Introduction to pediatric assessment – orientation workshop.

Objectives:

2. Care Of Children Who Are Hospitalized

PEDIATRIC ASSESSMENT

PHYSICAL GROWTH

One important set of parameters required for pediatric health assessment is physical growth. The parameters of weight, length, or height, and head circumference (dependent on age) are essential in serial physical growth measurements. (Chest circumference is of less importance.) For example, by plotting a child's growth on a chart, the nurse is able to determine normal or abnormal growth curves according to the child's age.

HEALTH HISTORY

Because the historian in a pediatric history is less often the child and most likely the caregiver, it is very important to document the historian's relationship to the child. The child should be included in the history taking as is appropriate for her or his age and development. Other than the child or caregiver, information can be obtained from medical and school records, diaries, clinic notes, and agencies such as crippled children's services, public health departments, and home health agencies.

Chief Complaint: The caregiver is often the individual who seeks health care for the child and provides a description of the perceived problems, especially for infants, toddlers, and young preschoolers whose age and mental status prevent them from offering genuine descriptions of their problem. You must frequently rely on the caregiver's intuition in such cases. The caregiver is usually acutely aware of cues to the child's illness. For instance, changes in sleeping patterns (difficulty falling asleep, reversion to night waking), regression to outgrown behaviors (bedwetting, finicky eating, thumb sucking), and unusual physical complaints in an otherwise healthy child (headaches, stomachaches) are important signs that the child may be experiencing stress or illness, and warrant further investigation. The older preschooler, school-aged child, and adolescent are able to provide verbal descriptions of their complaints.

Past Health History

Pertinent information should be elicited regarding the birth history, including prenatal, labor and delivery, and postnatal history.

Birth History

Obtaining the birth history may be one of the more sensitive topics of the past health history. You must feel comfortable and show sensitivity when inquiring about whether the pregnancy was planned, the date prenatal care was first sought, and birth order of pregnancy, taking into account miscarriages and abortions.

Prenatal:

1. Did you plan your pregnancy for _____(insert month)?

2. How many weeks after thinking that you were pregnant did you go to a health care provider for a check-up?

3. How many children have you carried to full term?

4. Were there any pregnancies that you were not able to carry to full term? What happened?

5. Did you take any prescribed or over-the-counter medications?

6. Did you drink alcohol or caffeine, or smoke cigarettes during pregnancy?

7. Did you take any drugs during pregnancy, such as marijuana, crack cocaine, amphetamines, or hallucinogens such as LSD and mescaline? If so, what were the amounts and frequency of use?

8. Were there any problems or illnesses that either you or your health care provider were worried about during pregnancy (pregnancy-induced hypertension, preterm labor, gestational diabetes, TORCH infection [toxo-plasmosis, rubella, cytomegalovirus, and herpes])?

Labor and Delivery:

1. How many weeks did you carry the baby before
delivering?

2. Was the labor spontaneous or induced?

3. How many hours long was the labor?

4. Was the baby delivered vaginally or by cesarean section? If by cesarean section, why?

5. Was any analgesia or anesthetic used?

6. Did you hold your baby immediately after delivery? (This question will provide information about the
neonate s condition at delivery.)

7. Immediately following delivery, what was the baby's color?

8. What were the baby's Apgar scores at 1 and 5 minutes?

9. What were the birth weight and length of the baby?

10.Was the baby's father at the birth with you?

11.Where was the baby born (home, hospital, automobile, or other location)?

Postnatal:

1. Did you and your baby go home together? (If answered no, inquire as to the reason for separate discharges.)

2. If hospital delivery, how long was the hospitalization for you and the baby?

3. Did the baby have any breathing or feeding problems during the first week?

4. To your knowledge, did your baby receive any medications during the first week?

5. How would you describe the baby's color at 1 week? (For the light-skinned baby, ask if the skin was pale,
pale pink, blue, or yellow. For the dark-skinned baby, inquire about the color of the sclera, oral mucosa, and
nail beds.)

6. Was the baby circumcised?

7. Did you start breast- or bottle-feeding your baby?

8. Were there any problems with your choice of feeding?

9. Did you or the baby have a fever after delivery?

10. Did you have anyone to help you take care of the baby in the first few weeks after delivery?

Medical

Inquire about the circumstances and outcomes of any hospitalizations or emergency department visits. Keep in mind that some children's caregivers may use the emergency department for episodic health care and may not have regular health care providers.

Injuries/ Accidents

Determine if the child has a pattern of frequent injuries or accidents. Repeat trauma may indicate abuse.

Childhood Illnesses

Document past and current exposure to measles, mumps, rubella, pertussis, and chickenpox.

Immunizations

Immunizations provide protection against many contagious diseases of childhood. Maternal antibodies pass through the placenta and breast milk, offering the baby limited protection from disease. A schedule of recommended childhood immunizations is located in Appendix C. Many health care providers follow the immunization schedule as a guide for well-child check-ups. A record of immunizations is often important for school admission and to avoid repeat vaccinations.

Family Health History

Inquire about age and health status (if deceased, age and cause of death) of the child's mother, father, siblings, grandparents, aunts, and uncles. Ask about diseases in the family that could affect the child's health, including heart disease, diabetes, mental retardation, seizures, allergies, asthma, congenital disorders, alcoholism, and attention deficit hyperactivity disorder (ADHD). Also ask about sudden infant death syndrome (SIDS).

Social History Work Environment

Day care facilities and schools are the child's equivalent of a work environment. Inquire about the number of hours the child attends a day care facility per week. Inquire about the child's academic performance. In addition, ask if the child is home alone before or after school.

Home Environment

Ask about potential exposure to lead in chipping paint because lead is harmful to the developing brain and nervous system of fetuses and young children. This group is four to five times more likely to absorb lead by ingestion than are older children (Fisher & Vessey, 1998).

Child's Personal Habits

1. Determine what activities the child enjoys.

2. Ask how the child copes with stress and if a security object (blanket, stuffed toy) helps calm the child.

3. Determine if the child is prone to temper tantrums and what type of discipline is used.

Health Maintenance Activities Sleep

Determine if the child takes naps and if the child shares a bedroom, because children's different sleep habits may lead to interrupted sleep.

Diet

Questions concerning diet need to be tailored to the child's developmental level. Refer to Nutritional Assessment, Dietary History for questions appropriate to each developmental level.

Safety

Childproofing the environment, especially for young children, is an essential practice. Box 14-1 lists questions to include in your interview.

NUTRITIONAL ASSESSMENT

Good nutrition is essential for optimal health and disease prevention. Educating a child early in life about the importance of healthy eating habits can play a role in safeguarding the child against future disease. Never has there been a time in our history where so much emphasis is being placed on health promotion and preventing diet-related diseases or deficiencies. Nutritional assessment enables the nurse to provide anticipatory guidance, identify at-risk individuals, and collaborate with the health care team for early referral of the child as needed. A variety of methods are employed to assess the child's nutritional status, including history of dietary intake, analysis of laboratory data, anthropometric data, and physical examination.

BOX 14-1 Questions about childproofing the environment

1. Would you tell me how you have childproofed your home?

2. Do you have gates on the top and bottom of the stairs?

3. Are the slats on the crib less than 2³/₈ inches apart?

4. Have you taken the crib mobile down and taken out the bumper pads (applies to infants who are trying to pull up)?

5. Is all sleepwear flame retardant?

6. Is the hot water thermostat turned down to 120° Fahrenheit?

7. Have you installed potty locks to keep the toilet lid down?

8.Do you keep curtain and blind strings out of reach?

9.Have you placed all sharp items such as razors and knives out of reach of the child?

10.Do you monitor your child in the bathtub?

11.Do you always drain the water in the tub after getting out?

12.Have you placed cushioned covering on the tub's water faucet and drain lever?

13.Do you use a nonskid bath mat in the tub?

14.Are there outlet covers on every outlet in the house?

15.When you are cooking, do you keep the pot or pan handles turned in?

16.Have you taken tablecloths off all tables?

17.Do you keep the phone cord out of reach?

18.Is the slack taken up on all electrical appliance and lamp cords?

19.If you have a raised hearth, have you covered it with bumpers, pads, or towels?

20.Are all of your plants out of reach?

21.Are slip protectors under all rugs?

22.If you have a pool in the yard, is it fenced in, or is there a protective cover on top?

23.Do you empty pails that contain liquid after using them?

24.Are medications, cosmetics, pesticides, gasoline, cleaning solutions, paint thinner, and all other poisonous mate
rials out of the child's reach?

25.Do you have your local poison control telephone number next to each phone?

26.Do you have syrup of ipecac in the house? Do you know why it is used and its expiration date?

27.Do you have smoke detectors close to or in the child's bedroom, and on each floor of the house?

28.Do you have a fire extinguisher on each floor?

29.Have you devised and practiced an escape route plan in case of fire?

30.Are you CPR trained?

31.What would you do in case of an emergency?

32.Where do you place your child's car seat-in the front or back seat, facing front or rear? Do you place your child
in the car where an air bag is supplied?

33.Does your child use protective gear such as a helmet or knee and elbow pads if participating in an activity in
which injuries may occur?

34.Do you keep plastic dry cleaner overwraps, latex balloons (unattended by a caregiver), plastic trash bags, and
grocery bags out of the child's reach?

Dietary Intake

There are numerous ways to determine if a child is receiving adequate nutrition. One vehicle for doing so is through a record of dietary intake. Dietary intake is elicited through a 24-hour recall, food diary, or food frequency questionnaire. As with all open-ended questions, an accurate response is variable. Accuracy is hard to obtain if the child has multiple caregivers. Involving the primary caregiver and extended caregivers will be an important task. When obtaining the 24-hour food recall, inquire about the previous 24 hours. Involve any family members present during your interview. Ask the individual to recall the amount and types of food eaten by the child, including the amount and type of liquids consumed during the past 24 hours. A food diary is quite similar to the 24-hour recall in that you are requesting the family to keep track of the same information for a 3-7-day time span. Instruct the caregiver to allow others such as day care providers to record the time, type, and amount of foods and liquids consumed directly on the diary. A food frequency questionnaire can be used during the interview to collect information about consumption of foods from all the food groups. Information collected includes what type, and the amount and frequency of consumed liquids and foods.

Dietary History

Another important tool for assessing dietary risk factors is a diet history. Dietary histories can identify a host of nutritional and behavioral problems, and anticipatory guidance can be provided for deficient areas of nutritional health. The following questions concerning diet are divided into age groups:

A. Infants (0-12 months)

1. Are you breast- or bottle-feeding? (Breastfeeding provides superior immunologic properties.)

2. How many wet diapers does your baby have in a 24-hour period? (Infants should have at least six
very wet diapers every 24 hours.)

3. If bottle-feeding, is the formula iron-fortified? How much formula does your baby drink per day,
or how often does your baby breastfeed and how long are the feedings? (Newborns to 1 month of
age drink up to 32 ounces per day, 1—3-month-olds drink up to 42 ounces a day, 3-6-month-olds drink
up to 40 ounces day, 6-12-month-olds drink up to 32 ounces per day; breastfed babies may want to
feed every 2 hours, and should take at least one breast and suck for 10 minutes to completely
empty the breast.)

4. How long does it take for your baby to finish a bottle? (Generally, an infant should complete their
bottle within 15-20 minutes. An oral/motor dysfunction or congenital heart disease could be suspected if the infant is unable to complete a bottle within the normal time frame.)

5. Does your baby go to bed with the bottle in the crib? (Allowing the baby to fall asleep or keep the
bottle in the crib may lead to dental caries.)

6. Have you introduced iron-fortified cereal? (Iron-fortified cereal can be introduced between 4 and 6
months of age and should be continued until the second birthday. Often, the child's hematocrit will fall about 1 year of age as a result of being a "picky eater.")

7. Do you give your baby honey? (Honey should not be given to children younger than 1 year of age
because of the risk of botulism.)

8. Have you started solid foods? (Readiness cues include sitting without support, extrusion reflex present, being able to lean forward indicating desire for more, and turning away to indicate refusal of food.)

9. If solid foods have been started, how often do you introduce a new food? (Introduce one new food every 3-5 days in order to differentiate food allergies. Many pediatricians recommend starting vegetables first to avoid a "sweet tooth" phenomenon, then following with fruits, and starting meats at about 8-9 months of age.)

10.Do you give your baby fruit juices? (Excessive use of fruit juices can leave the baby feeling full and not wanting to take adequate amounts of formula.)

B. Toddlers (1—3 years old)

1. Have you started your child on whole milk? (Whole milk can now be safely substituted for formula. The
caregiver is encouraged to switch from whole to 2% milk at 2 years of age.)

2. How much milk does your child drink? (The recommended amount of milk per day is 16 ounces,
with a maximum of 1 quart.)

3. Is your child drinking from a cup? (Transitioning the child from bottle to cup occurs at or before 1
year of age. An early transition helps prevent dental caries. If the child is filling up on milk via a bottle, a variety of foods are not being taken in.)

4. Have you transitioned your child to soft table foods? (Generally, at about 12 months of age, a
child is able to chew soft food.)

5. Are you present in the room while your child is eat ing? (Supervising the child is important to prevent
choking.)

6. Does your family include the child during meal times? (Starting family meals at an early age has
many positive benefits such as establishing routines and communication between family members.)

7. Is your child starting to feed him- or herself? (During the later phase of infancy and early toddlerhood, the child will begin to take an interest in self-feeding.)

8. Do you let your child eat any of the following foods: nuts, popcorn, whole hot dogs, grapes, raw
vegetables, or hard candy? (These foods/snacks may present a choking hazard.)

9. Do you offer your child at least two healthy snacks per day? (Offering small nutritious snacks through
out the day will help provide the toddler with adequate nutrition not achieved at mealtimes.)

10.Is your child eating foods from all food groups? (A good rule of thumb for determining the right amount of food for a child is ensuring they eat 1 tablespoon of each food group per age in years; thus, a 2-year-old would need to eat 2 tablespoons of vegetables.)

C. Preschooler (3-5 years)

1. How much milk does your child drink per day? (The preschooler needs to drink at least 20 ounces
of milk per day.)

2. How much juice does your child drink? (Limiting juice to no more than 8-12 ounces per day will
help the child take more food at meals and snacks.)

3. Does your child eat a variety of foods from all food groups? (Utilize the same rule of thumb for ade
quate food intake as described for toddlers.)

4. Many of the same questions for the toddler group apply to the preschooler (questions 5, 6, and 9).

D. School-aged child (6-12 years)

1. How many servings of milk does your child drink per day? (School-aged children should receive 800
mg of calcium per day, which is equivalent to about 21 ounces of milk.)

2. Has your child switched from 2% to skim milk? (At the age of 6, children should switch to skim milk.)

3. Is your child eating three meals per day? (Children often skip breakfast because of early morning time
constraints.)

4. Does your family sit down together for at least one meal per day? (Meals at this age tend to occur on
the run because of extracurricular activities planned for dinnertime.)

