefs and practices, and coping mechanisms.
• Physical Examination: Vital signs, pain assessment, length/height, weight, and head-to-toe assessment are performed. Infant examinations also include measurement of the head circumference. Measurement of the weight, length/height, and head circumference is used to assess development and should be plotted on standard growth curves to determine progress. Read more about monitoring growth and development in the “Nursing Care For Clients From Infancy Through Adolescence” chapter.
• Review of Laboratory and Diagnostic Results

History

Historical information is primarily obtained from the parents or caregivers for pediatric clients from birth through early childhood. For children ages 5 to 12, the nurse still relies primarily on the parents or caregivers, although comments made by the client are often relevant. When appropriate, adolescent clients should be offered some private time with the health care provider and/or nurse in the absence of parents or caregivers to permit open discussion of pertinent historical information and preventive health care issues. Read more information about adapting nurse care for adolescents in the “Nursing Care For Clients From Infancy Through Adolescence” chapter.

Physical Examination

Recall that infants older than six months and toddlers who have stranger anxiety are often more cooperative during a physical exam when held by their parent or caregiver. To gain the child’s trust, the nurse should use a calm, warm approach and smile before touching the client. See Figure 14.9^[2] for an image of a health professional using a warm approach while performing a physical examination on a pediatric client.

Nurses use a variety of techniques to gain cooperation from pediatric clients during a physical exam, such as incorporating toys, distracting objects, and pictures for infants, toddlers, and young children. Engaging two- to four-year-olds with stories about imaginary animals can also create an effective diversion. When an otherwise typically behaving child older than four years does not cooperate with a physical examination, even in the presence of a familiar parent or caregiver, it may indicate a previous traumatic encounter between the client and another examiner, and the nurse should try a different approach. The possibility of an underlying psychosocial problem or behavior disorder should be considered if a child older than four years is extremely uncooperative or combative during a physical exam.^[3]

The examination of an infant, toddler, or child should be performed in the presence of a parent or guardian. However, if the parents’ or guardian’s presence may interfere with the examination (such as due to suspected child abuse), a staff member serving as a chaperone should be present. Staff chaperones should also be present during examination of the breasts, genital, or anorectal areas of male and female adolescent clients. The gender of the chaperone should be determined by the client’s wishes and comfort, if possible. The use and identity of the chaperone should be identified in the medical record.^[4]

General Survey

The nurse can gain insight into a pediatric client’s health status and family dynamics by making observations during the physical examination. Characteristics regarding a client’s general appearance include the following^[5]:

• Degree of comfort: Calm, nervous, shy
• State of well-being: Appears healthy, ill, distressed
• Activity level: Alert, active, fidgety, drowsy, lethargic
• Physical appearance: Well-groomed or disheveled
• Behavior and attitude: Happy, cooperative, sad, irritable, agitated, uncooperative, combative
• Body habitus: Normal weight, overweight, underweight, short, tall
• Nutritional and fluid status: Appears well-nourished and well-hydrated or appears malnourished and/or dehydrated

Observations may help the nurse form initial hypotheses, which may include the following^[6]:

• If a child appears ill, the nurse should make additional focused observations to gather additional data that the child may not be able to verbally express:
  • A child who lies or sits completely still who noticeably winces when an attempt is made to change position or move a body part may have an acute gastrointestinal or musculoskeletal condition that requires urgent medical care. Read more about gastrointestinal and musculoskeletal assessment in the “General Assessment” section of the “Other Childhood Disorders” chapter.
  • A child who appears dyspneic and is sitting upright and slightly forward with their arms extended and hands resting on the knees might be experiencing an exacerbation of asthma or other causes of respiratory distress that requires urgent medical care. Read more about respiratory assessment in the “Focused Assessment of the Respiratory System” section of the “Respiratory Childhood Disorders” chapter.
  • If an infant is crying, the pitch and intensity of the cry should be noted. A boisterous hardy cry is reassuring. A weak and listless cry or a high-pitched, screeching cry may indicate serious conditions requiring urgent medical care.
• The nurse should observe a pediatric client’s developmental status based on their age, including motor function, interaction with surrounding objects and people, response to sounds, and speech pattern for clues about whether the patient is developing typically or requires a comprehensive developmental assessment. Review information about developmental status in the “Nursing Care For Clients From Infancy Through Adolescence” chapter.
• If the child and/or caregiver makes little or no eye contact, has a flat affect, or does not smile socially, and these characteristics are not related to their cultural beliefs, the nurse should suspect neglect or abuse and perform follow-up assessments and interventions.^[7] Review information about “Neglect and Abuse” in the “Maladaptive Coping Behaviors” chapter.

The presence of separation anxiety, stranger anxiety, or regression in hospitalized or chronically ill pediatric clients should be documented and addressed by the nurse.^[8] Review information about these reactions in the “Nursing Care For Clients From Infancy Through Adolescence” chapter.

