1: General principles of children’s nursing

Section 1 General principles of children’s nursing




1.1. Introduction


1.2. Emergency care of a child



1.1 Introduction


Children’s wards are dedicated to the management of children with acute or chronic illness, injuries or complications. They are specially staffed and equipped for the prevention of complications or the reduction of their severity.


For some, children’s nursing may be a daunting prospect. You may have queries and concerns prior to going to a children’s ward. This book aims to answer some of the questions you may have. Remember, even though you may not know it, there are skills you already have that you can apply to children’s nursing. Experience and skills acquired in other areas of life will equip you and prepare you for your children’s nursing experience.



What to expect


What is expected of the role of the children’s nurse?



image Work as part of the multidisciplinary team


image Provide psychological and physiological care to children that is individualized and holistic


image Be an advocate for the child and parents


image Provide support for the families’ needs


image Care for relatives of the child and significant others


image Display appropriate and effective communication skills


image Take part in ethical and moral decision making


image Prioritize care


image Assist with and undertake research-based care


image Accept changing practices and innovations


image Gain an awareness of self-development


image Support and educate less-qualified colleagues


image Record observations/document care


image Attend to all invasive lines


image Administer medications.



The multidisciplinary team (MDT)



Medical staff




image Includes clinical directors of paediatrics or medical/surgical directorates. Specialist doctors may be involved in the management of the paediatric environment. Some paediatric areas are staffed by individual specialists from other disciplines such as anaesthesia or medicine.



Physiotherapist




image Assists with children’s respiratory functions, e.g. breathing pattern and depth to prevent complications


image Preserves existing motor skills, restores mobility, and considers the role of all limbs whether strong or weak


image Works towards reducing stiffness, contractions and spasticity


image Re-educates motor function, co-ordination and balance.



Occupational therapist




image Restores children’s ability to perform daily activities. This may involve relearning skills (e.g. feeding or dressing) and adapting objects that the child can use.


image Evaluates children’s perceptual and cognitive functions


image Assesses the need for modifications in a child’s home.



Speech and language therapist




image Assesses children’s swallowing and gag ability


image Provides specialized speech therapy, communication advice and aids to assist with speech.



Dietician




image Ascertains nutritional and fluid requirements


image Gives advice regarding enteral or parenteral feeding requirements and regimes.



Social worker




image Discusses long-term or short-term care options with a child and their family


image Supports families and the child by assisting with social issues, e.g. financial support at home


image Can provide carers and home adjustments.



Play specialist




image Is essential in the provision of play therapy


image Prepares children for procedures and events.



Other staff:




image Secretarial support


image Porters


image Technicians for servicing equipment


image Chaplains, priests or relevant officials of all religions


image Clinical pharmacists


image School teachers.



Children are different


Children are in a state of constant development, both physically and psychosocially. Children are not ‘mini adults’, as was previously thought many years ago. They have their own special requirements that must be met in specific ways. Their ability to cope with hospitalization is influenced by their age, developmental stage and previous experiences. This is what makes their needs different from those of adults.



Development aspects of a child (Piaget theory of development)


Generally, children are viewed as one group that think the same way. However, children’s cognitive development (the ability to reason, think and understand) alters with age. Thus the child’s views and experiences of illness and hospitalization will be affected by his/her stage of cognitive development. It can be hard to know how much a child can understand and how to communicate with children of varying ages. This is where Jean Piaget’s (1896–1980) theory of development can be a useful guide. Knowledge of this four-staged theory will help you to understand how children interpret illness.


The four stages of this theory are:



1. Sensorimotor (birth to 2 years)


2. Preoperational (2–6 years)


3. Concrete operational (6–11 years)


4. Formal operational (11 years plus).


The stages of development and how they influence a child’s beliefs and understanding are outlined below:



Sensorimotor (birth to 2 years)


Learning is mainly through the senses and physical activity. Babies are born with a large collection of reflexes (physical responses triggered involuntarily by a specific stimulus) (Bee and Boyd 2009). They use sucking, grasping and hearing to make sense of their surroundings. Babies are sensitive to sound and can link familiar objects with sound, for example mother with her voice. The child is strongly attached to familiar caregivers and will display upset when separated from them.