5. Does your child eat a hot lunch at school? (A school lunch will provide approximately one-third
of the total recommended daily allowance.)

6. Does your child brush their teeth at least two times per day? (Caregivers are encouraged to brush their
child's teeth at least once a day until the child has mastered cursive writing. You can foster autonomy
by allowing your child to brush his or her teeth in the morning.)

7. Does your child eat sugary snacks? (Limit sugar intake to prevent dental caries and avoid empty
calories.)

8. Do you allow your child to sit in front of the television and eat a meal? (Obesity is on the rise, and
spending excessive time watching television seems to contribute to decreased physical activity.)

9. How often does your child eat fast food per week? (Incidence of obesity increases with frequent consumption of fast food.)

E. Adolescent (13-18 years): The same questions asked during the school-aged child's interview can be used,
but answers to the questions of the adolescent directly may yield important information.

Laboratory Evaluation

Data gathered during a nutritional assessment will give the interviewer an indication of at-risk factors. Inadequate caloric intake is a nutritional problem. Two commonly ordered laboratory tests are serum albumin and prealbumin. Both tests reflect adequate calorie and protein intake. A serum albumin reflects the previous month's food intake. The prealbumin reflects a shorter period of time, which is the previous 1 week of intake. A complete blood cell count, which includes hemoglobin, hematocrit, and red cell indices, provides an indication of adequate iron status. Cholesterol screenings have become more frequently ordered in children whose family history predisposes them to elevated cholesterol levels.

Anthropometric Data

Anthropometric measurements refer to the science of measuring the human body as to height, weight, and size of component parts, including skinfolds. Anthropometric data provides information about growth patterns and the nur-titional status of children. The physical growth parameters of weight and length/height are found in Appendix B. Measurements of skinfold thickness and arm circumference are important indicators of body fat stores, nutritional status, and skeletal muscle mass.

Skinfold thickness is a more reliable indicator of body fat than is weight. The most common measurement site is over the tricep muscle in the child. This measurement may be threatening for the child. To alleviate anxiety let the child sit in the caregivers lap. While the child's arm is dangling at her or his side in a fully relaxed position, lift the fold of subcutaneous tissue and skin away from the triceps muscle. Place the calipers on the skin next to the fingers, while lifting the fold of skin. Hold the skinfold in place while measuring the triceps skinfold. Repeat this step twice and average the three reading^ to obtain the skinfold thickness value.

Arm circumference is measured at the midpoint of the upper arm. To locate the midpoint of the upper arm, have the child flex th)e arm at a 90° angle. Measure from the acromion process (the lateral extension of the spine of the scapula, forming the highest point of the shoulder) to the olecranon process (a proximal projection of the ulna that forms the point of the elbow) and mark the midpoint with a washable ink pen or marker. Ask the child to hold their arm in a relaxed position at their side. Using a tape measure, measure the circumference.

Physical Examination

The physical examination of nearly all body systems can identify nutritional deficiencies. Examination techniques are described throughout this chapter. Table 14-1 summarizes physical signs and symptoms of poor nutritional status.

Figure 14-6 Measuring Infant Head Circumference

Microcephaly, a congenital anomaly characterized by a small brain with a resultant small head and a mental deficit, is an abnormal finding. Another abnormality, hydro-cephalus, is an enlargement of the head without enlargement of the facial structures.

Chest Circumference

Figure 14-7 Measuring Chest Circumference

Chest circumference is measured up to 1 year of age. It is a measurement that, by itself, provides little information but is compared to head circumference to evaluate the child's overall growth. Measure the chest circumference by placing the tape measure around the chest at the nipple line (Figure 14-7). Measure at the end of exhalation. From birth to about 1 year, the head circumference is greater than the chest circumference. After age 1, the chest circumference is greater than the head circumference. A measured chest circumference below normal limits is abnormal. A below-normal chest circumference for age can be attributed to prematurity.

Skin inspection

Color

Observe the color of the body, especially at the tip of the nose, the external ear, the lips, the hands, and the feet. These areas are prominent locations for detecting cyanosis or jaundice.

Lesions

Inspect the skin for lesions, noting the anatomic location, distribution, shape, color, size, and exudate. No skin lesions should be present except for freckles, birthmarks, or moles (nevi), which may be flat or elevated. Several abnormal skin conditions are associated with lesions. Eczema or atopic der matitis (AD) is a common skin disorder involving inflammation of the epidermis and superficial dermis. The lesions of AD are usually symmetrical, scaly, erythematous patches or plaques with possible exudation and crusting. Inhaled allergens such as pollens, molds, or dust mites, or food allergens are thought to induce mast-cell responses that cause AD. Erythema toxicum, a benign rash whose cause is unknown, appears as small, erythematous, maculopapular lesions that erupt on the newborn. Another lesion is telangiectatic nevi, commonly known as stork bites. Refer to Chapter 7 for specific information. Diaper dermatitis is characterized by diffuse redness, papules, vesicles, edema, scaling, and ulcer-ations on the area covered by a baby's diaper. It is the result of a bacteria and urea reaction on the skin. A dark-black tuft of hair or a dimple over the lumbosacral area is abnormal and may indicate that the neonate has a vertebral defect known as spina bifida occulta.

Palpation

Temperature

Temperature is assessed by palpating the skin with the back of the hand. Skin surface temperature should be warm and equal bilaterally. Hands and feet may be slightly cooler than the rest of the body. Generalized hyperthermia may be indicative of a febrile state, hyperthyroidism, or increased metabolic function caused by exercise. Generalized hypothermia may be indicative of shock or some other type of central circulatory dysfunction.

Texture

Use the finger pads to palpate the skin. The technique of palpating the skin of a younger child can be accomplished by playing games. For example, use the finger pads to walk up the abdomen and touch the nose. The skin of a child normally is smooth and soft. A common variation occurring in the infant is milia, which are small, white papules on the cheeks, forehead, nose, and chin due to sebum that occludes the opening of the follicles. Milia resolve spontaneously within a few weeks. Newborns may also have vernix caseosa, a thick, cheesy, protective, integumentary deposit that consists of sebum and shed epithelial cells.

Turgor

Skin turgor or elasticity reflects the child's state of hydration. It is assessed by pinching a small section of the child's skin between your thumb and forefinger and quickly releasing it. The upper arm and abdomen are optimal areas to assess. Good turgor and adequate hydration is evidenced when the skin rapidly returns to its original contour after it is released. Decreased skin turgor, a sign of dehydration, is present when it slowly returns to its original contour or remains pinched or "tented" after it is released.

Edema

Edema, an accumulation of fluid in the interstitial spaces, is assessed by pressing the thumb into an area of the body that appears puffy or swollen. Edema is most evident in dependent parts of the body (arms, hands, legs, ankles, feet, sacrum). Periorbital edema may be observed in children on the eyelids. Normally the skin surface stays smooth. If pressure leaves an indentation, pitting edema is present.

Hair

To evaluate the scalp for lesions or signs of infestations, don gloves and lift the scalp hair by segments. Note the scalp's color, which should be similar to the child's skin. There should be no signs of lesions or infestations. Seborrheic dermatitis (cradle cap), caused by increased production of sebum, looks like yellow, greasy-appearing scales and crusts on the scalp of a light-skinned infant. In dark-skinned infants, the scaling is light gray. Head lice (pediculosis capi-tis) may be seen crawling within the hair. Refer to Chapter 30 for more information about seborrheic dermatitis and head lice.

Head

Inspection

Shape and Symmetry

With the child sitting upright either in the caregiver's arms or on the examination table, observe the symmetry of the frontal, parietal, and occipital prominences. Normally, the shape of a child's head is symmetrical without depressions or protrusions. The anterior fontanel may pulsate with every heart beat. The infant of Asian descent generally has a flattened occiput, more so than infants of other races. A flattened occipital bone with resultant hair loss over the same area is abnormal and is usually caused by the infant being in the supine position for prolonged periods of time.

Head Control

Head control is assessed when the infant is in a sitting position. With the head unsupported, observe the infant's ability to hold the head erect. At 4 months of age, most infants are able to hold the head erect and in midline. To evaluate for head lag, pull the infant by the hands from a supine to a sitting position. Again by 4 months of age, the head should stay in line with the body when being pulled forward. Documented prematurity, hydrocephalus, and illnesses causing developmental delays are possible causes of head lag. Significant head lag after 6 months of age may indicate brain injury and should be further investigated.

Palpation

Fontanel

Place the child in an upright position. Using the second or third finger pad, palpate the anterior fontanel at the junction of the sagittal, coronal, and frontal sutures. Palpate the posterior fontanel at the junction of the sagittal and lambdoidal sutures. Assess for bulging, pulsations, and size. Crying will produce a distorted, full, bulging appearance. The anterior fontanel is soft and flat. Size ranges from 4 to 6 centimeters at birth. The fontanel gradually closes between 9 and 19 months of age. The posterior fontanel is also soft and flat. The size ranges from 0.5 to 1.5 centimeters at birth. The posterior fontanel gradually closes between 1 and 3 months of age. It is normal to feel pulsations related to the peripheral pulse.

If palpation reveals a bulging, tense fontanel, this is abnormal and indicates increased intracranial pressure. A sunken, depressed fontanel occurs with dehydration, A wide anterior fontanel in a child older than 2^V2 years is an abnormal finding. An anterior fontanel that remains open after 2V₂ years of age may indicate disease such as rickets. In rickets, there is a low level of vitamin D relative to decreased phosphate level. A posterior fontanel greater than 1.5 cm in diameter is abnormal and occurs with congenital hypothy-roidism.

Suture Lines

With the finger pads, palpate the sagittal suture line, which runs from the anterior to the posterior portion of the skull in a midline position. Palpate the coronal suture line, which runs along both sides of the head, starting at the anterior fontanel. Palpate the lambdoidal suture. The lambdoidal suture runs along both sides of the head, starting at the posterior fontanel. Ascertain if these suture lines are open, united, or overlapping. Grooves or ridges between sections of the skull are normally palpated up to 6 months of age. Suture lines that overlap or override one another, giving the head an unusual shape, warrant further investigation. Craniosynostosis is premature ossification of suture lines, whereby there is early formation and fusion of skull bones. Craniosynostosis may be caused by metabolic disorders or may be a secondary consequence of microcephaly. Figure 14-8 illustrates a superior and lateral view of an infant head.

Surface Characteristics

With the finger pads, palpate the skull in the same manner as the fontanels and suture lines. Note surface edema and contour of the cranium. Normally, the skin covering the cranium is flush against the skull and without edema. A softening of the outer layer of the cranial bones behind and above the ears combined with a ping-pong ball sensation as the area is pressed in gently with the fingers is indicative of craniotabes, an abnormal finding. Craniotabes is associated with rickets, syphilis, hydrocephaly or hypervitaminosis.

Figure 14-8 Infant Head Structures. (A) Superior View (B) Lateral View

Another abnormal finding in a newborn is a cephalhematoma, or a localized, subcutaneous swelling over one of the cranial bones. Refer to Chapter 7 for additional information about a cephalhematoma.

Another variation in the newborn that causes the shape of the skull to look markedly asymmetric is known as caput succedaneum or swelling over the occipitoparietal region of the skull. A newborⁿs head may also feel asymmetric due to molding of the cranial bones as a result of induced pressure during delivery.

Eyes

General Approach

From infancy through about 8—10 years, you should assess the eyes toward the end of the assessment, with the exception of testing vision, which should be done first. Remember that the child's attention span is short, and attentiveness decreases the longer you evaluate. Young children generally are not cooperative for eye, ear, and throat assessments. Place the young infant, preschooler, or school-aged or adolescent child on the examination table. The older infant or the toddler can be held by the caregiver.

Vision Screening

General Approach

Several screening tests are available to evaluate visual acuity in children including the adult Snellen, Snellen E, and Allen. The child's age and developmental level determine the measures used. The adult Snellen chart can be used on children as young as 6 years, provided they are able to read the alphabet. The Snellen E chart, which shows the letter "E" facing in different directions, is used for a child over 3 years of age or any child who cannot read the alphabet. Test eveiy 1-2 years through adolescence. If the child resists wearing a cover patch over the eye, make a game out of wearing the patch. For example, the young child could pretend to be a pirate exploring new territory. Use your imagination to think of a fantasy situation. The Allen test (a series of seven pictures on different cards) can be used with children as young as 3 years of age (American Academy of Pediatrics Committee on Practice and Ambulatory Medicine, Section on Opthalmology, 1996).

Snellen E Chart

Ask the child to point an arm in the direction the E is pointing. Observe for squinting. Vision is 20/40 from 2 to approximately 6 years of age, when it approaches the normal 20/20 acuity. The test is abnormal if results are 20/40 or greater in a child 3 years of age or 20/30 or greater in a child 6 years or older, or if results are different in each eye.

Nearsightedness or myopia is the result of congenital cataracts, retinal trauma, or a tumor.

Allen Test

With the child's eyes both open, show each card to the child and elicit a name for each picture. Do not use any pictures with which the child is not familiar. Place the 2-3-year-old child 15 feet from where you will be standing. Place the 3-4-year-old child 20 feet from you. Ask the caregiver to help cover one of the child's eyes. Show the pictures one at a time, eliciting a response after each showing. Show the same pictures in different sequence for the other eye. To record findings, the denominator is always constant at 30, because a child with normal vision should see the picture on the card (target) at 30 feet. To document the numerator, determine the greatest distance at which three of the pictures are recognized by each eye, for example, right eye = 15/30, left eye = 20/30. The child should correctly identify three of the cards in three trials. Two- to three-year-old children should have 15/30 vision. Three- to four-year-old children should be able to achieve a score of 15/30 to 20/30. Each eye should have the same score. If the scores for the child's right and left eyes differ by 5 feet or more or either or both eyes score less than 15/30, refer the child to an ophthalmologist.

Strabismus Screening

The Hirschberg test (corneal light reflex) and the cover-uncover test screen for strabismus. The latter is the more definitive test.

Hirschberg Test

Hold a pen light by the side of your head with one hand so the light is facing straight ahead. The pen light should be approximately 12 inches from the child's head. Using your other hand turn the child's head so the light is in the midline position toward the child's eyes. Make a general observation of the light reflection relative to both cornea noting symmetry and central location. The reflected light should be seen symmetrically in the center of both corneas.

Esotropia, thought to be congenital, occurs when the light reflection is displaced to the outer margin of the cornea as the eye deviates inward. Some theories suggest that neurological factors contribute to its development. Exotropia occurs when the light reflection is displaced to the inner margin of the cornea as the eye deviates outward. This abnormality can result from eye muscle fatigue or can be congenital. More information on eye abnormalities can be found in Chapter 31.

Cover-Uncover Test

This test is performed on infants greater than 6 months of age through school-age. Stand 2 feet in front of the child. Place the child in a seated position on the examining table or caregiver's lap. Ask the child to focus attention on the pen light by the side of your head. Place a cover card or your hand over one eye. Wait until the uncovered eye focuses then remove the occluder and evaluate the eye just uncovered for focusing movement.