Vital Signs

When performing a physical examination on a pediatric client, recall that some of their normal vital sign ranges differ from those of an adult client. See Tables 14.5a, 14.5b, and 14.5c for the normal ranges of temperature, pulse, and respiratory rate in pediatric clients. Blood pressure and oxygen saturation levels in the pediatric client are also further discussed below.^[9]

Table 14.5a. Temperature Ranges by Source^[10]

Table 14.5b. Heart Rate Ranges by Age^[11]

Table 14.5c. Respiratory Rate by Age^[12]

Blood Pressure

Blood pressure measurements routinely begin around three years of age in children. It may begin earlier if there are concerns for cardiac issues. Normal blood pressure values are determined by the child’s gender, height and age. See the following box for additional information regarding normal and abnormal blood pressure values for pediatric clients.

Oxygen Saturation

Oxygen saturation is typically measured in children using a pulse oximeter. Normal oxygen saturation levels via pulse oximeter are 95-100% in both children and adults.^[13],[14]

Pain Assessment

Infants and children express pain in different ways based on their developmental stage. Even premature neonates experience pain, and because their nervous systems and pain inhibition mechanisms are not fully developed, they are hypersensitive to painful stimuli. Nurses must take this into consideration when performing painful procedures on neonates to prevent potential life-long adverse effects on organ systems and neurobehavioral development. It is also important to note that just like with adults, children experiencing chronic pain will manifest pain differently than those experiencing acute pain. Acute pain indicators are discussed in the following subsections based on developmental level.^[15]

Neonate and Infant

Neonates and infants cannot verbally express their pain, so behavioral observations are made to determine the presence of pain. Infants may express pain in the following ways^[16]:

• Kicking/ waving arms and legs or drawing knees to chest
• Arching their backs or body rigidity
• Crying, screaming, or groaning
• Increased irritability or difficulty being consoled
• Not eating or sleeping well
• Abnormal facial expressions

The NIPS tool is appropriate for assessing pain in pre-term and full-term infants, and the FLACC scale is used for infants two months of age and older. These scales are further discussed under the “Pain Scales” subsection.

Toddler

Toddlers aged one to two years old may express pain verbally using words such as “owie” or “hurt” to express their pain. It can be helpful for nurses to involve parents or caregivers when assessing pain in this age group because the parent may be better able to understand what the toddler is trying to convey during the assessment. Toddlers often behaviorally express pain in the following ways^[17]:

• Crying or yelling
• Protecting the painful area through guarding
• Physical resistance such as pushing medical equipment or caregivers away
• Behavior regression or increased clinginess
• Being uncooperative or refusing a favorite toy, food, or activity
• Not eating or sleeping well

Pain assessment tools such as the FACES scale can be helpful in assessing pain in toddlers. Nurses can also use dolls to ask a toddler to show the location of their pain.

Preschooler

Preschoolers aged three to five years can typically verbally express their pain and its severity by using pain scales such as the FACES scale. They may also behaviorally express their pain in similar ways as toddlers as discussed under the “Toddler” subsection. It is helpful to encourage preschoolers to talk about their pain and reassure them that they have not done anything wrong to deserve the pain, as this age group often sees pain as a punishment for wrongdoing. As with toddlers, it can be helpful for nurses to use a doll to ask the preschooler to show the location of the pain.^[18]

School-Aged Child

Children aged 6-12 years old are considered school aged. School-aged children, especially as they reach the older end of the age range, are generally able to give a detailed description of their pain. They begin to understand that pain is generally time-limited and due to an injury of sorts. It is important to remember that cultural factors may begin to influence school-aged children’s beliefs about pain and pain management, such as believing that they deserve their pain, or they just need to “deal with” their pain. School-aged children are generally able to use a numerical pain scale, though they may also use the FACES scale if they are unable to use a numerical scale. It can also be helpful to ask a school-aged child to show how big their pain is with their hands. School-aged children typically express pain in the following ways^[19]:

• Crying
• Protecting the painful area through guarding
• Physical resistance such as pushing medical equipment or caregivers away
• Behavior regression or increased clinginess
• Being uncooperative or refusing a favorite toy, food, or activity
• Not eating or sleeping well or having nightmares
• Avoiding things such as activities
• Clenching fists, gritting teeth, body tension or stiffness, closing eyes, or grimacing^[20]

Adolescent

Adolescents typically have a good understanding of pain and have had some experience with acute pain. Adolescents can usually self-report the severity of their pain using a numerical pain scale, although they may be reluctant to fully express their pain due to previous experiences when reporting pain, especially if they were told to “be tough” or “not complain.” Adolescents may also hide their pain when around their peers to appear tough, so it may be necessary to assess pain in a private setting for accurate results. Adolescents typically express pain in the following ways^[21]:

• Difficulty eating or sleeping
• Demonstrating changes in appetite
• Avoiding favorite activities
• Displaying tense muscles
• Protecting the painful area through guarding
• Displaying behavioral regression

Children With Disabilities

Children with disabilities can present unique challenges to accurate pain assessment because they may not be able to fully express their pain. Some helpful measures to assess pain in children with disabilities are as follows^[22]:

• Observing for mood changes
• Observing for changes in behavior such as seeking comfort or making gestures to a specific body part
• Observing for changes in eye contact or attention
• Observing for changes in activity level
• Observing for crying, gasping, or moaning

Pain Scales

Standardized pain scales allow for consistent assessment and individualized treatment plans. Common scales for assessing pain in infants and children are NIPS, FLACC, FACES, or OLDCARTES.