The toddler period (18–24 months) can be difficult for some children. They can have a temperament profile of high activity, intensity of emotion and low adaptability. It can be frustrating for this age group when they are unable to communicate their needs. From 2 years onwards, language acquisition is a key development.



Preoperational stage: 2–6 years


Phenomenism is the most developmentally immature explanation of illness at this stage. The child is unable to explain illness (e.g. How do people get colds? From the sun or the wind. How does the sun give you a cold? It just does that’s all. God does it in the sky).


Contagion is a more mature concept of the prelogical stage. The cause of illness is seen to be located in objects or people who are in proximity to the child, but not necessarily touching them (e.g. How do people get colds? When somebody comes near you. How? I don’t know, by magic I think).


In the preoperational stage, children’s concerns are:



image Separation anxiety, leading to feelings of insecurity, abandonment, anxiety, loneliness


image Inaccurate understanding of the body can lead to fears of mutilation


image Changes in rituals, routines, and an unfamiliar environment can cause a child to feel insecure


image Inability to reason beyond the present and immediate environment so explanations have to be related to the here and now


image Illness may be seen as punishment so child needs demonstrations of love and affection to reassure him/her about this.



Concrete operational stage: 6–11 years


This stage is where differentiation of self from others occurs. A child is less egocentric and can apply thinking and reasoning to real objects and events. They can be confused about location of internal organs. Illness concepts are defined as contamination and internalization.


Contamination means that a child can distinguish between cause and effect in illness (e.g. If somebody has got a rash and you touch them you get it; if you go outside in the cold without a coat, the cold touches your body and goes all over it).


Internalization is a more mature understanding of the fact that illness may be located within the body but have an external cause (e.g. you breathe in cold air and get a cough; if someone with a cold kisses you, the germs go in your mouth and make you ill).


In the concrete operational stage, children’s concerns are:



image Fear of loss of motor skills


image Worry about separation from school and peers


image Mutilation fantasies


image Increased concerns related to modesty and privacy


image Imposed passivity may be seen as punishment.



Formal operational stage: 11 years plus


Child can understand and explain illness in complex terms. They are able to reason logically, think in abstract terms, and systematically explore problems. Illness concepts may be physiological and psychological (e.g. worry and stress can cause ulcers and heart disease and it is possible to get in a state and worry yourself sick).


In the formal operational stage, children’s concerns are:



image Altered body image due to puberty


image Lack of privacy


image Separation from peers, school and family


image Frustration with being dependent on others for help


image Threats of helplessness, and strong desire for mastery


image Dislike of being excluded, so will want to be involved in discussions about care and treatment decisions


image Prone to construe beyond their knowledge so may assume headaches to be a brain tumour.


Be aware that children’s understanding can vary considerably depending on their life experiences. These ages are approximate to each stage as some children mature quicker and are more capable of processing information than others. Hence, this is a flexible guide that will help you provide developmentally appropriate care and reduce the negative effects of hospitalization for the child.



Reflection


Reflection is a way in which professionals pay attention to significant aspects of an experience they had in order to make sense of it within the context of their work. One can reflect during an action or after an experience has taken place (Schon 1983). Continuing professional development is essential in nursing and reflection facilitates this (Palmer et al 1994). By reflecting on and taking action to resolve the contradictions that occur in their practice, children’s nurses can self-evaluate and come to know themselves. Consequently, they learn to become increasingly effective in their chosen field and they develop unique nursing knowledge.


This advocates the use of some sort of guide to ensure this happens and there are many cognitive models of reflection available, for example Boud et al (1985), Gibbs reflective cycle (1988) (see Fig. 1.1) and Johns model of structured reflection (1995) (see Table 1.1).


image

Fig. 1.1 The Reflective Cycle (Gibbs 1988)


Table 1.1 Johns’ model of structured reflection (10th edition)






















Write a description of the experience
Cue questions
Aesthetics What was I trying to achieve?
Why did I respond as I did?
What were the consequences of that for:
the patient?
others?
myself?
How was this person feeling? (Or these persons?)
How did I know this?
Personal How did I feel in this situation?
What internal factors were influencing me?
Ethics How did I feel in this situation?
What factors made me act in incongruent ways?
Empirics What knowledge did or should have informed me?
Reflexivity How does this connect with previous experiences?
Could I handle this better in similar situations?
What would be the consequences of alternative actions for:
the patient?
others?
myself?
How do I now feel about this experience?
Can I support myself and others better as a consequence?
Has this changed my ways of knowing?