The normal finding is neither eye moves when the occluder is being removed. Infants younger than 6 months of age display strabismus due to poor neuromuscular control of eye muscles. It is abnormal for one or both eyes to move to focus on the penlight during assessment. Assume strabismus is present. Strabismus after 6 months of age is abnormal and indicates eye muscle weakness.

Inspection

Eyelids

Sit at the child's eye level. Observe for symmetrical palpebral fissures (opening between the margins of the upper and lower eyelids) and position of eyelids in relation to the iris. Normally, the palpebral fissures of both eyes are positioned symmetrically. The upper eyelid covers a small portion of the iris, and the lower lid meets the iris. Epicanthal folds are normally present in children of Asian descent. An epicanthal fold is an excess skinfold over the angle of the inner canthus of the eye. It is abnormal for a portion of the sclera to be seen above the iris as it is in children with hydro-cephalus. As the forehead becomes prominent, the eyebrows and eyelids are drawn up, creating a setting sun appearance of the child's eyes. Children with Down syndrome have a fold of skin covering the inner canthus and lacrimal caruncle. During embryonic development, the fold of skin slants in a downward direction toward the nose.

Lacrimal Apparatus

If lacrimal duct obstruction is suspected, use the index finger to lightly palpate the lacrimal sacarea while bracing the child's head with the other hand. Note drainage from the lacrimal duct orifice. The child's caregiver reports that the child is unable to produce tears, an abnormal finding. The lacrimal ducts should be open by 3 months of age. Dacryocystitis is an infection of the lacrimal sac caused by obstruction of the lacrimal duct. It is characterized by tearing and discharge from the eye.

Anterior Segment Structures

Sclera

The sclera is observed mainly to determine its color. Normally, the newborn exhibits a bluish -tinged sclera related to thinness of the fibrous tissue. The sclera is white in light-skinned children and a slightly darker color in some dark-skinned children. A yellowish color to the sclera indicates jaundice, which is due to hemolysis of red blood cells, non-functioning liver cells, or obstruction of bile in the common or hepatic duct.

Iris

Using the light source on the opthalmoscope, observe the iris for lesions and color. Up to about 6 months of age, the color of the iris is blue or slate gray in light-skinned infants and brownish in dark-skinned infants. By 12 months of age, complete transition of iris color has occurred. Small white Hecks, called Brushfield's spots, noted around the perimeter of the iris are abnormal. Brushfields spots are found on the iris of the child with Down syndrome. The spots develop during embryonic maturation.

Pupils

The pupils should be inspected for size, shape, equality, and response to light. Pupils should be equal in size; however, a small number of individuals (5%) normally have pupils of different sizes (Jarvis, 1996). To test for pupillary light reflex, dim the room lights. Position the child according to age. Move the lighted instrument in from the side and observe the change in the size of the pupils. The pupils should react equally and accommodate to light. An abnormality is suspected if one or both pupils are nonreactive. Any central nervous system insult (e.g., head injury, meningitis, seizures) may cause an abnormal response.

Inspection

Red Reflex

Turn the opthalmoscope to 0 diopters. Stand 10-12 inches from the client and observe the pupil through the opthalmo-scope's window. Note the color of the reflex within the eye. In children, the red reflex appears as a brilliant, uniform red glow. In newborns and infants, the red reflex will appear lighter. In many darker-skinned individuals, the reflex will appear darker. Black spots or opacities within the red reflex are abnormal and may indicate a cataract. Chromosomal disorders, intrauterine infections, and ocular trauma are possible causes of cataracts in newborns. A yellowish or white light reflex (cat's eye reflex) is also abnormal and may indicate retinoblastoma, a malignant glioma located in the posterior chamber of the eye.

Retina

Assess the retinal background for color. Divide the retina into four quadrants and follow the retinal arteries and veins from the disc to periphery. Note the size and distribution of retinal arteries and veins. The retinas background is generally pink but may be lighter in some Caucasians and darker in African American individuals. There is no difference in normal vasculature among children and adults. A red to dark-red color is abnormal. Some areas may be rounded or flame shaped. Hemorrhage is seen in trauma. Bleeding into the optic nerve sheath is found in children who have been physically shaken.

Optic Disc

At a 15° lateral position to the eye, move in closer to the eye approximately 1 inch from the child. Move the diopter to -5 to 0. Locate a vessel and move medially (nasal side) to locate the disc. Observe the color of the disc along with margin definition. The disc is creamy yellow to salmon in color. The disc is lighter in an infant. It measures about 1.5 mm in diameter and is round in shape. The margins of the disc are regular and clearly defined. If abnormal, the margins are blurred. In papilledema, the optic disc margins are abnormal. The margins are poorly defined (blurred) related to increased intracranial pressure.

Ears

Auditory Testing

General Approach

Perform auditory testing at about 3^ years of age or when the child can follow directions. Prior to 3 years of age, the following are a few parameters for evaluating hearing:

1. Does the child react to a loud noise?

2. Does the child react to the caregiver's voice by cooing,
smiling, or turning eyes and head toward the voice?

3. Does the child try to imitate sounds?

4. Can the child imitate words and sounds?

5. Can the child follow directions?

6. Does the child respond to sounds not directed at him
or her?

External Ear

Inspection of Pinna Position

Position the child on the caregiver's lap or examining table. Draw an imaginary line from the outer canthus to the top of the ear. The top of the ear should be at or a little above the imaginary line. An abnormal finding occurs when the top of the ear is below the imaginary line drawn from the outer canthus to the top of the ear. Kidneys and ears are formed at the same time in embryonic development. If a child's ears are low set, renal anomalies must be ruled out. Low-set ears can also occur in Down syndrome.

Internal Ear Inspection

A cooperative child may be allowed to sit for the assessment. A young child may be held as shown in Figure 14-9A. Restrain the uncooperative young child by placing him or her supine on a firm surface. Instruct the caregiver or assistant to hold the child's arms up near the head, embracing the elbow joints on both sides of either arm. Restrain the infant by having the caregiver hold the infant's hands down.

With your thumb and forefinger grasping the otoscope, use the lateral side of the hand to prevent the head from jerking. Your other hand can also be used to stabilize the child's head. Pull the lower auricle down and out to straighten the canal. This technique is used in children up to about 3 years of age. Use the adult technique after age 3. Insert the speculum about V4 to Vg inch, depending on the child's age. Suspected otitis media must be evaluated with a pneumatic bulb attached to the side of the otoscope's light source. Select a larger speculum to make a tight seal and prevent air from escaping from the canal. If a light reflex is present, focus on the light reflection. Gently squeeze the bulb attachment to introduce air into the canal. Some nurses prefer to gently blow air through the tubing rather than squeezing air into the canal. Observe the tympanic membrane for movement.

The tympanic membrane is transparent and pearly gray to light pink in color. The membrane is smooth and continuous. Light from the otoscope is reflected off the membrane. The tympanic membrane moves when air is introduced into the canal.

Figure 14-13 Location of Retractions

Palpation

Tactile Fremitus

Fremitus is easily felt when a child cries. If the infant or young child is not crying, it is advisable to defer this procedure until later in the assessment, perhaps after the throat and ear examinations, which usually produce crying. With the child in the same position as inspection, instruct the older child to repeat "99." As the child is crying or repeating "99," use both hands to palpate the chest simultaneously. Repeat the procedure until the anterior, posterior, and lateral sides are assessed, comparing the contralateral side. A soft vibration over the chest wall is normal. Increased sound production is caused by consolidation, as in pneumonia. Decreased sound production is caused by conditions such as pulmonary edema or pleural effusions.

Percussion

Percussion is performed to further assess the underlying structures of the thorax. The chest is percussed to determine dullness or hyperresonance caused by consolidation, fluid, or air trapping. However, in the newborn it is usually unreliable because an adult's fingers are too large in relation to the small chest (Seidel, Ball, Dains, & Benedict, 1995). Normal diaphragmatic excursion in infants and young toddlers is one to two intercostal spaces.

Auscultation

Breath Sounds

Use the same assessment techniques as for an adult. Sometimes, it is difficult to differentiate the various adventitious sounds because a child's respiratory rate is rapid; for example, differentiating expiratory wheezing from inspiratory wheezing can be difficult. Mastering the technique takes time and practice. Of the three types of breath sounds—bronchial, bronchovesicular, and vesicular—the bronchovesicular are normally heard throughout the peripheral lung fields up to 5-6 years of age, because the chest wall is thin with decreased musculature. Lung fields are clear and equal bilaterally.

The common terms used to describe adventitious breath sounds are crackles (formerly called rales), rhonci, and wheezes. Crackles may be caused by conditions such as bron-chiolitis, CF, and bronchopulmonary dysplasia. Wheezing during infancy and early childhood may be common. Children with asthma and bronchiolitis may present with wheezing. Stridor is a high-pitched inspiratory crowing sound occurring with croup and acute epiglottitis.

Heart and Peripheral Vasculature

General Approach

The cardiovascular physical assessment has two major components: (1) assessment of the precordium and (2) assessment of the periphery. It is best to perform the cardiac assessment near the beginning of the examination, when the infant or young child is relatively calm. Do not get discouraged during the assessment. The novice nurse is not expected to identify a murmur and location within the cardiac cycle. Be patient because skill will come only with practice. Cardiac landmarks change when a child has dextrocardia. In this condition, the apex of the heart points toward the right thoracic cavity, thus heart sounds are auscultated primarily on the right side of the chest.

Inspection

Apical Impulse

With the child's entire chest exposed, look diagonally across the chest for the apical impulse. In infants and young children, the heart lies more horizontally in the chest than in an adult; therefore, the apical impulse is located at the fourth intercostal space and just left of the midclavicular line. The apical impulse of a child 7 years or older is at the fifth intercostal space and to the right of the midclavicular line. The impulse may not be visible in all children, especially in those who have increased adipose tissue or muscle. If the apical impulse is shifted toward the left side or downward expect pathology. Cardiac enlargement or a pneumothorax can cause the location of the apical impulse to deviate. The apical pulse moves laterally with cardiac enlargement. A pneumothorax shifts the apical impulse away from the area of the pneumothorax, which occurs when air enters the pleural cavity from a perforation, commonly as a result of injury to the chest wall.

Precordium

Observe the precordium for any movements other than the apical impulse, which is normally visible. Movements other than the apical impulse are abnormal, and if noticed, they should be described in terms of type, location, and timing in relation to the cardiac cycle. Another abnormality is a heave, or a lifting of the cardiac area secondary to an increased workload and force of the left ventricular contraction. A child with congenital heart disease is at risk for developing congestive heart failure (CHF) with associated volume overload and may have heaves. Large left-to-right shunt defects, such as a VSD, cause right ventricular volume overload.

Palpation

Thrill

A thrill is a vibration that is similar to what one feels when a hand is placed on a purring cat. It is most commonly produced by blood flowing through a narrow opening from one chamber to another such as in a septal defect. Palpate as for an adult or use the proximal one-third of each finger and the areas over the metacarpophalangeal joints. Place the hand vertically along the heart's apex and move the hand toward the sternum.

Place the hand horizontally along the sternum, moving up the sternal border about ^V2 to 1 inch each time. When at the clavicular level, place the hand vertically and assess for a thrill at the heart's base. Use the finger pads to palpate a thrill at the suprasternal notch and along the carotid arteries.

A thrill is not found in the healthy child. A thrill's anatomic location corresponds to a particular structural abnormality within the heart. For example, a thrill in the pulmonic area is felt at the second and third intercostal space on the upper left sternal border. A thrill at the second intercostal space on the right upper sternal border is attributed to pathology in the aorta.

Peripheral Pulses

Use the same finger to assess each peripheral pulse. The sensation of one finger pad versus another can be different. Use the finger pads to palpate each pair of peripheral pulses simultaneously, except for the carotid pulses. The carotid pulses should not be palpated together because excessive stimulation can elicit a vagal response and slow down the heart. Palpating both carotid pulses at the same time could also cut off circulation to the child's head. Palpate the brachial and femoral pulses simultaneously. Pulse qualities are the same in the adult and the child. A brachial-femoral lag, when femoral pulses are weaker than brachial pulses when palpated simultaneously, is abnormal and occurs in a cardiac defect know as coarctation of the aorta (COA). COA is due to a narrowing of the aorta before, at, or just beyond the entrance of the ductus arteriosus, which causes reduced blood flow to the lower body.

If coarctation of the aorta is suspected (as when a brachial-femoral lag is present), obtain all four extremity blood pressures and compare the upper and lower extremity readings on each side. Remember to use an appropriately sized cuff. Refer to the section Vital Signs: Blood Pressure for information about determination of proper cuff size. Take the upper extremity blood pressure in the right arm. Because weak or absent leg pulses accompany coarctation, measurements are difficult to obtain. Use a Doppler transducer to intensify the sound of the pulse. Until you feel proficient, the Doppler technique requires two people for accurate measurement; have the caregiver hold the child's leg still while you assess the pulse. Locate the posterior tibial pulse with the Doppler transducer and make an "X" with a pen where the pulse is felt or heard. Place an appropriately sized cuff on the lower right leg. The lower edge of the cuff should be ^Vo inch to 1 inch above the presumed posterior tibial pulse location. Apply a small amount of ultrasound gel to the area surrounding the presumed pulse. Turn the Doppler transducer on and adjust the volume control while the attached probe is locating the pulse. When a pulse is identified, proceed with the blood pressure measurement. Only the systolic number is obtained with this technique. Repeat the steps on the left side of body.

Normally, upper and lower extremity blood pressures are equal. If the systolic blood pressure in the leg is lower than that in the arm and femoral, popliteal, posterior tibial, or dor-salis pedis pulses are weak or absent, you can assume coarctation of the aorta is present. If undiagnosed, as the child becomes older, the upper extremity pulses are bounding.

Auscultation

Heart Sounds

Auscultating the infants or the young pediatric child's heart is difficult because the heart rate is rapid and breath sounds are easily transmitted through the chest wall. Have the child lie down. If this position is not possible, the child should be held at a 45° angle in the caregiver's arms. A quiet environment and child is optimum in order to properly listen to the heart. Use the Z pattern to auscultate the heart. Place the stethoscope in the apical area and gradually move it toward the right lower sternal border and up the sternal border in a right diagonal line. Move gradually from the child's left to the right upper sternal borders (Figure 14-15). Perform a second evaluation with the child in a sitting position.

Fifty percent of all children develop an innocent murmur at some time in their lives. Innocent murmurs are not associated with pathology and are accentuated in high cardiac output states such as fever. When the child is sitting, they are heard early in systole at the second or third intercostal space along the left sternal border and are softly musical in quality; they disappear when the child lies down. Be aware of sinus arrhythmias during auscultation of the hearts rhythm. Sinus arrhythmia is normal in many children. On inspiration, the pulse rate speeds up, the pulse rate slows with expiration. To determine if the rhythm is normal,

ask the child to hold his or her breath while you auscultate the heart. If the heart rate variability stops, then a sinus arrhythmia is present.

