NLE Paediatric Nursing — Paediatric Assessment, Hospitalization & PainRevision Notes

Exam Tips

• Remember the sequence: OBSERVE → AUSCULTATE → PERCUSS → PALPATE. In children, EARS and THROAT are LAST.
• If an NLE question asks 'What should the nurse do FIRST during a physical assessment of a toddler?' — the answer involves observation and/or auscultation BEFORE any invasive or touching steps.
• BP cuff size rule: bladder covers 2/3 of the arm. Too small = falsely HIGH; too large = falsely LOW.
• Always use apical pulse (full minute) for infants; always count respirations by watching the abdomen (full minute).

Key Points

• The golden rule: sequence the exam from LEAST distressing to MOST distressing.
• Always OBSERVE and AUSCULTATE (heart, lungs, abdomen) BEFORE palpating or percussing — crying distorts breath and heart sounds.
• Examine the EARS, MOUTH, and THROAT LAST in infants and toddlers, as these are the most frightening parts.
• Examine infants and toddlers on the PARENT'S LAP whenever possible to reduce fear and improve cooperation.
• Allow toddlers and preschoolers to HANDLE equipment first (stethoscope, penlight) — this is therapeutic play and builds trust.
• Keep the child clothed until needed; expose ONLY the area being examined to preserve dignity.
• For newborns, count the APICAL heart rate for a FULL MINUTE using a stethoscope at the 4th intercostal space.
• Count RESPIRATIONS for a FULL MINUTE in infants — watch abdominal movement because infants are ABDOMINAL/DIAPHRAGMATIC breathers.
• Blood pressure cuff bladder must cover approximately 2/3 of the upper arm; a cuff that is too small gives a FALSELY HIGH reading.
• Routine BP measurement begins at approximately 3 years of age.
• Preferred temperature routes: AXILLARY or TYMPANIC for routine assessment in young children; avoid rectal when possible.
• Apical pulse is used (instead of radial) in children under approximately 2 years old — radial pulse is unreliable at this age.

Definitions

Section Title

Principles of Paediatric Physical Assessment

Common Mistakes

• Auscultating after palpation — always auscultate the abdomen and lungs BEFORE palpating to avoid stimulating bowel sounds and altering breath sounds.
• Counting infant respirations for only 30 seconds and doubling — this is inaccurate because infant breathing is IRREGULAR; count the full 60 seconds.
• Using an adult-sized BP cuff on a child — this gives a falsely LOW reading (opposite error: a too-small cuff gives a falsely HIGH reading).
• Separating a toddler from the parent during the physical exam — keep the parent present and use the lap-hold technique.
• Examining the throat or ears first in a young child — this causes immediate crying and ruins the rest of the exam.

Formulas

Exam Tips

• Memorise newborn HR (110–160) and RR (30–60) as anchors, then remember BOTH decrease as the child ages.
• Adolescent vital signs (HR 60–100, RR 12–20) match adult norms — a useful memory anchor.
• For shock recognition: TACHYCARDIA first, hypotension LAST — always prioritise the child with unexpected tachycardia.
• NLE questions may give you a scenario with vital signs — identify which finding is ABNORMAL for that age group.

Key Points

• KEY TREND: As a child grows older, HEART RATE and RESPIRATORY RATE DECREASE, while BLOOD PRESSURE INCREASES.
• Newborn (0–1 month): HR 110–160 bpm, RR 30–60 breaths/min, Systolic BP ~60–90 mmHg.
• Infant (1–12 months): HR 90–160 bpm, RR 30–53 breaths/min, Systolic BP ~70–100 mmHg.
• Toddler (1–3 years): HR 80–140 bpm, RR 22–37 breaths/min, Systolic BP ~80–110 mmHg.
• Preschool (3–5 years): HR 80–120 bpm, RR 20–28 breaths/min, Systolic BP ~80–110 mmHg.
• School-age (6–12 years): HR 70–120 bpm, RR 18–25 breaths/min, Systolic BP ~85–120 mmHg.
• Adolescent (13–18 years): HR 60–100 bpm, RR 12–20 breaths/min, Systolic BP ~95–120 mmHg.
• A newborn's normal HR of 110–160 bpm would be tachycardia in an adult — this is developmentally normal.
• TACHYCARDIA is the EARLIEST compensatory sign of shock in children. HYPOTENSION is a LATE and OMINOUS sign.
• Fever raises both heart rate and respiratory rate — always reassess vital signs in context of temperature.
• Normal newborn RR of 30–60 includes periodic breathing (brief pauses); apnea >20 seconds is pathologic.