Boud et al (1985) Returning to the situation


What



image is the purpose of returning to the situation?


image exactly occurred in your own words?


image did other people do?


image do you see as key aspects of the situation?


So what



image were you feeling at the time?


image are your feelings now?


image were the effects of what you did or did not do?


image what ‘good’ emerged from this situation?


image were your experiences in comparison with your colleagues?


image are the main reasons for feeling differently from your colleagues?


Now what



image are the implications for your colleagues or the clients?


image needs to happen to alter the situation?


image are you going to do about the situation?


image happens if you decide not to alter anything?


image might you do differently if faced with a similar situation again?


image are the best ways of getting further information about the situation should it arise again?



Critical thinking


Critical thinking involves the development of cognitive processes such as higher-level thinking and reasoning. It encourages the individual to become open-minded, consider alternative perspectives, and respect the right of others to hold different opinions (Clarke & Holt 2001). Critical thinking can be used when situations or problems arise whereby there is no definitive answer. Children’s nurses need to be equipped and ready to find solutions, make decisions, and solve unique and complex problems within their clinical environment. As a children’s nurse you will have to contend with tensions, prioritize care and deal with difficult technical terms when trying to get your view across. Critical thinking can facilitate your expression or articulate to others the sensitivity, complexity of making decisions in practice (Edwards 2007). To think critically, one needs to be inquisitive, curious, enthusiastic, willing to seek the truth and courageous about asking questions to obtain the best action for patients. Table 1.2 shows the phases involved in the critical thinking process.


Table 1.2 Main areas to consider as part of critical thinking























































Phase 1
1. Interpretation and organization of the information Descriptions of the situation or problem
Logically assemble the information in the mind or on paper
Use a concept or mind map starting with a broad concept with linking words that are interrelated and connected.
If possible attempt to apply a systematic, organized and diligent approach to the situation (disorganized and abstract is also satisfactory at this time)
2. Hidden assumptions What are these?
Values, attitudes and beliefs held by all those involved, are they opposite to your own beliefs or interests
Consider positive and negative judgements that might be included
Try to be open minded
3. Nursing knowledge involved (both objective and subjective) Look for the evidence: theoretical/research
The ethical principles involved
Knowledge from past experiences (personal or professional)
Practical knowledge/skills
What are your gut feelings about this – use your intuition
4. Break down the situation/information into parts Is there a relationship between the parts?
How does one effect the other?
Analysis – examination of the ideas/arguments and possible courses of action.
5. Consider all of the options Include other people’s views/perspectives
Continual questioning of the issues involved
Consideration of all of the possibilities
Flexibility – view the situation in many different ways with a variety of ideas.
Be inquisitive, curious, courageous about asking questions to obtain all of the information
6. Are there any conflicting issues What are they?
Nurse–patient
Professional–ethical
Nurse–nurse/doctor–nurse/other HCP–nurse
Air the concerns with each other
Team-working, communication, negotiation skills to resolve conflicts
7. Consider all of the options, again, synthesizing of ideas Try to make sense of the muddle that is formulating in your mind or on paper
Put them in some type of order with the preferred solution and consider the consequences of one decision over another
Delete the ones that no longer apply or there are no resources, can never happen
What is the best way forward and why?
8. A decision has to be made A decision/solution/conclusion has to be reached
Self confidence and trusting own reasoning when making decisions / solving problems
Phase 2
9. Defending the decision A reason why that decision was made
How the decision was reached
Has to be explained how the decision was arrived at
Justification has to be given
10. Accountability and responsibility for the decision made Taking / accepting responsibility for the decision that has been made
Being accountable legally, ethically and professionally
11. Evaluation of the process Critical reflection/reflective practice
Self-regulation/changing practices in the light of new insight and knowledge
Correcting oneself if found to be wrong
Learning from the situation/process/action plan for future learning needs
Personal learning and continuing professional development (CPD)
12. Creativity and innovation Implementation of the decision/solution
Implementing change, doing things in a different way, being creative and innovative (may go back to the start)
Changing, refining or developing new policies/procedures
Moving practice forward, doing things differently due to knowledge gained


Infection control issues


Patients who are admitted to a children’s ward are immunologically vulnerable and invariably have a reduced immune response. This may be due to the individual child’s general condition, their inability to take nutrition, or fasting practices in hospital. It might be due to prescribed treatments or drug therapies such as antibiotics, non-steroidal anti-inflammatory drugs (NSAIDs), antacids, chemotherapy and steroids. The children’s nurse must be vigilant in relation to infection control practices to prevent the child from obtaining a hospital-acquired infection. Listed below are a number of areas that children’s nurses need to be aware of so they can address a child’s potential reduced immune response.