Si is best heard at the apex of the heart, left lower sternal border. S2 is best heard at the heart base. A fixed split S2 that does not vary with respiration is abnormal, and you can suspect an atrial septal defect (ASD). In children, S2 physiologically splits with inspiration and becomes single with expiration. This phenomenon is due to a greater negative pressure in the thoracic cavity. In children, S₃ often sounds like the three syllables of the word "Kentucky," especially when accompanied by tachycardia. A loud third heart sound maybe present in children with CHF or VSD.

Figure 14-15 Z Auscultation Pattern for Young Children

Abdomen General Approach

If possible, ask the caregiver to refrain from feeding the infant prior to the assessment because palpation of a full stomach may induce vomiting. Children who are physically able should be encouraged to empty the bladder prior to the assessment. The young infant, school-aged child, or adolescent should lie on the examination table. For the toddler or preschooler, have the caregiver hold the child supine on the lap, with the lower extremities bent at the knees. If the child is crying, encourage the caregiver to help calm the child before you proceed with the assessment. Observe nonverbal communication in children who are not able to verbally express feelings. The order of abdominal assessment is inspection, auscultation, and palpation. Auscultation is performed second because palpation can alter bowel sounds. During palpation, listen for a high-pitched cry and look for a change in facial expression or for sudden protective movements that may indicate a painful or tender area.

Inspection

Observe the abdomen for a distinct separation of the rectus muscles with a visible bulge along the midline known as diastasis recti. Normally the abdominal musculature is continuous. A separated abdominal muscle that lies vertically is abnormal. The gap between the two edges may range from 1 to 5 centimeters. Diastasis recti is more common in African-American infants and usually disappears by early childhood.

Peristaltic Wave

Observe the abdominal wall below the xiphoid process and above the symphysis pubis for wave-like movements. Peristalsis is not normally visible. Visible peristaltic waves seen moving across the epigastrium from left to right are abnormal and may occur in the gastrointestinal disorder pyloric stenosis. In this condition, the pyloric muscle hypertrophies, resulting in obstruction at the pyloric sphincter. Refer to Chapter 23 for more information about pyloric stenosis.

Auscultation

After performing auscultation of the lungs, it is helpful to proceed to auscultating the abdomen because doing so allows you to complete a good portion of auscultation all at once. If the child is not cooperating, a simple distracting phrase such as "I can hear your breakfast in there" is helpful during auscultation.

Palpation

General Palpation

Perform the exact same technique and sequence of light and deep palpation as done with the adult. On palpation, an olive-shaped mass felt in the epigastric area and to the upper right of the umbilicus is abnormal and is indicative of pyloric stenosis. Abdominal distension coupled with palpable stool over the abdomen and the absence of stool in the rectum is abnormal. ATI aganglionic segment of the colon is responsible for Hirschsprung's disease, which produces these abnormal gastrointestinal (GI) findings. A sausage-shaped mass that produces intermittent pain when palpated in the upper abdomen is abnormal. This is a manifestation of another GI disorder called intussusception. Bowel sounds heard in the thoracic cavity, a scaphoid abdomen, an upward displaced apical impulse, and signs of respiratory distress are abnormal findings in the newborn and suggest a diaphragmatic hernia. More information on gastrointestinal alterations are found in Chapter 23.

Liver Palpation

For infants and toddlers, use the outer edge of your right thumb to press down and scoop up at the right upper quadrant. For the remaining age groups, use the same technique as for an adult. The liver is not normally palpated, although the liver edge can be found 1-2 cm below the right costal margin in a normal, healthy child. The liver edge is soft and regular. It is abnormal for the liver edge to be palpated more than 2 cm below the right costal margin and be full with a firm, sharp border. Hepatomegaly occurs in several disease states such as viral or bacterial illnesses, tumors, congestive heart failure, and fat and glycogen storage diseases. Viral and bacterial illnesses and tumors cause liver cells to multiply in number, creating an enlarged liver. In heart failure, the hepatic veins and sinusoids enlarge from congestion, resulting in hemorrhage and fibrosis of the liver. In fat and glycogen storage diseases, fat and glycogen accumulate within the liver, and fibrosis ensues.

Musculoskeletal System

General Approach

The extent or degree of assessment depends greatly on the child's or caregiver's complaints of musculoskeletal problems. Be aware that, during periods of rapid growth, children complain of normal muscle aches. Try to incorporate musculoskeletal assessment techniques into other system assessments. For instance, while inspecting the integument, inspect the muscles and joints. Inspecting the musculoskeletal system in the ambulatory child is accomplished by allowing the child to move freely about and play in the examination room while you inquire about the health history. Your observations of the child enable you to assess posture, muscle symmetry, and range of motion of muscles and joints. Do not rush through the assessment. Throughout the assessment, incorporate game playing that facilitates evaluation of the musculoskeletal system. Observe range of motion and joint flexibility as the child undresses.

Inspection

Muscles

Assessment of the muscles includes examination of muscle mass (size), muscle tone, muscle strength, gross and fine motor ability, and involuntary movements.

Muscle Mass (Size)

Note the symmetry and alignment of muscle mass by comparing one side of the body with the other. Muscles should have a firmness when palpated. In most instances muscle size and firmness will be equal. Muscles should be measured if hypertrophy or atrophy is suspected.

Muscle Tone

Muscle tone is best evaluated by observation of active range of motion. Note any resistance, rigidity, spasticity, hypotonia, flaccidity, or paralysis as the child performs range of motion of the neck, spine, and extremities. Increased muscle tone (spasticity) is abnormal and may indicate cerebral palsy (CP), which results from a nonprogressive abnormality in the pyramidal motor tract. One of the more common contributing factors, perinatal asphyxia, causes abnormal posture and gross motor development and varying degrees of abnormal muscle tone. Refer to Chapter 32 for more information about CP.

Muscle Strength

To evaluate the strength of the infant's shoulder muscles, place your hands under the axillae and pull the infant into a standing position. The infant should not slip through your hands. Be prepared to catch the infant if needed. Evaluate the infant's leg strength in a semi-standing position. Lower the infant to the examination table so the infants legs touch the table. Place the infant older than 4 months in a prone position. Observe the infant's ability to lift the upper body off the examination table using the upper extremities.

In children beyond infancy note the symmetry of strength by testing muscles with and without your resistance. To test hand strength, ask the child to squeeze your fingers hard. To test upper extremity strength, have the child flex each of her/his arms while you attempt to pull the forearm into extension. To test lower extremity strength, ask the child to keep the legs extended straight while you attempt to push each into flexion. Another method of testing the legs involves asking the child to stand, rising from a supine position. The child with good muscle strength is able to rise to a standing position without using the arms for leverage. The inability to rise from a sitting to a standing position is abnormal and occurs in the child with Duchenne's muscular dystrophy (MD) due to generalized muscle weakness. A further discussion of MD can be found in Chapter 34.

Gross and Fine Motor Ability

Assessment of gross motor function determines the child's ability to move large muscles in a coordinated and integrative manner. The status of gross motor function may be noted through observation of the coordination of the body in walking, sitting, and other activities that require the use of large muscles and joints. Fine motor function is assessed by determining the child's ability to coordinate small muscles. These types of movements require more precision and refinement in execution and in the visual-perceptual integration. Examples of these skills include grasping, holding, manipulating, and releasing objects. Use the Denver II to screen gross and fine motor skills that are appropriate for the child's specific age.

Involuntary Movements

Normally, no involuntary movements occur. If they are present, note their location, frequency, rate, and amplitude. Note if the movements can be controlled at will. Abnormalities include tremors, tics, twisting, and jerking and irregular movements.

Joints and Spine

Observe the medial, lateral, toe, and heel aspects of both shoes for signs of abnormal wear. Compare one shoe to the other for signs of excessive wear. Ask the ambulatory child to walk at least 10 feet. Note the scapulas position and symmetry. Note the flexibility of the radiocarpal, elbow, shoulder, hip, tibiofemoral, and tibiotalar joints while the child is walking. Inspect the joints from head to toe. The infants spine is C-shaped. Head control and standing create the normal S-shaped spine of the adult. Lordosis, an exaggerated lumbar curvature of the spine, is normal as the child begins to walk. A toddlers protruding abdomen is counterbalanced by an inward deviation of the lumbar spine. Lordosis is abnormal after 6 years of age. Lordosis can be attributed to bilateral developmental dislocation of the hip or postural factors such as progression of congenital kyphosis, or can occur secondary to contractures of hip flexors. The spine should also be assessed for scoliosis. Refer to Chapter 34 for the procedure and further information.

Count the fingers and toes. Polydactyly, extra fingers or toes, may be found in certain congenital syndromes. A fusion between two or more digits, called syndactylism, is abnormal. It is also associated with certain congenital syndromes. It is abnormal for a young male (usually 2-12 years old) to present with a painless limp from the affected hip. The limp is accompanied by limited abduction and internal rotation, muscle spasm, and proximal thigh atrophy. These are manifestations of Legg-Calve-Perthes disease, also called coxa plana. It is caused by an interruption in the blood supply to the capital femoral epiphysis with avascular necrosis of the femoral head resulting. More information can be found in Chapter 34.

Tibiofemoral Bones

Instruct the child to stand on the examination table and with the medial condyles together. Measure the distance between the two medial malleoli. Measure the distance between the two medial condyles. Normally, the distance between the medial malleoli is less than 2 inches (5 cm). The distance between the medial condyles is less than 1 inch (2.5 cm). If the distance between the medial condyles is less than 1 inch (2.5 cm) and the distance between the medial malleoli is more than 2 inches (5 cm), the child has knock-knee, or genu valgum. This is common between 2 and 4 years of age. Genu valgum persisting after 6 years of age is abnormal. If the measured distance between the two medial condyles is greater than 1-2 inches, bowleg or genu varum is present. Genu varum is a commonfinding in infants and toddlers until walking has been firmly established. Genu varum persisting after 2 years of age is abnormal and may be caused by rickets.

Palpation

Joints

Palpate the joints for heat, tenderness, and swelling. Joint flexibilty values are within the same range as an adult. Findings are the same as the adult. Swollen, inflamed, painful joints, seen in juvenile rheumatoid arthritis (JRA), are abnormal. JRA causes synovial inflammation and degeneration of the joint. Its cause is unknown.

Feet

Stand in front of the child. Hold the right heel immobile with one hand while pushing the forefoot (medial base of great toe) toward a midline position with the other hand. Observe for toe and forefoot adduction and inversion. Repeat on the left foot.

Normal findings are that the toes and forefoot are not deviated. Metatarsus varus (club foot) is characterized by medially adducted and inverted toes and forefoot. Clubfoot usually results from an abnormal intrauterine position of the fetal foot. Heredity also plays a role in the etiology.

Hip and Femur

The hips should be evaluated to detect developmental dys-plasia of the hip (DDH). One method, the Ortolani maneuver, should be performed by a trained individual at the very end of the assessment because it may produce crying. The test is performed on one hip at a time. Evaluate the hips up until 12 months of age. Place the infant supine on an examination table with the feet facing you. Stand directly in front of the infant. With the thumb, hold the lesser trochanter of the femur and with the middle and third fingers, hold the greater trochanter (Figure 14-16A). These two fingers should rest over the hip joint. Slowly press outward and abduct until the lateral aspects of the knees nearly touch the table (Figure 14-16B). The tips of the fingers should palpate each femoral head as it rotates outward. Listen for an audible clunk, which indicates a positive Ortolani's sign. With the fingers in the same locations, adduct the hips to elicit a palpable clunk (Ortolani's sign). As each hip is adducted, it is lifted anteriorally into the acetabu-lum. Abnormal findings indicating DDH include a positive Ortolani's sign; a sudden, painful cry during the test; asymmetrical thigh skin folds; uneven knee level; and limited hip abduction. Epidemiology of DDH is related to familial factors, maternal hormones associated with pelvic laxity, firstborn children, and breech presentations.

Neurological System

The neurological examination includes evaluation of function within six major areas: (1) the cerebrum, (2) cranial nerves, (3) the cerebellum, (4) the motor system, (5) the sensory system, and (6) reflex status.

Cerebral Function

Cerebral function is tested through an evaluation of behavior and mental status and includes appearance, judgment, memory, thought processes, language and speech, mood and affect, and orientation. An infant functions mainly at the subcortical level. Memory is about three-fourths developed by 2 years of age, when cortical functioning is acquiring dominance. Level of consciousness is also assessed as a function of the central nervous system. Because the infant cannot verbally express level of consciousness, instead assess the newborn s ability to cry, level of activity, positioning, and general appearance.

(A)

(B)

Figure 1 4-16 Ortolani Maneuver. (A) Hand Placement (B) Hip Abduction

Cranial Nerves

A thorough assessment of cranial nerve function is difficult to perform on the infant less than 1 year old. Difficulty is also encountered with toddlers and preschoolers because they often cannot follow directions or are not willing to cooperate. Testing for the school-aged child or the adolescent is carried out in the same manner as for an adult.

Infant (Birth to 1 2 Months)

To test cranial nerves (CNs) III (oculomotor), IV (trochlear), and VI (abducens), move a brightly colored toy along the infants line of vision. An infant older than 1 month responds by following the object. Also evaluate the pupillary response to a bright light in each eye. CN V (trigeminal) is tested by assessing the rooting or sucking reflexes. CN VII (iacial) is tested up until 2 months by assessng the sucking reflex and by observing symmetrical sucking movements. After 2 months of age, an infant will smile, allowing assessment of symmetry of facial expressions. A positive Moro reflex in an infant less than 6 months old is evidence of normal functioning of CN VIII (acoustic). CNs IX (glossopharyngeal) and X (vagus) are examined by using a tongue blade to produce a gag reflex. Do not test if a positive response was already elicited by using a tongue blade to view the posterior pharynx. To test Cranial Nerve XI (accessory), evaluate the infant's ability to lift the head up while in a prone position. CN XII (hypoglossal) is assessed by allowing the infant to suck on a pacifier or a bottle, abruptly removing the pacifier or bottle from the infants mouth, and observing for lingering sucking movements.

Toddler and Preschooler (1 to 6 Years)

The older preschooler is able to identify familiar odors. Most children readily identify the smell of peanut butter and chocolate. Test CN I (olfactory) one side at a time by asking the child to close the eyes and to identify the smell of peanut butter and chocolate. Test each nostril with different substances while occluding the other nostril with your finger. Test vision (CN II [optic]) using Allen cards. CNs III, IV, and VI are tested in the same fashion as for the infant. CN V is tested by giving the child something to eat and evaluating chewing movements. Sensory responses to light and sharp touch are still not easily interpreted in these age groups. Observe facial weakness or paralysis (CN VII) by making the child smile or laugh. An older preschooler may cooperate by raising the eyebrows, frowning, puffing the cheeks out, and closing the eyes tightly on command. To evaluate CN VIII, ring a small bell out of the child's vision and observe the response to unseen sounds. Test CNs IX and X in the same manner as for the infant. CN XII is difficult to assess in this particular age group.