Neonatal Infant Pain Scale (NIPS)

The Neonatal Infant Pain Scale (NIPS) is a tool that assesses six behavioral reactions to painful procedures in preterm and full-term newborns. It contains six items with scoring described in the following box.

Table 14.5d. Neonatal Infant Pain Scale Criteria

FLACC Scale

The FLACC scale (i.e., the Face, Legs, Activity, Cry, Consolability scale) is a measurement used to assess pain for children between the ages of two months and seven years or individuals who are unable to verbally communicate their pain. The scale has five criteria, which are each assigned a score of 0, 1, or 2. The scale is scored in a range of 0–10 with “0” representing no pain. See Table 14.5e for the FLACC scale.^[23]

Table 14.5e. The FLACC Scale^[24]

FACES

The FACES scale is a visual tool for assessing pain with children and others who cannot quantify the severity of their pain on a scale of 0 to 10. See Figure 14.10^[25] for the FACES Pain Rating Scale. To use this scale, use the following evidence-based instructions. Explain to the client that each face represents a person who has no pain (hurt), some pain, or a lot of pain. “Face 0 doesn’t hurt at all. Face 2 hurts just a little. Face 4 hurts a little more. Face 6 hurts even more. Face 8 hurts a whole lot. Face 10 hurts as much as you can imagine, although you don’t have to be crying to have this worst pain.” Ask the person to choose the face that best represents the pain they are feeling. Note that the client reports which face best represents how they are feeling, and the nurse is not selecting a face based on how the client appears to feel.^[26]

OLDCARTES

For adolescents or older children, the OLDCARTES method of assessing pain may be appropriate. This consists of asking the following questions^[27]:

• Onset: When did the pain start? How long does it last?
• Location: Where is the pain?
• Duration: How long has the pain been going on? How long does an episode last?
• Characteristics: What does the pain feel like? Can the pain be described in terms such as stabbing, gnawing, sharp, dull, aching, piercing, or crushing?
• Aggravating factors: What brings on the pain? What makes the pain worse? Are there triggers such as movement, body position, activity, eating, or the environment?
• Radiating: Does the pain travel to another area or the body, or does it stay in one place?
• Treatment: What has been done to make the pain better and has it been helpful? Examples include medication, position change, rest, and application of hot or cold.
• Effect: What is the effect of the pain on participating in your daily life activities?
• Severity: Rate your pain from 0 to 10.

Diagnosis

General nursing diagnoses for ill children and their defining characteristics are described in Table 14.5f below. Additional nursing diagnoses for specific medical disorders are described in the “Childhood Respiratory Disorders” and “Other Childhood Disorders” chapters.

Table 14.5f. Selected Nursing Diagnoses for Ill Children^[28]

Outcome Identification

Outcome identification encompasses the creation of short- and long-term goals for the client. These goals are used to create expected outcome statements that are based on the specific needs of the client. Expected outcomes should be specific, measurable, and achievable, realistic, and timely. These outcomes should be achievable within a set time frame based on the application of appropriate nursing interventions.

Examples of expected outcomes include the following^[29]:

• The client will seek out opportunities for socialization within 24 hours.

• The client will report three ways to effectively manage anxiety by the end of the teaching session.

• The client will verbalize acceptance of the affected body part within one week.

• The client will demonstrate how to appropriately perform a self-care skill after the teaching session.

• The client will demonstrate how to independently dress themselves within two weeks.

Interventions

Registered nurses plan interventions based on achieving the expected outcomes of the client. Prior to implementing interventions, all nurses must determine if previously planned interventions are still safe and appropriate for the client based on their current circumstances. Nursing Interventions Classification (NIC) outlines several general nursing interventions for pediatric clients under the category titled Child Care, which is defined as “facilitating developmentally appropriate care to support physical, cognitive, social, and emotional growth.”^[30] Selected NIC interventions for the Child Care category are described in the following box.

Sample care plans for hospitalized pediatric clients can be viewed using the information in the following box.

Evaluation

Evaluation of client outcomes refers to the process of determining whether or not client outcomes were met by the indicated time frame. This is done by reevaluating the client as a whole and determining if their outcomes have been met, partially met, or not met. If the client outcomes were not met in their entirety, the care plan should be revised and reimplemented. Evaluation of outcomes should occur each time the nurse assesses the client, examines new laboratory or diagnostic data, or interacts with another member of the client’s interdisciplinary team.