Broad-spectrum antibiotics




image These antibiotics do not only destroy the invading bacteria, but also devastate the normal flora present in the gastrointestinal tract (GIT) and can lead to diarrhoea.


image Broad-spectrum antibiotics destroy resident flora living in the mucous membranes of the mouth and vagina, allowing pathogens (commonly Candida albicans, which causes thrush) to colonize, leading to fungal infections.



NSAIDs


These are prescribed to relieve pain. This group of drugs works by reducing the release of prostaglandin during the inflammatory response. Prostaglandin has a number of roles in the body:



image Sends messages to the brain and pain may be felt


image Simulates the inflammatory response, which leads to swelling, putting pressure on localized nerve endings, resulting in pain, redness and heat


image Stimulates the clotting cascade, so any interference with its release can induce bleeding of the nose, vagina, or bleeding from wounds, etc.


image Controls renal blood flow and if prostaglandin is reduced then glomerular filtration rate (GFR) will be reduced leading to sodium and water retention


image NSAIDs are acidic and increase the acidity of the stomach and so can lead to the formation of ulcers; strict adherence to administering these drugs after meal times is essential (Galbraith et al 2008)


image It is essential that children taking NSAIDs should not take other protein-bound anticoagulants (such as aspirin) as these displace highly protein-bound drugs from proteins, leading to more free anticoagulants in the bloodstream


image These drugs reduce the inflammatory response and as such healing mechanism may also be delayed.



Antacids




image Antacids are drugs that neutralize acidity of the gastric juice


image Can give rise to an increase in production of bacteria living in the stomach, small and large intestine, which can lead to diarrhoea.



Administration of chemotherapy and radiotherapy




image Administration of chemotherapy and radiotherapy can depress the bone marrow


image Bone marrow produces neutrophils and monocytes, which mature to become macrophages


image Administration of chemotherapy and radiotherapy can lead to increased risk of patients becoming neutropenic, which leads to an increased risk of septicaemia.



Steroids




image Steroid hormones are synthesized by the adrenal cortex, and cortisol is a naturally occurring hormone


image Corticosteroids are anti-inflammatory and suppress the immune response, which affects healing; this can lead to susceptibility to infection and impaired wound healing


image Patient may be exposed to bacteria, which would not normally breach innate immune defences (Galbraith et al 2008).



Reduced nutritional intake


Adequate nutritional intake (e.g. glucose, fats, protein, vitamins and minerals) is required to produce the cells and molecules of innate immunity. If nutrients are not available, new molecules and cells cannot be produced, reducing the body’s innate defence’s protection against infection. The nutritional requirements for wound healing (see Section 2) include an adequate protein intake. Proteins supply the amino acids necessary for repair and regeneration of tissues, and produce many of the proteins involved in the immune responses. There are hospital practices that exacerbate bad nutrition and hence affect the child’s immune response:



image Preoperative patients only need to be fasted for 4–6 hours.


image Postoperative feeding should be initiated immediately; leaving fasting until the return of bowel sounds is traditional, ritualistic and unnecessary.


image The prescription of 5% dextrose solution to maintain nutrition only promotes malnutrition as one litre of 5% dextrose solution contains approximately 800 kcal.


Note: All healthcare professionals and families can reduce the risk of transmission of hospital-acquired infection in children by following infection control practices, as outlined in Table 1.3.