Cerebeliar Function

Tests for cerebeliar function mainly involve evaluation of posture, balance, and coordination. General evaluation of function includes observation of the child's body posture, stance, and gait; watching the child walk heel-to-toe, jump, skip, hop, and throw. The Romberg test is administered to evaluate balance by having the child stand with feet together, arms at side, and eyes open and then closed. If the child falls, loses balance, or leans to one side, the result is positive and indicates cerebellar dysfunction.

Motor System

Motor system function usually is evaluated as part of the musculoskeletal system examination and was discussed in that section.

Sensory System

Sensory function involves the body's response to various types of stimulation and usually is assessed during testing of cranial nerve function.

Reflex Status

Assessment of reflex status includes deep tendon reflexes (DTR), superficial, and newborn (often referred to as infant) reflexes.

Deep Tendon Reflexes

Measurement of the DTRs reveals the intactness of the reflex arc at specific spinal levels and are tested in the same manner as with an adult. The following reflexes are routinely tested: upper extremities—biceps, triceps, and brachioradi-alis; lower extremities—patellar and Achilles. DTRs are evaluated for strength and symmetry of right and left sides, which should be equal. The tendon is slightly stretched and tapped with a reflex hammer. The expected response is contraction of the muscle.

Superficial Reflexes

With superficial reflexes the receptors are in the skin rather than the muscles as in the DTRs. Superficial reflexes that are tested include the abdominal, cremasteric (testes), gluteal (buttocks), and plantar. They are elicited by stimulating the skin.

Newborn (Infant) Reflexes

During infancy, examination includes identification of the presence or absence of newborn reflexes, which must be lost before motor development can proceed. See Chapter 7 for discussion of these reflexes.

Female Genitalia General Approach

Place the up-to-preschool-aged child on the caregiver's lap or examination table. Ask the caregiver to assist by holding the legs in a froglike position. Place the child older than 4 years on the examination table in a semilithotomy position, without the feet in stirrups. Reserve the lithotomy position with the feet in stirrups for the older adolescent. Explain the procedure prior to the assessment. Never ask the caregiver of the infant or young school-aged child to leave the room during this portion of the examination because the caregiver is a source of comfort to the child. Drape the older-than-preschool-aged child.

A vaginal/pelvic exam is not routinely performed on young females; however, it is warranted when signs of possible sexual abuse are present. Refer to Chapter 36 for information regarding sexual abuse. The assessment is undertaken by a health care provider who is trained to perform pediatric vaginal examinations and can evaluate these problems. Any female who has reached menarche needs to be evaluated for a pregnant uterus.

Inspection

Perineal Area

Stand directly in front of the child. Assess Tanner's stage (Appendix F). Use the thumb and forefinger to separate the labia. Identify the labia majora and minora, clitoris, urethral meatus, hymen, and vaginal orifice. Observe color, size, and discharge from structures. Observe intactness and scarring of the hymen and vaginal orifice. The infant's labia minora are sometimes larger than the labia majora. The hymen is sometimes intact up until the point of sexual activity. It is abnormal for the female infant to display a rudimentary penis in the clitoral area, which is a finding in ambiguous genitalia. Genital ambiguity occurs during embryonic development as a consequence of genetic causes or androgens or androgen inhibitors that reverse genital characteristics. A bloody discharge noted at the vaginal opening or on the diaper is abnormal. It is not uncommon to note pseudomen-struation in an infant under 2 weeks of age. Maternal hormones such as estrogen are the cause.

Maie Genitalia

General Approach

Female nurses may encounter difficulty assessing a reluctant adolescent. Be firm when explaining that this portion of the assessment is a required part of his examination. Infants and toddlers do not object to the assessment. In case the infant or toddler urinates during the examination, have a diaper or disposable cloth available to catch the stream of urine. The older school-aged child and the adolescent should be draped in order to maintain modesty. Assess Tanner's stages during inspection.

Penis

Note the position of the urethral meatus. Note the size of the penis. If you are not able to determine circumcision status, ask the caregiver if the child was circumcised. The meatus is normally found on the tip of the penis. A disappearing penis phenomenon occurs normally in infants with increased adipose tissue in the area surrounding the penis. Reassure the caregiver that this is normal and will resolve after adipose tissue is lost. It is abnormal for the urethral meatus to be located behind or along the ventral side of the penis, a condition known as hypospadias. During the third month of fetal development, the urethral meatus fails to move toward the glans penis. Mothers who take phenytoin (Dilantin) for epilepsy are at greater risk for having children with hypospa-dias. Another abnormality is epispadius in which the meatal opening is on the dorsal surface of the penis. During the third month of fetal development, the urethral meatus fails to move toward the glans penis.

Scrotum

Evaluate scrotal size and color. Note if the testes are seen in the scrotal sac. The scrotum appears proportionately large in size when compared to the penis. The sac color is brown or black in dark-skinned children and pink in light-skinned children. Two testes should be present, but, in infants, they may retract into the inguinal canal or abdomen due to various stimuli, including cold and palpation.

Palpation

Scrotum

Place the infant in a supine position on the examination table. Instruct the young child to sit cross-legged to inhibit the cremasteric reflex (retraction of the testes from the scrotum) from occurring. Locate each testis within the scrotal sac by using the fingers of one hand in a milking motion to descend the testes. Palpate and note the size, shape, and mobility of each testis. Both testicles are palpated in the scrotum. They are smooth, round, or oval shaped and freely movable. It is abnormal to be unable to palpate the testes. Cryptorchidism is a failure of the testis to descend into the scrotal sac. One or both testes failing to descend within the inguinal canal occurs during embryonic development. An enlargement of the scrotum is abnormal and is seen in a congenital hydrocele, which results from failure of the fetal male reproductive tract to develop properly. This mass will transilluminate. Refer to Chapter 22 for additional information about genitourinary disorders.

Hernia

Place the infant supine on the examination table. All other children should stand during the examination. Use your little finger for the infant's exam and the index finger for the younger child's. Follow the inguinal canal as is done on an adult male. If possible, perform the assessment on a crying infant. Have preschoolers and early school-aged children attempt to blow up a balloon while you palpate the inguinal areas. Palpate the inguinal areas while the older school-aged child or adolescent coughs. No swelling or masses are palpated. A hernia palpated above the inguinal ligament is an abnormal finding. Indirect inguinal hernias occur during embryologic development as a result of persistent patency of the processus vaginalis testis.

Anus

As a rule, rectal assessments are not performed on children unless you detect a problem or suspect abuse. In these cases, refer the child for further evaluation if you are not trained specifically for this procedure and follow your institution's guidelines.

Inspection

Ask the child to lie on the abdomen. Gently separate the buttocks to allow direct visualization of the anal opening. Observe for bleeding, fissures, prolapse, skin tags, hemorrhoids, lesions, and pinworms. During separation of the buttocks, observe any movement of the anus. Stroke the perianal area with your finger, and note any movement. This is called the anal reflex or anal wink. No bleeding, fissures, prolapse, skin tags, hemorrhoids, lesions, or pinworms should be present. An anal reflex normally is observed. An absent anal reflex is abnormal. Conditions such as a spinal cord lesion, trauma, and tumors that interrupt nervous innervation to the anal sphincter cause this finding.

Key Concepts

The parameters of weight, length, or height, and head circumference (dependent on age) are essential for assessing physical growth. Using standardized growth charts, these measurements are used in determining normal and abnormal patterns.

A pediatric health history includes biographical data, past health history, family health history, social history, and health maintenance activities.

A nutritional assessment enables the nurse to provide anticipatory guidance, identify at-risk individuals, and collaborate with the health care team for early referral of the child as needed.

A developmental assessment has several purposes: (1) validation that a child is developing normally or detects problems early, (2) identification of concerns of care-givers and child, and (3) provision of an opportunity for anticipatory guidance and teaching about age-appropriate expectations.

In performing the physical assessment, techniques for approaching children vary from one age group to the next. However, a basic principle during any physical assessment is building a trusting relationship.

Vital signs include temperature, respiration, pulse, and blood pressure, which are compared to normal ranges

for the child's age. These measurements provide information about the child's basic physiological status.

The skin is observed for color and lesions and palpated to determine temperature, texture, turgor, and edema.

The head is inspected for shape, symmetry, and control, and the fontanels, suture lines, and surface characteristics are palpated.

Examination of the eyes includes vision and strabismus screening, and assessment of the anterior and posterior segment structures.

The thorax and lungs are examined using inspection, palpation, percussion, and auscultation.

Assessment of the heart and peripheral vasculature consists of inspection (apical impulse, precordium),palpation (thrills, peripheral pulses), and auscultation of heart sounds.

The order of abdominal assessment is inspection, auscultation, and palpation.

The extent or degree of musculoskeletal assessment depends on the caregiver's and child's complaints of problems.

A neurological examination includes assessment of infant reflexes (depends on age) and cranial nerves.

Review Questions

1. Describe the components of a health history for a child. What information is gathered in the following areas: (a) past health history, (b) social history, and (c) health maintenance activities?

2. List two environmental problems that put a child at risk for illness or death.

3. What is the purpose of a nutritional assessment?

4. What information is included in a nutritional assessment?

5. Describe factors that could lead to invalid results from a developmental screening test?

6. State an easy rule of thumb for determining normal systolic blood pressure in children older than 1 year.

7. How would the nurse obtain a height and weight for a 12-month-old child?

8. Describe the sequence for assessing the abdomen.

9. Describe the cranial nerve assessment of an infant and a toddler.

CARE OF CHILDREN WHO ARE HOSPITALIZED

Perhaps the most complex skill to learn is selecting relevant concepts and principles from nursing, the physical and social sciences, and the arts and humanities, and then applying this knowledge while delivering care to children and their families. The importance of this approach has evolved over many years as nursing and child health leaders studied the experiences of ill children and pursued ways of improving their health and welfare. Understanding historical dimensions provides the context for recognizing the critical contributions of these early leaders and for assessing new trends and practices.

TRADITION OF CARING FOR ILL AND HOSPITALIZED CHILDREN

Traditionally, the medical care of children was referred to as pediatrics, or the science of the child, with the primary focus on applying medical knowledge and techniques to diagnosing and curing disease. Children were regarded as small adults with limited recognition of physiological or psychosocial differences, individuality, or other attributes that directly affected care, treatment, and outcomes. With advances in medical science, increased attention to the uniqueness of childhood, and the desirability of having separate facilities, children's hospitals were constructed toward the end of the 19th century. For many years, it was believed that limited caregiver visits were in the best interest of hospitalized children because of the intense physical and emotional reactions to separation at the time of leave-taking. It was thought, at the time, that this kind of desperate response was detrimental to recovery. Other reasons for restricting visits included fears of infection, disrupting the work of the staff, interfering with the child's rest, and confidentiality issues (Giganti, 1998).

After an extensive study of the care of children in hospitals in Britain and the issuance of the Platt Report in 1959, changes occurred (Shields & Nixon, 1998). This historic document described policies and practices in the care of hospitalized children, how these practices adversely affected child development and recovery, and the kind of changes necessary for child-centered pediatric care and education. As knowledge about the psychology of childhood, the detrimental effects of separation, and the impact of hospitalization on the emotional life of the child expanded, hospital policies and practices gradually changed. In the late 1950s, liberal visiting policies, rooming-in practices, and a focus on familyoriented care began to be implemented in many hospitals throughout the United States. One of the most significant changes was liberalizing caregiver visiting from weekly or a few hours each day to 24 hours a day with rooming-in accommodations. Although the benefits of changes have been well documented, restricted visiting practices in pediatric intensive care units continued to exist as recently as 1994 (Giganti, 1998).

Pioneers in pediatric nursing generated new knowledge and deeper understanding of children during periods of illness through their astute observations and extensive study of individual children and their responses. These theorists proposed that the unique experiences of children and families, their growth and developmental stages, and their talents and strengths were critical factors in coping with illness and hospital stays. Through their research, writing, and teaching, they clearly documented the significant contributions of nursing to the health and welfare of children and families and to the community of health professionals who work together to implement policies beneficial to these children and families. Their work was the impetus for creating the knowledge base in the field and the emergence of sophisticated research designs that have revolutionized the care of ill and hospitalized children.

PREPARATION FOR CLINICAL NURSING IN THE CARE OF CHILDREN AND THEIR FAMILIES

To begin learning about the care of ill children, it is important to reflect on one's own experiences and strengths, review theories about child growth and development, and realize that, even through the trauma and stress of illness and hospitalization, children continue to grow physically, emotionally, socially, and spiritually. The predominant goal is to identify and preserve the strengths of children while trying to enhance their growth in the midst of stress and intrusions into their bodies, their space, and their very being. To do this successfully takes an understanding of the lives of individual children and their families, and the courage and commitment to accurately discern and meet their emerging needs. Introspection, reflection, and understanding of personal styles and journeys in learning make it possible for nurses to mature in the transition from novice to expert.

While preparing for the care of children and their caregivers, several assumptions and questions may arise. The questions in Box 16-2 are designed to direct the kind of inquiry that will lead to accuracy and effectiveness in providing sensitive nursing care. These are in addition to those questions directly related to the ongoing plan of care and clinical pathways. Thorough assessment and understanding the rationale for plans are included in the initial phase of preparation.

THE NATURE OF ILLNESS IN CHILDHOOD

Illness in infants, children, and adolescents is characterized by acute or traumatic episodes, chronic conditions, or situations requiring surgical intervention or for which surgery is the elective treatment. Some health problems require medical or surgical treatment before birth; others are incompatible with life but amenable to surgical correction (e.g., some forms of congenital heart disease, tracheoesophageal atresias, gastrointestinal atresias). Genetic and environmental factors and general vulnerability, particularly in situations of poverty and stressful living conditions, also influence the incidence of disease and injury in childhood and adolesence.

REACTIONS AND RESPONSES OF CHILDREN TO THE STRESSORS OF ILLNESS AND HOSPITALIZATION

High levels of anxiety in children are created by the rapid onset of illness and injury, particularly when there have been limited experiences with childhood disease. Even children who have been previously hospitalized fear repeating those events that caused pain and stress. Many factors contribute to the distress of young children during hospitalization; existing fears and fantasies may be intensified. Their logic may be illogical; many have not developed a concept of time; and others may have fantasies that are real to them as they try to explain the unknown. Normal fears are exacerbated, and children become anxious when they think they may be in pain, separated from caregivers, harmed, or mutilated in some way (Algren & Algren, 1997). They often perceive a threat to basic needs for love and protection, control and independence, and fulfillment of basic physiological needs when in reality none exist. Some fear they may die (Lamontagne, Hepworth, Byington, & Chang, 1997). To allay these fears, children need the constant support of caregivers and nurses directly responsible for care and guidance.