Definitions

Section Title

Normal Paediatric Vital-Sign Ranges

Common Mistakes

• Applying adult HR and RR norms to children — a HR of 130 in a newborn is normal; do not label it tachycardia.
• Thinking a normal BP means the child is not in shock — children maintain BP until late decompensation.
• Forgetting that the direction of change matters: HR goes DOWN with age, BP goes UP with age.
• Not accounting for fever when interpreting vital signs — fever of 1°C typically raises HR by ~10 bpm.

Exam Tips

• Know the PRIMARY fear of each age group: Toddler = SEPARATION; Preschooler = BODILY MUTILATION; School-age = LOSS OF CONTROL and loss of COMPETENCE; Adolescent = LOSS OF IDENTITY and PEER SEPARATION.
• For NLE questions about preparing a child for a procedure: match the preparation timing and language to the developmental stage.
• A preschooler who refuses to sleep and is quiet after a procedure may have unexpressed fears — use therapeutic play to assess.
• Adolescents need privacy from parents, especially for sensitive assessments — this is both a communication and ethical principle consistent with RA 9173's patient rights.

Key Points

• Match your communication strategy to the child's DEVELOPMENTAL STAGE, not just chronological age.
• INFANTS: Communicate through crying; respond best to a soft voice, rocking, holding, and the presence of a consistent primary caregiver.
• TODDLERS: Limited language; prepare them JUST BEFORE the procedure (not hours ahead — their sense of time is very short). Allow choices within limits, respect comfort objects (toy, blanket — termed 'transitional objects'), expect regression and negativism.
• PRESCHOOLERS: Magical thinking; greatest fear is BODILY MUTILATION/HARM. Use simple, concrete, non-threatening words. Say 'the cuff will hug your arm' instead of 'take your blood pressure.' NEVER say 'give you a shot' — say 'a little poke.' Reassure that illness and procedures are NOT PUNISHMENT. Allow medical play with dolls. Use BANDAGES after procedures because preschoolers fear their 'insides will leak out.'
• SCHOOL-AGE CHILDREN: Logical thinking; want EXPLANATIONS and reasons. Give honest, factual information. Respect modesty and privacy. Involve them in their own care.
• ADOLESCENTS: Treat with RESPECT and HONESTY. Ensure PRIVACY and CONFIDENTIALITY. Interview SEPARATELY from parents for sensitive topics. Allow participation in decision-making. Peer relationships are a priority.
• UNIVERSAL RULES: Always tell the truth — NEVER say 'it won't hurt' if it will. Get down to the child's eye level. Use the child's name. Praise cooperation afterward.
• TIMING: The younger the child, the CLOSER to the event you give preparation — toddlers immediately before; school-age children can be prepared days in advance.
• NEVER offer a choice that doesn't exist — 'Do you want the medicine in a cup or a syringe?' (both are acceptable), but 'Do you want your medicine or not?' is not a real choice.

Definitions

Section Title

Developmental Communication and Preparation for Procedures

Common Mistakes

• Preparing a toddler for a procedure hours or a day in advance — toddlers need preparation immediately before (minutes), not far in advance.
• Using threatening or technical words with preschoolers — words like 'cut,' 'dye,' or 'shot' cause unnecessary fear.
• Telling a child 'it won't hurt' to reassure them — this destroys trust when it does hurt.
• Keeping the parent outside the room for all procedures — parents should be present as comforters in most situations.
• Not applying a bandage after a procedure on a preschooler — they genuinely fear that their blood or insides will leak from the wound.