Table 1.3 Infection control practices































Type Reasons Practice
The use of a single room This is generally used to protect staff and other patients in the ward area (isolation) or to simply protect the patient due to immunosuppression (protective isolation) Protective clothing is not generally required, visitors do not go from patient to patient and are not in contact with other patients
Visitors do not handle infectious material
Wash hands before and after the visitor leave the room is all that is necessary
Hand-washing This is responsible for a large proportion of cross infection, and is the most important method of preventing the spread of infection (Finn 1997) Thorough hand washing before attending a patient ensures the majority of micro-organisms acquired transiently from other patients are removed
An awareness of micro-organisms demonstrates the importance of thoroughly washing and drying hands
Protective clothing The transmission of micro-organisms on staff clothing is possible, but unlikely
It is more likely to arise on the front
Contaminated uniforms with body fluids increases the microbial load, plastic aprons provide adequate protection as they are impermeable		 Plastic aprons under cloth gowns if there is a risk of spillage
Disposable gloves for any activity
Discarded after use and wash hands
If no contact occurs with other patients, infection is unlikely to spread if the nurse leaves the room
Masks and eye protection Recommended for infections that are spread by respiratory droplets
They do not work when wet, as damp masks do not filter micro-organisms effectively
Efficiency diminishes when worn for long periods
Easily contaminated by the hands during repositioning or removal, and as such are unreliable against airborne infections, especially viral (ICNA 1984)		 Not necessary for most procedures Are important to protect health care workers and should be worn for any activity where there is a risk of body fluid splashing into the face
Waste material If contaminated with blood or body fluids should be discarded in a yellow waste bag, in the patient’s room
The outer surface of waste bags does not become significantly contaminated, no reason to enclose the waste in a second bag		 All body fluids should be safely discarded directly into a bedpan washer or macerator
Equipment Beds, curtains, bedclothes, toys, bedpans, sphygmomanometers
The majority of micro-organisms are not able to survive in the absence of moisture, warmth and nutrients, then as long as the equipment and other surface areas are kept clean and dry, the potential for the multiplication of bacteria will be removed		 If it is known that microorganisms can contain spores and able to survive when food is scarce, hot water or special chemicals may be required to cleaning


Care planning and documentation


In paediatrics, the care is always discussed and planned with the primary carer as they know the child best and are usually very involved in the delivery of the care together with the nurses. The care needs to be planned and negotiated so that everyone is clear and happy with each others’ roles and contribution. This always needs to be documented.


Key points to remember about nursing documentation:



image Should contain all the relevant information needed to care for the child


image Should be a structured plan based on a holistic assessment of the child’s and family’s needs


image Should be discussed and planned with both the child and primary carer(s)


image Should reflect primary carer’s preferred contribution to the child’s care


image Should be personalized to each child


image Should be written clearly and legibly with black pen


image Should be updated, reviewed and evaluated regularly to ensure relevancy.



Nursing models


Care plans are normally structured around an organizing framework, called a nursing model such as the Partnership Model. Some paediatric units prefer the philosophy of family-centred care. This is where the care is planned around the whole family, not just the individual child/person, and in which all the family members are recognized as care recipients.



Nursing process


Nursing models should include all four steps of the nursing process: assessment, planning, implementation and evaluation. These four steps will help to identify the child’s needs and write a care plan to meet those needs.



Assessment


The first step in the development of a care plan is the thorough assessment of the child’s physical, psychological and social needs, along with the family’s needs. You need to:



image Explain to the child the purpose of the assessment and seek their agreement


image Undertake a comprehensive assessment using a child- and family-centred approach


image Obtain information directly from the child as much as possible to demonstrate respect for their knowledge and experience


image If assessing a non-verbal child or infant, seek the relevant information from the parents or primary carer


image Identify the physical, psychological, social, developmental, cultural, spiritual and sexual needs of the child


image Assess and record baseline observations and report anything out of normal range


image Ask the child and carer if they have any questions or concerns and address those concerns


image Provide information about the process and prepare child and carer for what to expect


image Obtain informed consent for any interventions or investigations planned.



Planning


This includes setting goals/outcomes and identifying specific interventions to fulfil these goals and expected outcomes. These need to be documented clearly and legibly.



image From the assessment identify the short-, medium- and long-term needs of the child.


image Take account of how child or young person would like to be involved in the delivery of their care.


image Take account of parents’, carers’ and family members’ views of the child’s care needs and how they would like to contribute to their child’s care.


image Then set the goals/outcomes and identify specific interventions to fulfil these goals and expected outcomes.


image Negotiate and agree the care plan with the child and primary carer, taking account of all relevant information.


image Agree roles and responsibilities with those involved in caring for the child.


image Explain the care plans to the child and family and clarify any information that is unclear.


image Care plans should be individualized to each child and family situation.


image Document and record all relevant information and communication during the care planning process.