The developmental level of the child and their perceptions and interpretations of experiences are more important than the actual events. Their limited life encounters and immature intellectual capacities contribute to difficulty in comprehending what is happening. This is particularly true when there are physical intrusions into the bodies of toddlers and preschoolers. For them, the intactness of their bodies is important; they feel the distress of exposure and intrusion acutely. The impact of hospitalization is also affected by the nature and severity of the health problem, the condition, and the degree to which activities and routines differ from those of everyday life. Children's anxieties are also due to separation from caregivers and familiar persons and environments; the presence of strangers; equipment that looks ominous; the distress of other children; and the pain and discomfort of intrusions and interventions. Although age, maturity, vulnerability to anxiety, and previous experiences make a difference in the intensity of stress responses, there are many stressors pervading the hospital experience for children of all ages. The primary fears producing stress are lack of control, fear of intrusions and "hurt," and separations from the significant persons in their lives. The cultural variations of families, their values and practices related to illness, general responses to stress, and attitudes regarding child rearing also have a significant influence on the child's behavior and responses. The potentially negative impact of illness and hospitalization may be modified by a variety of factors, including age, developmental level, anxiety level of caregivers, individual characteristics/ temperament of the child, child and caregiver coping skills, caregiver-family-child relationships, religion, previous hospital/surgery experiences, ethnic and cultural beliefs, and the type and quality of preparation for hospitalization and/or surgery (Fox, 1997).

Children, like persons of all ages, share fears of the unknown, unfamiliar environments, and situations where control is difficult to maintain. It is also distressing when language is heard but not understood. Children notice and become anxious when they see ominous-looking apparatus and strangers in unusual attire (surgical caps, masks, and garb), when they hear unfamiliar noises, or smell strange odors. They become distressed when they hear or see other children crying and wonder what may happen to make them cry also. They are also uncertain about how they will fulfill their essential needs if no one is nearby.

ALLEVIATING THE ANXIETIES OF CHILDREN

To lessen the anxieties of children, it is helpful to understand the common situations creating distress and then intervene in such a way so stressors are minimized or eliminated. Those procedures involving any bodily intrusion are most feared, as are those involving equipment and technology. It is particularly stressful when darkness is involved as often happens in radiological examinations.

Stress-point nursing, which includes thoughtful preparation for situations anticipated to be stressful by using both procedural (description of the treatment and sequence of steps) and sensory information (how this might feel) according to the cognitive level of the child, identification of the child's role during the event, and rehearsal with the same nurse who provides supportive care throughout can help children manage stressful events (Wolfer & Visintainer, 1975). The principles embedded in stress-point intervention are most effective when occurring during difficult stressors, e.g., new tasks, and when interventions are focused on the issues of greatest concern to the family (Burke et al., 1999). Even those situations that may appear minor to an adult are frightening to a young child. An example is when children are being transported to another area of the hospital for tests and become anxious and resist because of fears that caregivers may not be able to find them. Anticipating this would prompt the nurse to put a sign on the door, so the child could be "found." In a similar situation, children may not want to leave their room with anyone other than their caregiver because they fear getting lost. Reassurance of always being with someone and having a picture of an animal or cartoon character (different for each room) on the wall inside and outside the room helps children feel more confident about their place. To strengthen children's sense of feeling secure, it is important for nurses to let them know when they are leaving for the day, say good-bye, and tell them about their new nurse and when they will return.

MAJOR FACTORS THAT SUPPORT COPING DURING ILLNESS AND HOSPITALIZATION

During illness, there are several dominant factors influencing the child's ability to cope and learn to use coping methods. These include the inner strengths, talents, and attributes of the child and several external determinants including the expertise of the nurse, the support of families, the quality of the partnership between the nurse and the family, the supportiveness of the environment on the children's unit, and the effectiveness of support through play.

Inner Strengths, Talents, and Attributes of the Child

Each child is a unique individual with different temperaments and capacities for managing adverse situations. Inner strengths include the ability to cope because of past episodes of getting through difficult situations with the assistance of adults in their world. Some children however, may appear to be more resilient than they are because they want to appear strong or stoic. Other inner strengths include the abilities to express thoughts and fears, seek information in order to understand situations and expectations, and then feel the success of mastery. Children's talents also help in coping. For example, through drawing, writing prose or poetry, and other creative activities, children not only express their thoughts and feelings, but also use these media to cope. Others may have a curiosity about how things work and seek information and opportunities to discuss their condition and experiences, or use computers. Some have the kind of personality, charm, and ability to interact and communicate in a way that attracts others. Although it is difficult to contemplate, physical attractiveness or the nature of a child's illness or situation may also facilitate coping because staff members may prefer to care for and support children with certain characteristics or health problems. For example, children who are cute or highly responsive to others, or those with oncologic problems, cardiac diseases, unusual conditions, or complex technological care may be more appealing or challenging to staff. Although this is an area for future research, relationships between physical attractiveness and nurses' perceptions and interpretation of behavior has been demonstrated (Bordieri, Solodky, & Mikow, 1985).

Expertise of the Nurse

With extensive study and experience, nurses become experts in understanding the verbal and nonverbal behavior of ill children, discerning the meaning intended, and responding skillfully and accurately (Figure 16-3). The expert nurse knows nursing practice is a discipline where one must be constantly attentive to changes and unpredictable signs and symptom. Depth of knowledge about nursing as an art and science, growth, development, and family theory is the source of wise and effective clinical judgments and interventions for both the child and caregiver.

Figure 1 6-3 Nurse Comforting a Child during Hospitalization. Used with permission of Alfred I.duPont Hospital for Children, Delaware. Photographer: Cynthia Brodoway.

It is important to recognize that in any given situation, one nurse may succeed where another may not, giving rise to the need for appreciating the contributions of many nurses and the need for consultation and collaboration.

The expert nurse sees the strengths of each child and uses these to design, implement, and evaluate nursing care. They lend their own strengths to children and caregivers, who rely on them to learn and use coping skills, and to understand and manage the exigencies of illness successfully. These nurses also understand the emotional and physical comfort of the child is most important, rather than personal satisfactions gained when children or caregivers like them or express appreciation for their care and concern. All the nurse's physiological and psychological senses are critical in identifying and meeting children's needs. Children are often so acutely ill that they are unable to communicate their needs. It is important not only to look, but to see; not only to listen, but to hear; not only to touch, but to feel; and not only to smell and to taste, but to discriminate. The nurse's senses and the ability to read and interpret verbal and nonverbal behavior are the best means of assessing children's needs. The nurse can see the subtle changes of a child indicating early signs of dehydration, and facial or body indicators of fear or sadness; can hear the sounds of distress, both physiologically and psychologically including changes in breathing, or cries of pain or misery; and can feel the tension of anxiety. Nurses have diagnosed acute illness through the odor of the acetone breath of a child not previously known to have diabetes, the unique cry of an infant with cri du chat syndrome, or through the salty taste a grandmother described on the face of an infant with cystic fibrosis. The highest level of skill is attained when the nurse accurately identifies the child and/or family needs for help, validates the need, uses knowledge and all resources available to meet this need, and then evaluates the effectiveness of interventions. This is in essence, the classic, dynamic nurse-patient relationship first iterated by Orlando (1961).

Support of Children by Caregivers

The support of families is a critical factor in the way that children respond to and cope with illness (Wolfer & Visintainer, 1975; Melnyk, 1995; Lamontagne et al, 1997) (Figure 16-4). With the turn of the century, the differences and complexities of family life become more evident, and many caregivers have difficulty in being physically or emotionally available to children. Stress may be intensified by existing problems or recent changes, e.g., moving, divorce, newly blended families, families with adopted and foster children, and those with other members experiencing serious physical and mental health problems. Depending on the situation surrounding an illness or trauma, caregivers themselves may find coping to be an arduous task while trying to support their child.

In many situations, caregivers may find it difficult to be psychologically or emotionally ready to manage. At these times, it is beneficial to have a network of friends and family able to offer their strengths, time, and assistance. The support of caregivers is dependent upon the empathic responses, assistance, and cooperation rendered by nurses, Physicians, and other family members, as well as their own strengths in managing stressful situations. The presence of caregivers is of paramount importance particularly for young children, yet the issues surrounding the ability to stay with children and facilities to accommodate caregivers are considered in light of the needs of the family and the child. The critical importance of caregiver presence in the hospital may need to be explained to families because young children are often cared for by others during the day, and the impact of separation in a strange environment may not be fully understood.

Usually, there are choices of accommodations: roomingin; caregiver sleeping rooms within the pediatric unit; or dayvisiting and home-sleeping. The selection of arrangements is complex, but, whenever possible, rooming-in is of the highest priority for infants and young children. Whatever arrangements are chosen, caregivers need assurance that children will receive support and comfort, particularly during times of discomfort and discontent. They also need to know that if they are unable to be present other supportive adults (e.g., grandparents, other significant adults) could stand in their stead. Many hospitals also enlist the skills of volunteer grandmothers and grandfathers for rocking, cuddling, reading, and providing comfort and companionship for children.

Relationship Between Nurses and Families

The quality of collaborative relationship and interactions between nurses and caregivers is fundamental to facilitating a child's coping ability. A highly successful design based on this philosophy is the nursing mutual participation model of care (NMPMC) used by Brody (1980) in outpatient pediatric settings and Curley (1988, 1997) in children's hospitals. This model was designed to alleviate stress and to empower caregivers to maintain their role during their child's acute illness and recovery. Using this approach, caregivers are equal partners in planning, implementing, and evaluating care. In order for this model to be effective, however, it is essential for the nurse to believe the presence and support of families is essential for optimal healing, recovery, and prevention of additional trauma. Rather than a hierarchical relationship, where the nurse and other health professionals assume an authoritarian role, caregivers and nurses form a partnership, where each lends their talent and expertise to benefit the child and the family. Nurses who use this interactive, participative model of practice engage in a deliberative method of establishing and maintaining helping relationships with caregivers by creating a caring, trusting atmosphere for discussion, and exploring needs and issues of concern. This is best accomplished by consistently identifying and validating immediate needs for help and exploring how these can best be met. Mutuality in the relationship is nurtured by honesty, openness, sensitivity, and commitment to fostering a healing environment for the child. Refer to Box 16-3 for ways of implementing the NMPMC.

Play as Therapeutic in Facilitating Coping

Hurlock (1978) defined play as any voluntary activity engaged in for the purpose of enjoyment. Play fosters the development of cognitive, psychomotor, language, and psychosocial skills. Blake (1954) proposed the child gains mastery of fears and relief from the tension within through play. Therapeutic play is an intervention used by nurses and child life staff prepared in this technique, to aid ill and hospitalized children express thoughts and feelings. This kind of play-also helps nurses better understand the thoughts, feelings, and experiences of children (Kuntz, Adams, Zahr, Kellen, Cameron, & Wassen, 1996). Play moderates reactions to stress and has beneficial physiological benefits as well (Zahr, 1998). For example, anger and pentup energy can be released through physical activities such as pounding boards and punching bags/balls and games like throwing beanbags in holes for points. Play situations are created, but the child chooses the items and decides on the way to use these according to their level of comfort and readiness.

Art supplies and materials, including paper, crayons, pencils, paint, brushes, finger-paints, water, and clay encourage creative expression thoughts and feelings. A miniature house that contains hospital clothing, child and adult doll figures, hospital equipment, and supplies fosters the inclination of children to don the roles of hospital personnel and treat "their patients" in a safe, simulated setting. This kind of play dramatizes perceptions of their experiences and gives children the opportunity to act out and talk through situations, particularly those difficult to understand or accept. The use of play, including clothing and hospital equipment, is also highly effective in teaching and preparing children for situations related to their specific hospital experience as well as playing out events after they have occurred.

It is highly advantageous for a pediatric unit to have an organized Child Life Program, a well-equipped playroom with toys, games, and facilities for the use of hospital equipment, and a schoolroom for children with prolonged hospitalizations.

PREPARATION OF CHILDREN FOR SURGERY

When children are admitted for surgical procedures or examinations requiring anesthesia, both the timing and the content of the child's and family's preparation should be considered. Generally, children should be prepared close to the time of the surgical procedure and the dialogue, audio, and visual materials should be age appropriate and relevant to the child's cognitive development (Figure 16-12). Prior to instruction, it is helpful to ascertain what they know and how they feel (Lamontagne, et al, 1997). Preparing parents also helps improve the child's understanding and ease in asking questions, since family concerns and anxieties strongly influence the child's reaction to preoperative experience (Noble, Micheli, Hensley, & McKay, 1997). Children's fears focus mainly on the unfamiliar environment, pain, mutilation, and separation from parents, and with parental presence these fears may be alleviated (Algren & Algren, 1997). For example, in uncomplicated preoperative situations where caregivers are prepared and able, their presence during induction of anesthesia is reassuring to children and minimizes the stress of separation. The need for heavy sedation decreases with parent-present induction (PPI), promoting more rapid recovery from anesthesia (LaRosa-Nash & Murphy, 1997).

Most hospitals have well-established protocols and resources to prepare children and caregivers for different kinds of surgery. These include tours of the facility and the use of films, puppets, and discussions (Figure 16-13). Books are also helpful, and a list of children's literature to prepare children for surgeiy is in the resource section at the end of this chapter.

Most children want to know if it will hurt and may be afraid something will go wrong or they will wake up during the operation. It is reassuring to know that the "anesthesia doctor" is always there during the surgery and that this will not occur. Explanations regarding anesthesia need to be carefully considered. For example, the phrase "put to sleep" may be frightening, particularly when this has been used in reference to a euthanized pet. Among alternatives to reduce this kind of fear may be a phrase like, "a special kind of sleep" and adding, "you will be awakened when it's over and come back here where (person in family) will be waiting for you." During a child's immediate preparation for surgery, every effort should be made to minimize stress. Young children who do not understand the rationale for withholding food and fluids need to be carefully observed so they do not take food or fluids inadvertently. When children of young ages have same-day surgery, it is advisable for caregivers to snack-proof the house on the evening before and not eat in the presence of the child on the day of surgery. Using a matter of fact approach rather than emphatic denials of food requests avoids an association of food deprivation and disapproval. Saying, "remember that the nurse said that all children having surgery (or this test) are allowed to eat and drink only after their operation (test) but not before, so you will feel better faster," is more encouraging during the waiting period.

To prevent fear associated with preoperative injections, noninjectable medications should be used whenever possible. In transporting young children to the surgical suite, it is unwise to use their crib, because doing so may precipitate postoperative fears related to sleep; e.g., the young child may reason that if you fall asleep, you may be taken away again. For example, for several days after surgery, 3½-year old Danny was "awake all night" and only fell asleep when he was on the sofa in the playroom or sitting on his mother's lap. In play, he took several dolls and aggressively put them in and then took them out of their "hurt beds"—he then used buses and trucks to take them outside the room so no one could find them. In subsequent play sessions, his fears were expressed and misconceptions explained, following which he gradually returned the dolls to their beds and resumed more restful nighttime sleep several days later.