Exam Tips

• Memorise the three stages with a mnemonic: PDD — Protest, Despair, Detachment.
• The NLE may show a scenario: 'A 2-year-old who screamed for the first day of hospitalisation is now quietly playing and smiles at the nurse. The mother visits and the child ignores her.' This is DETACHMENT — the most serious stage.
• Nursing priority for a toddler in protest stage: FACILITATE PARENTAL PRESENCE, do not try to stop the crying by distracting — protest is healthy.
• Key word in NLE scenarios about adolescent hospitalisation: look for loss of INDEPENDENCE, PRIVACY, or PEER CONTACT as stressors.

Key Points

• The THREE MAJOR STRESSORS of hospitalisation are: (1) SEPARATION from family/home, (2) LOSS OF CONTROL, and (3) FEAR OF BODILY INJURY AND PAIN.
• TODDLERS are MOST affected by SEPARATION ANXIETY — it is the greatest source of their distress.
• SEPARATION ANXIETY progresses through THREE STAGES: PROTEST → DESPAIR → DETACHMENT.
• STAGE 1 — PROTEST: The child cries loudly, screams, clings to the parent, searches for the parent, rejects strangers. This is a HEALTHY and expected response.
• STAGE 2 — DESPAIR: The child becomes withdrawn, sad, quiet, and uninterested in play or food. The child may appear calmer, but this is DEPRESSION, not adjustment.
• STAGE 3 — DETACHMENT (Denial): The child appears superficially adapted — becomes friendly with staff but shows LITTLE OR NO INTEREST in the parent when they visit. This is the MOST SERIOUS and DANGEROUS stage — it represents resignation, not adjustment.
• KEY NURSING INTERVENTIONS for separation anxiety: ROOMING-IN (parent stays with child), liberal visiting hours, assign CONSISTENT CAREGIVERS (primary nursing), maintain HOME ROUTINES and RITUALS, keep COMFORT OBJECTS at the bedside.
• REGRESSION is normal — reassure parents; do NOT scold or shame the child for regressing.
• To minimise LOSS OF CONTROL: offer safe choices, maintain daily routines, allow the child as much autonomy as safely possible, give honest information.
• ADOLESCENTS experience loss of identity and separation from peers as major stressors — encourage peer communication and involve them in care planning.

Definitions

Section Title

Child's Response to Hospitalisation: Separation Anxiety and Regression

Common Mistakes

• Interpreting Stage 3 (Detachment) as a positive sign — a toddler who is suddenly friendly with staff and ignores parents is NOT adapting well; this is alarming.
• Confusing Despair (Stage 2) with Detachment (Stage 3) — Despair = sad and withdrawn; Detachment = appears happy but emotionally disconnected from parents.
• Telling parents that their toddler 'settled down nicely' during detachment — this must be recognised and addressed, not praised.
• Forgetting that regression does NOT indicate a problem requiring treatment — it is a coping mechanism that resolves once stressors are removed.

Exam Tips

• Match the pain scale to the age: FLACC (infant/non-verbal) → FACES (~3 yr+) → NUMERIC (~7–8 yr+). This is a direct NLE question pattern.
• For NLE scenarios with a 6-month-old post-operative infant: the correct pain scale is FLACC.
• For a 4-year-old child: use the FACES/Wong-Baker scale — they can point to a face but cannot reliably use numbers.
• Remember: a quiet child is NOT necessarily a pain-free child — use the appropriate behavioural scale.