Implementation


This involves carrying out the interventions planned and recording the child’s response to the interventions.



image Prioritize the interventions required and carry out the interventions according to the care plan.


image Ensure care is delivered consistently to meet the goals/outcomes.


image Work with MDT to meet the identified healthcare needs.


image Work in partnership with parents and primary carers to deliver the care required.


image Record and monitor child’s response to the interventions.


image Keep child and carer informed on the progress and outcomes of interventions and investigations.


image Be flexible in the delivery of interventions that are non-urgent.



Evaluation


This involves reviewing how the interventions have worked, and determining any changes which need to be made to the care plan.



image Ensure that any changes made are negotiated and agreed with the child and carer.


image Monitor the quality of the care plans to ensure delivery of evidence-based care.


image Evaluate the quality of care delivered.


image Ensure that care is individualized and uses a child and family centred approach.



Essential skills for preregistration students


The Nursing and Midwifery Council (2007) have identified essential skills suitable for pre-registration students necessary for entry to the branch programme and for entry to the register. The skills are listed under five key areas:



1. Care, compassion and communication


2. Organizational aspects of care


3. Infection prevention and control


4. Nutrition and fluid management


5. Medicine management.


The new standards for preregistration nursing education introduced in 2010 will replace the existing Standards of proficiency for preregistration nursing education (NMC 2004).



Government directives in children’s nursing


Many organizations have developed core principles to promote better standards of hospital care for children and their families and to safeguard children’s rights. The National Services Framework (NSF) (Department of Health 2003) have set standards for children in hospital to ensure that:



image hospital services meet the needs of children, young people and their parents, and


image they provide effective and safe care, through appropriately trained and skilled staff working in suitable, child-friendly, and safe environments.


It would be useful to read the documents that fully outline these standards which can be located on the website www.nhs.uk/NHSEngland/NSF/Pages/Children.aspx.


More recently, a common core set of knowledge and skills for all people who work with children has been identified (Children’s Workforce Development Council 2010) and these link closely with the NSF standards. The common core has been divided into six key areas which sets out the basic knowledge and skills that everyone who works with children are expected to have.



Core set of knowledge and skills




1. Effective communication and engagement with children, young people and families.


2. Child and young person development.


3. Safeguarding and promoting the welfare of children.


4. Supporting transitions.


5. Multi-agency working.


6. Sharing information.


The Department of Health and Department for Children, Schools and Families have produced a long-term strategy to improve health outcomes for all children (Department of Health & Department for Education and Skills 2009). The Healthy Lives, Brighter Futures: Strategy builds on the National Service Framework for Children, Young people and Maternity Services and the Every Child Matters reforms to improve the quality and consistency of services provided for children and families.



Voluntary organizations


In Europe the EACH organization (European Association for Children in Hospital) promotes the welfare of all children, before, during and after a hospital stay. EACH is made up of 19 associations from Europe, which promote the care of hospitalized children through the EACH charter. The EACH Charter contains a list of 10 rights for all children in hospital (www.each-for-sick-children.org/each-charter). These are listed in Table 1.4.


Table 1.4 The 10 rights of children in hospital















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Related posts:

  1. 5: Psychosocial and ethical care
  2. 2: Assessment and investigations of a child
  3. 4: Common conditions in children and reasons for admission
  4. 3: Children’s nursing interventions

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Jun 15, 2016 | Posted by in NURSING | Comments Off on 1: General principles of children’s nursing

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Article 1 Children shall be admitted to hospital only if the care they require cannot be equally well provided at home or on a day basis
Article 2 Children in hospital shall have the right to have their parents or parent substitute with them at all times
Article 3 Accommodation should be offered to all parents and they should be helped and encouraged to stay
Parents should not need to incur additional costs or suffer loss of income
In order to share in the care of their child, parents should be kept informed about ward routine and their active participation encouraged
Article 4 Children and parents shall have the right to be informed in a manner appropriate to age and understanding
Steps should be taken to mitigate physical and emotional stress