The goal for optimal preoperative preparation is to provide and reinforce information for children and parents, encourage emotional expression and fears, and teach coping strategies while minimizing intrusive, distressing, and painful procedures.

FACILITATING COPING WITH EXPERIENCES OF DIAGNOSTIC/THERAPEUTIC PROCEDURES

When children know what to expect, there is greater potential for maintaining control and mastering fears during uncomfortable and frightening procedures. Although time may be limited, as often happens in acute illnesses, an explanation should always come first. When caregivers understand the procedure, they are better able to enhance the explanation by making comparisons to previous experiences or using terms most familiar to the child. The presence of supportive caregivers during treatments and procedures cannot be overemphasized. However, there may be circumstances where they are unable or prefer not to participate, and caregiver involvement should not include restraining. Because infants and toddlers are in the formative stage of developing language and cognitive skills, the presence of caregivers with their gentle handling and soothing words decreases the pain and anxiety of procedures. The role of adults during and after is also critical in alleviating the emotional and physical discomforts experienced. Preschoolers benefit most from the use of demonstrations and role-play using play equipment, e.g., using a doll or animal to apply a cast, change a dressing, or start intravenous fluids. The child should choose the subject of the procedure as many do not like to use their favorite doll or toy animal. Box 16-4 describes various components of preparing children and caregivers for treatments and procedures.

Follow-up includes the fun activity or comfort measure agreed on in advance, encouraging expression/description of how the child experienced the procedure through conversations, and/or play. Considerable insight can be gained by asking children and caregivers what could have been done to make the experience easier to manage. Questions like "now that this is over, what helped you the most in getting ready [or during the procedure]?" or, "what should I be sure to tell other children about what it is like and how it feels when they have their bandages changed?" may help with future explanations.

CHILDREN WITH CHRONIC ILLNESS

Children with long-term health problems are well acquainted with health care settings, and each new experience is framed within the context of previous experiences. Caregivers of these children are often experts about disease processes and treatments on a day-to-day basis and the children themselves become increasingly competent in self-care as they get older. Nurses also become highly skilled as coordinators of family-centered care and assume roles of coordinator, leader, teacher, team member, and primary care provider. Care conferences to promote caregiver-professional collaboration are an excellent medium for planning when children have been hospitalized for long periods of time (MeClain & Bury, 1998).

The field of pediatric rehabilitation nursing has evolved over the past 25 years to become a specialty committed to the care of families and children with disabilities and other chronic conditions (Edwards, Hertzberg, Hays, & Youngblood, 1999). Pediatric rehabilitation facilities as well as clinics and community agencies are sites for offering extensive services by interdisciplinary teams of health care providers to meet the needs associated with these children's complex, long-term health problems, including developmental, educational, economic, mobility, psychosocial, and vocational services. As children grow and develop over time, individual and family needs change, requiring many adaptations and transitions to different health care facilities or health care personnel.

EMERGENCY CARE

Many children and adolescents with acute and life-threatening illness and injuries are first diagnosed and treated in an emergency room. The caregiver and child's stress and anxiety is often overwhelming because of the uncertainties, acuity, and decisions integral to these situations. Painful, invasive, and perplexing tests and treatments are performed quickly, with minimal opportunities for optimal preparation and support. However, most caregivers want to be present when invasive procedures are performed and nearly all want to participate in the decision about their presence (Boie, Moore, Brummett, & Nelson, 1999)

PEDIATRIC INTENSIVE CARE UNITS

The pediatric intensive care unit (PICU) is a special environment because of the crisis orientation of care. There is also a potential for sensory overload and sensory deprivation.

DISCHARGE AND THE AFTER EFFECTS OF HOSPITALIZATION

Throughout hospitalization, children and caregivers need to be prepared for discharge, post-hospital and/or post-surgical care, and the effects of this experience. This often involves extensive teaching and preparation for the transition especially when there has been prolonged hospitalization, painful treatments and procedures, or changes in body image. For these children, adolescents, and families, it is important to prepare them, teachers, and other significant persons to reenter home, school, and community.

The kind of preparation is dependent on the continued needs of the child and caregivers for care and support in coping with fears and anxieties. In those situations where there is a change in appearance or mobility, the transition from hospital to home may be difficult. Some may benefit from spending brief periods with family and friends outside the hospital during the rehabilitation process to adapt gradually, e.g., those who have had an amputation or neurological changes. Peers may also need to be prepared by using discussions and films.

Changes in behavior post hospitalization are most evident in children between 6 months and 6 years of age. These include changes in eating, sleeping, and elimination, and in psychosocial behavior such as regression or becoming more aggressive, withdrawn, or fearful. The intensity and duration of these responses are dependent on many factors including the impact of the illness and hospitalization, frequency of intrusive procedures, level of cognitive development and maturity, previous experiences, and perceptions about being comforted in the process of coping with stressful events. When caregivers of children younger than 5 who spent a day in ICU were interviewed about their child's behavior, they reported changes related to regressive behaviors and withdrawal, aggression and demanding behavior and fears and anxieties about sleeping and separation (Youngblut & Shiao, 1993). Most changes in behavior may occur after 2-3 days of hospitalization because children encounter multiple tests, treatments, and separations from those who provide support. This is also a time when caregivers are anxious and may be less able to give psychological support (Thompson & Vernon, 1993). In fact, moderate lengths of stay that involve more than minimal separation from home, yet insufficient time for accommodation may place children at greater risk for post hospital distress than longer or shorter stays.

There are many considerations in teaching caregivers about the potential changes in behavior after hospitalization. In addition to responding to illness and hospitalization, children may react to previous home sleeping arrangements, particularly when the caregiver has slept closely adjacent to the child while in the hospital. Therefore, for some children, it may be helpful for the caregiver to sleep in a separate room from the child for a few nights prior to discharge. As the time for discharge approaches, caregivers may feel relief about resuming their family life, yet also feel apprehensive about caring for the child at home. In addition to preparing the family for physical aspects of care, it is also important to know of the potential for the child's behavioral changes in response to the hospital experience. Therefore, it is advantageous to first ask caregivers how they think their child will respond to this experience of illness/hospitalization at home. Their responses are helpful as a basis for an individualized teaching plan using the considerations in the Family Teaching box.

Implementing a parent-focused program (COPE—Creating Opportunities for Parent Empowerment) has also been used to improve young children's outcomes during and after hospitalization by effectively reducing anxiety and enhancing involvement in their child's care (Melnyk & Alpert-Gillis, 1998). In fact, in posthospital experiences, children of mothers who received child behavioral information through the COPE program (potential changes in behavior and ways to manage in the hospital and at home) had fewer negative behavioral changes than mothers who did not receive the information (Melnyk, 1994). This suggests it is helpful for caregivers to know children may act differently after discharge particularly in sleeping, eating, and separations.

PAIN MANAGEMENT

Pain, an important symptom seen in children, can be caused by pressure, over stretching, injury, or reduced oxygen supply to body tissues. It also can be a unique problem, a symptom of a specific disease or health problem, or the result of disease or treatment. However, since many health care professionals are still under the impression children do not experience pain or are less sensitive to pain than adults, information about pediatric pain management strategies is essential to delivering holistic, effective care.

This chapter discusses the pediatric pain experience. The text provides information about the developmental implications of pediatric pain, especially in infants and toddlers who generally cannot describe their pain. Acute pain, pain lasting three to five days, and attributed to a specific cause such as surgery or an injury, is differentiated from chronic pain, or pain that lasts for long periods of time or comes and goes frequently over long periods of time. Treatment options for all pain problems are reviewed and appropriate assessment techniques for pediatric clients, including formal assessment scales, a review of physiological pain indicators, and a description of pediatric pain behaviors are included. The importance of nursing care and advocacy for children in pain is stressed throughout the chapter.

Appropriate pain relief is important for physiological as well as psychological reasons. For example, babies have improved mortality and morbidity after cardiac surgery when they receive appropriate pain medications (Anand & Hickey, 1987). Proper and effective pain management also promotes wound healing and decreases the length of hospital stay. Therefore, infants and children treated throughout the health care spectrum should be afforded the opportunity for effective analgesia—pain control using medications or other interventions.

PAIN PHYSIOLOGY

The nerve receptors specific to pain, called nociceptors, are located throughout the body in many types of tissue. There are two types of nociceptors, the C-nerve fibers (slowly conducting unmyelinated axons that transmit diffuse, dull, burning, and chronic pain) and the A-delta nerve fibers (mylinated nerves that fire impulses more rapidly and transmit sharp, well localized pain). A pain impulse starts when these receptors are stimulated by noxious stimuli (mechanical, chemical, thermal) provoking an electrical activity, called transduction (Annand, 2000). Transduction is followed by transmission whereby the pain impulse moves along peripheral sensory nerves to the spinal column and then to the brain (Price & Wilson, 1999) (Figure 18-1).

The intensity and duration of the pain impulses are affected by neural activity and chemical factors, termed modulation (Urban & Gebhart, 1999). Specifically, the prolonged firing of the C-fibers causes a chemical cascade that stimulates the N-methyl-D-asparate (NMDA) receptors, causing the spinal column receptors to be more responsive (Bennett, 2000). The release of chemical mediators such as substance P (McHugh & McHugh, 2000), a neuropeptide, sensitizes the nerve endings and increases the rate of firing (Zubrzycka & Janecka, 2000). Investigating the role of these chemical mediators may lead to new understanding and treatment of pain.

Figure 1 8-1 Physiology of Pain

The perception of pain completes the transmission cascade. Perception takes place in the cerebral cortex where meaning or recognition of the pain impulse occurs (Woolf & Decosterd, 1999). Until recently, the central role of pain was thought to be passive. However, studies over the past decade have shown that an extensive central pain network including the thalamus and some somatosensory structures exist (Schnitzler & Ploner, 2000). As the mechanism of the pain cascade continues to be studied, new information about treatment and pharmacologic management should improve.

GATE CONTROL THEORY

The gate control theory explains how pain impulses travel and are interpreted in the body (Melzack & Wall, 1965). At the level of the dorsal horn, a gating mechanism opens and closes to allow pain impulses through. The input of large fiber closes the gate (inhibits pain sensations) and the input of small fibers (allows pain sensations to travel to the brain) opens the gate. However, stimulating the larger afferent nerves that carry the pain impulses, such as rubbing an injured finger or applying cold or heat to an injury, can also blunt pain sensations. The gate's ability to open and close is influenced by stimulation, emotion, anxiety, distraction, sensation, and memory, and supports assessing and treating pain by using both physiological and psychological techniques.

COMMON PAIN MISCONCEPTIONS

Over the years, several misconceptions related to children's pain have surfaced.

Misconception 1: Infants do not feel pain. The 30-week human fetus is capable of transmitting pain impulses to the brain, and newborns have been observed withdrawing purposefully from painful stimuli and crying in response to pain. Even though the human fetus and newborn transmit and receive pain impulses, this transmission occurs more slowly than in children or adults because of immature myelination. Therefore, it is inaccurate to assume pain does not affect newborns because they cannot remember the pain. Effective and judicious pain relief for newborns and infants is important.

Misconception 2: Infants and children are more sensitive than adults to opioid pain medication. Infants and children need to receive weight appropriate doses of opioid pain medication. They are no more susceptible to the unwanted side effects of respiratory depression or hypotension than older children or adults, and several authors have documented the safety of opioids for children (Anand, 2001). Risks associated with some medications do not outweigh the analgesic benefit.

Misconception 3: Pain is a character building experience. Some people believe less medication is a good thing and children will have to learn to deal with the pain. However, pain interrupts a child's appetite, sleep, and play. Indeed, pain is traumatic and not character building. It is true the pain from a surgical procedure or childhood illness differs in severity, duration, and cause from the normal bumps and bruises of childhood, but appropriate pain treatment is warranted for ill or hospitalized children.

Misconception 4: Children and adolescents will become addicted to opioids if used to treat pain. The actual risk of addiction is very low in these age groups (Agency for Health Care Policy and Research, 1992). In studies where adolescents are permitted to self-administer pain medication, they generally use less medication for shorter periods of time, and even when used for long periods of time, adolescents do not exhibit sign of dependence on pain medication. Concerns about psychological dependence on controlled substances, however, should be considered when medicating for chronic or long-term pain. Refer to Box 18-1 for definitions related to addiction, tolerance, and physical dependence.

Misconception 5: Children who are playing, sleeping, or can be distracted are not experiencing pain. Toddlers and preschool age children will look for ways to escape their pain and engage in developmentally appropriate tasks (play, makebelieve) to relieve themselves from pain. Infants may sleep but still be in pain. A withdrawn adolescent may deny pain and be perceived as exhibiting developmentally appropriate behavior, but actually be experiencing unreported pain.

CHILD DEVELOPMENT AND PAIN

Children of various ages perceive pain in the context of their development level and their perceptions and understanding of the world around them colors their behaviors and perceptions about pain (Table 18-1).

PAIN ASSESSMENT

Accurate and complete assessment of a child's pain can lead to better and more effective intervention. Several areas related to pain assessment follow.

Pain interview and History

The initial assessment should include comprehensive information about the child's pain experiences, treatments, and successes. The nurse should also query the child and caregiver about interventions and coping strategies that have helped in the past. Questions should be asked about procedural and other types of painful experiences, and the PQRST format used to find out about pain. Following the PQRST system, the child is given the opportunity to describe and rate his or her pain using a self-rating scale (Box 18-2).

Caregivers should also be asked about the child's pain. For children developmentally or cognitively too young to rate or discuss their own pain, parent information should be valued as if the client had responded. Table 18-2 lists questions that the nurse can use in obtaining a pain history.

Assessment Measures

A number of assessment measures have been developed to quantify a child's pain. They are divided into two categories: objective measures used by the nurse or other health care

professional to score client behavior or vital sign changes,

and self-reporting instruments designed so children may rate

their own pain.

Objective Measures

Objective pain measures are ideal for the infant, preverbal child, or developmentally delayed child who is not able to actively participate in pain assessment (Fig.18-1). Most objective rating measures score behaviors and physiological changes to determine the intensity of pain experienced, and are most useful for acute pain since reliability and validity are less well established for long-term pain. Objective pain assessment measures are most effective when combined with selfreporting tools for children and adolescents because they are able to report or score their own pain. The postoperative pain scale is valid for children over 12 years of age as a measure of acute pain and provides an objective means of assessing the pain. However, instruments like this are best used for acute or short-term pain or when a child is unable to readily communicate pain. Objective measures are also a useful method of documenting improvements in pain intensity over time, especially postoperatively.

Fig.18-1. Facial expression of physical distress and pain in the infant

Subjective (Self-rating) Measures

In all types of pain, the most information can be gained when children measure the pain themselves. Several methods assist children rate their own pain, and the choice of a specific measure should be based on the child's developmental level and preferences, institutional policies, and instrument availability (Figures 18-3, 18-4, and 18-5). A quantifiable measure of pain also adds to validity when discussing pain treatment with members of the health care team because reporting a child's pain by numbers or measures is more credible than saying "she says she hurts." However, the limitation to all instruments is their availability and consistency of use when accurately assessing pain.

For the verbal child, a simple pain assessment scale of 0 to 10 or 0 to 5 may be the most helpful. Here, the nurse asks the child to rate pain on a scale where "zero is no pain at all" and ten is "the worst pain ever you can imagine" (Figure 18-6). The scale points should be documented when recording the child's measure of pain (i.e., "rates pain 5 out of 10" rather than "rates pain a 5"). Drawing a ten centimeter line and asking the child to point to the level of pain on the line may also be effective.

MANAGEMENT OF ACUTE PAIN

Feeling pain is a likely experience for most children when they come in contact with the health care system. With careful planning and consideration, much of this pain can be minimized or eliminated. Therefore, the nurse caring for the child in any situation should advocate for the child and parent or caregiver to help treat the child's pain. Every child has the right to appropriate and safe pain relief and nurses play a major role in assessing, treating, and managing a child's pain.

Goals of Acute Pain Management

Pain associated with a surgical procedure or a specific disease state is described as acute pain. The intensity of acute pain lades predictably over a few days or a week, and most hospitalized children experience a phase of acute pain that is nearly resolved by discharge. The impact of effective pain treatment for children cannot be underestimated. Pain has serious physical and psychological consequences, such as increased oxygen uptake in the blood and alteration in blood glucose metabolism. The benefits of aggressive pain treatment before, during, and after surgery or invasive procedures, has longer-term benefits. Prevention is better in treating acute pain because pain that has already occurred and is severe is difficult to control. Children and their families should be told that effective pain treatment is available and an expected part of their recovery care.

Goals and expectations of pain management should also be discussed with the child and family as they can be involved in choosing assessment strategies and developing pain management techniques. Whenever possible, the child and family should be prepared for pain associated with a procedure or surgical intervention. Finally, the preparation and discussion should include treatment options. The main goals of effective pain management are to relieve pain, maximize function, and minimize side effects.

Relieve Pain

The chosen treatment should first and most importantly improve or relieve the pain. However, it may not be practical or possible to relieve all the pain unless the child is unconscious. Children and their families need to understand the limitations of effective pain management.

Maximize Function

Effective pain treatment allows the child the opportunity to walk, eat, and otherwise participate in the recovery process. Adequate pain control may contribute to a shorter hospital stay and promote quicker return to normal function.

Minimize Side Effects

All medications have side effects; some are unpleasant. Most commonly prescribed pain medications also have the potential for unpleasant or harmful side effects, but these drugs are dosed or delivered so side effects are minimized. For example, a patient controlled device may deliver intravenous opioids so the client receives the amount of medication desired with few side effects. If side effects do occur most can be adequately treated with adjunct medication that promotes pain relief without other effects.

Nonpharmacologic Pain Management

A strong nurse-client-family relationship promotes accurate reporting of pain as the client learns to trust pain will be managed. An understanding of methods to comfort the child when caregivers are not available can assist in managing the child's pain. Several specific pain management modalities, which are most effective when taught prior to the anticipated pain, should be discussed with the child and caregivers. Some techniques may be practiced prior to the painful situation or the child may use strategies that worked in the past. However, it may not be practical or effective to use more than one modality at a time. In addition, nonpharmacologic techniques should be used in conjunction with pharmacologic treatments whenever possible because the intent of these strategies is not to replace pharmacologic treatments for pain but rather to enhance the effects of the medications.

Many children and caregivers have developed their own independent strategies to deal with pain. The nurse should always explore these individualized strategies of pain management with the child and family and inform other members of the health care team. All attempts should be made to promote and continue these strategies in the acute care setting.

Other successful nonpharmacologic interventions include biofeedback, caregiver involvement, hypnosis, cutaneous stimulation (rubbing, massaging, holding), and applying heat (promotes muscle relaxation, increases blood circulation) or cold (slows ability of pain fibers to transmit pain, decreases inflammation, decreases edema).

Pharmacologic Pain Management

The nurse is responsible for understanding the expected action, potential side effects, and interactions of medications prescribed for clients. Because nurses may be administering medication, they also need to be able to answer the family's questions and observe for side effects. With appropriate dosing, the medications can be used for children of all ages. A broad understanding of the classifications of analgesics follows.

Opioid Analgesics

Opioid analgesics are a class of medications derived from the opium plant for the specific purpose of relieving pain. Used alone or in combination with other medications, opioids are among the strongest pain medications and the cornerstone of management for moderate to severe pain, including acute pain (postoperative pain) and long-term chronic pain (cancer pain). Research confirms that the use of opioids for pain relief is unlikely to result in addiction even when used for the long term (Paice, 1992). Opioid analgesics are effective when administered in small, frequent doses. The technique of delivering small doses of the medication until the desired effect (pain relief) is observed is called titration. Titrating the dose up or down may be necessary in order to obtain adequate analgesia with minimal side effects. Opioids are unique in that they have no ceiling dose (there is no point after which they are no longer effective). In the most severe pain situations, opioid analgesics can be titrated to extremely high doses if needed to achieve adequate analgesia with minimal side effects.

Morphine is the gold standard of opioids, and the effectiveness, cost, and uses of other opioids are compared to morphine. For children, opioids are dosed by weight. Neonatal doses are reduced by one-third to one-quarter to account for their immature liver function and differences in metabolism. (See Table 18-5 for specific dosing recommendations).

Larger children (greater than 50 kilograms) may receive adult doses. Appropriate dosing is an important aspect of pain management and care should be taken to appropriately individualize the dose so as to promote adequate analgesia and minimize side effects. Most intravenous opioids can also be converted to oral doses of the same or similar opioids. Side effects of opioids are most commonly nausea, vomiting, and itching. Rather than discontinue the use of opiods, side effects should be treated. If a child is experiencing severe side effects from an opioid analgesic and not receiving adequate pain relief, a different, non-opioid pain medication should be added to the pain management protocol to augment pain relief while minimizing side effects.

Respiratory depression and hypotension are rare and dangerous side effects of opioid analgesic that can be treated with naroxolone (Narcan) at a dose that reverses respiratory depression but does not reverse analgesic effects. Dosing of Naroxolone: 0.1 mg/kg, IV, ETT, q 1-2 minutes to maximum, 2 mg/kg.

Opioids can be dosed at different intervals; commonly, they are on a PRN schedule and administered when pain is assessed or reported. However, this dosing interval is inappropriate for children. First, PRN dosing places the onus to request medication for pain on the child and many children do not report their pain. Second, children may fear the treatment for pain will be an injection. Third, despite repeated instructions, children may forget the pain medication is available upon request. Finally, very young children are not able to request pain medication because of undeveloped language skills. Therefore, an alternative to PRN dosing is "reverse PRN" medication delivery. Here, the nurse asks about or assesses the client's pain at the prescribed time interval the medication may be administered. Medication is then administered if pain is present. Often children respond favorably to this method.

Analgesics may also be administered using an around-the-clock dosing schedule. Here, the child receives pain medications at preset intervals. However, the effects of the medication should be continually reassessed to assure the child is receiving adequate analgesia. The side effects and level of analgesia are also continually monitored, and if side effects appear, the medication may be titrated, discontinued, or a substitute analgesic given.

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

Nonsteroidal anti-inflammatory drugs (NSAIDs) may be used independently to treat mild to moderate pain or in conjunction with opioids to treat more severe pain. NSAIDS work by inhibiting prostaglandins at the site of the pain. The most common NSAIDS are ibuprofen (Advil), naproxen (Naprosyn), and ketorolac (Toradol). Aspirin is also an NSAID, but rarely used in children because of its association with Reye's syndrome.

Other Drugs

Acetaminophen is not an anti-inflammatory drug because it does not inhibit prostaglandins. The drug of choice for fever in children, acetaminophen is also effective for relieving mild to moderate pain, and may be used in conjunction with opioids or NSAIDS for moderate to severe pain.

Patient-Controlled Analgesia

Patient-controlled analgesia (PCA) is a computer operated pump that allows the patient to self-administer pain medication. By pushing a button on the pump, children as young as 5 or 6 years old may self-administer intravenous opioids to relieve pain. Patient-controlled analgesia is available to most children in the acute care setting and may also be administered at home. The PCA dosing regime allows for a steady drug state and more consistent analgesia while avoiding the undesired side effects associated with delivering relatively large doses of bolus analgesics. The delivery of small frequent doses of opioids provides better pain relief without sedation. By maintaining a steady amount of the analgesic, the child receives better pain control at less risk (Figure 18-7).

There are several advantages of PCA pain relief over traditional treatment modalities. Aside from the already mentioned advantages of superior analgesia and safer drug delivery, PCA offers the child the ability to immediately and independently relieve pain. The dose is tailored to the patient s weight and easily titrated for a child's changing pain control needs. A number of medications are now available for delivery via a PCA pump: morphine, meperdine (Demerol), fentanyl, and hydromorphone (Dilaudid).

PCA pumps offer several programming options. The pump may be programmed in "PCA only" mode, where doses of the medication are delivered only when the client demands a dose by pushing the button. In the "PCA plus ( + ) continuous" mode, the pump delivers a pre-programmed background infusion of the analgesic and administers additional medication according to patient request. The PCA (+) continuous mode is especially effective for young children who are often remiss or do not realize they need to push the button to administer their analgesic. The use of different modalities should be tailored to the child's ability to push the PCA button, considering developmental level and the anticipated pain management needs.

Local/Regional Anesthesia

Several techniques are now available to relive pain using local or regional anesthesia. Here, the area of the body where the pain is expected to be may be numbed by using a local or regional anesdietic injection with or without an opioid. Procedural pain (lumbar puncture, bone marrow aspirate) may also be reduced by using a euteric mixture of local anesthetics (EMLA) (lidocaine and prilocaine) or TAC (tetracaine, adrenoline, cocaine) two local anesthetic creams (Zempsky & Karasic, 1997). Both are applied to the skin prior to the procedure (EMLA up to 3 hours), covered with an occlusive dressing, and can eliminate the pain of the initial injection for most children. Regional anesthesia is applied to a region of the body, usually in association with a surgical procedure by blocking or numbing specific nerves or nerve segments prior to the surgical procedure to prevent the pain sensation.

Some surgeries or procedures are performed using only local or regional anesthesia. In such cases, the area may be numb for a period of time (2-12 hours) following the procedure.

Epidural or Intraspinal Analgesia

Opioids and/or local anesthetics can also be administered via the epidural or intraspinal route. This method of delivery provides complete analgesia for surgery or postoperatively, when medications are delivered via a single injection that last 2-12 hours or by an indwelling catheter that remains in for 1 to 5 days. The catheter is generally removed after five days, because of the increased risk of infection.

CHRONIC PAIN

Chronic pain, when compared to acute pain, varies in its presentation, treatment, and expected outcomes. Persisting for long periods of time, generally longer than 3 months, chronic pain hinders daily function and changes a child's opportunity to participate in age-appropriate activities. Chronic pain, difficult and frustrating to treat, can appear as headache or abdominal pain in children.

Headaches

Recurrent and chronic headaches are a common neurologic complaint in children. In fact, 2.5% of 7 year olds suffer from headaches, and when 15 years old, 15.7% of these same children have similar complaints (Johnson & Oski, 1997). Children experience several types of headaches and special attention should be paid to rule out an organic cause of the headache. Headache can be the presenting symptom for several types of brain tumors (see Chapter 29) and major depression in children (Johnson & Oski, 1997). For other children, headache may be the diagnosis rather than a symptom of another disorder. Common headaches seen in children and adolescents include migraine and chronic tension headaches.

Migraine or cluster headaches are intense and often associated with nausea or photophobia (light sensitivity). They tend to involve the frontal or temporal regions of the head or are localized retro-orbitally (Johnson & Oski, 1997). The child can often predict the onset of a migraine headache by an aura, or premonition of its beginning. They last from several hours to days and can be very debilitating. Often, there is a positive family history of migraines. Several medications have been effective in treating migraine headaches, including Fiorinal, Midrin, and sumatriptan (Imitrex). Biofeedback and relaxation therapy as well as prophylactic treatment with propanolol (Inderal), phenobarbital, and amitriptyline (Elavil) have also proven successful (Johnson & Oski, 1997).

Chronic tension headaches are most often seen in adolescents or older school-aged children. They tend to involve the temporal or occipital regions bilaterally, are diffuse, extend to the neck, and are continuous during the day (Johnson & Oski, 1997). Stress in the child's life is a contributing factor in this type of headache and steps should be taken to identify the stressors. Often, these children become accustomed to having a headache and can no longer identify the inciting triggers or situations. Children suffering from chronic tension headaches are best treated with a program combining stress management, behavior management, and individual and family therapy (Johnson & Oski, 1997).

Abdominal Pain

Abdominal pain is another common chronic pain complaint in children (Berkowitz, 2000; Kirschner & Black, 1998). It is classified as visceral (dull or crampy and poorly localized), somatic (reflects peritoneal inflammation; is localized to the area of the involved viscera), or referred (caused by local irritation and referral along the organ's innervation pathway) (Kirschner & Black, 1998). An organic cause of a child's abdominal pain should always be explored because it may indicate colic, food allergy, intusussception, appendicitis, Meckel's diverticulum, peritonitis, urinary tract infection, or other pathology (Berkowitz, 2000).

Periumbilical pain is often associated with recurrent abdominal pain syndrome (RAPS), a common childhood disorder affecting children between the ages of 5 and 12 years of age that is severe enough to affect activities (Kirschner & Black, 1998). The pain rarely occurs at night and does not interrupt sleep. Sometimes, constipation is associated with RAPS. Nursing care for the child with chronic abdominal pain consists of support, education about coping techniques, assurance the experience is common and probably will be outgrown, and, if applicable, a bowel program regime (Kirschner & Black, 1998). However, 30-50% of children with RAP will experience abdominal pain as adults as well (Berkowitz, 2000).

Review Questions

1. Describe the physiology of pain. Chart or diagram the cycle of the pain impulse through the nervous system; include the components of the gate control theory.

2. Describe common pediatric pain misconceptions. Delineate scientific information correcting the misperceptions.

3. How do infants experience pain? What indicates an infant is experiencing pain?

4. What unique pain behaviors do toddlers exhibit? Preschoolers? School-aged children?

American Pain Society

4700 W. Lake Ave.

Glenview, IL 60025

(847) 375-4715

Fax: 877-734-8758

www.ampainsoc.org/

Pediatric Pain Discussion Group

www.santeI.lv/SANTEL/pediat/ped-pain.html

Pediatric Pain: Science helping Children