Key Points

• Pain is the FIFTH VITAL SIGN — it must be assessed routinely and documented in every child, regardless of age.
• INFANTS DO FEEL PAIN — the old myth that infants do not feel pain is WRONG and has been disproven. Untreated pain has physiologic consequences (elevated HR, BP, RR; poor feeding; impaired healing).
• Choose the pain scale APPROPRIATE for the child's AGE and ABILITY to self-report.
• FLACC SCALE: For INFANTS and NON-VERBAL children (~2 months to 7 years). Observational scale — the nurse scores the child's behaviour in 5 categories: FACE, LEGS, ACTIVITY, CRY, CONSOLABILITY. Each category is scored 0–2; total score 0–10.
• FACES/WONG-BAKER FACES SCALE: For children APPROXIMATELY 3 YEARS AND OLDER who can self-report. The child POINTS to the face that best matches how they feel. Shows 6 faces from smiling (0 = no pain) to crying (10 = worst pain).
• NUMERIC RATING SCALE (0–10): For children APPROXIMATELY 7–8 YEARS AND OLDER who understand numbers and abstract concepts. The child rates pain from 0 (no pain) to 10 (worst pain).
• NIPS (Neonatal Infant Pain Scale) / CRIES Scale: For NEONATES — combines behavioural and physiologic indicators.
• PHYSIOLOGIC INDICATORS of pain: increased HR, increased BP, increased RR, diaphoresis, pallor, pupil dilation. Note: physiologic indicators are NOT reliable for prolonged pain (body adapts — habituation).
• BEHAVIOURAL INDICATORS of pain in infants and young children: crying (especially a high-pitched cry), grimacing, furrowing of brows, clenched fists, guarding the painful area, refusal to move, sleep disturbances.
• After every pain intervention (pharmacologic or non-pharmacologic), REASSESS and DOCUMENT the response.

Definitions

Section Title

Paediatric Pain Assessment

Common Mistakes

• Using the numeric (0–10) scale with a toddler or preschooler — they cannot reliably use abstract numbers; use FLACC or FACES.
• Believing that a sleeping child is not in pain — children in pain do eventually sleep; do not withhold pain assessment because the child appears asleep.
• Relying solely on physiologic signs for prolonged pain — physiologic signs normalise over time even when pain persists (habituation); behavioural assessment is more reliable for chronic pain.
• Not reassessing after pain intervention — pain management is a continuous nursing process, not a one-time action.

Formulas

Exam Tips

• Paracetamol: 10–15 mg/kg q4–6h, NO anti-inflammatory effect, NO GI risk, SAFEST antipyretic for all ages.
• Ibuprofen: 5–10 mg/kg q6–8h WITH FOOD, only for ≥6 months, HAS anti-inflammatory effect.
• ASPIRIN + VIRAL ILLNESS in a child = REYE'S SYNDROME — this is a definite NLE question.
• For opioid monitoring: the priority assessment is RESPIRATORY RATE (respiratory depression is the most dangerous adverse effect).
• When computing doses: if the question gives weight in pounds, CONVERT to kg first (1 kg = 2.2 lbs).

Key Points

• Pain management integrates NON-PHARMACOLOGIC and PHARMACOLOGIC approaches — both are important for complete care.
• NON-PHARMACOLOGIC methods are FIRST-LINE ADJUNCTS and include: distraction (bubbles, toys, videos), positioning (upright, held by parent), swaddling, non-nutritive sucking (pacifier), oral sucrose, therapeutic touch, and guided imagery for older children.
• ORAL SUCROSE (24% solution): Effective for PROCEDURAL PAIN in NEONATES and YOUNG INFANTS — small amount given 2 minutes before the procedure. It activates endogenous opioid pathways.
• EMLA CREAM (Lidocaine 2.5% + Prilocaine 2.5%): Topical anaesthetic applied to the skin at least 60 minutes before needle sticks (IV insertion, venepuncture) to reduce procedural pain. Under an occlusive dressing.
• PARACETAMOL (Acetaminophen): DOSE = 10–15 mg/kg/dose PO or PR every 4–6 hours. Maximum ~75 mg/kg/day. Single-dose adult ceiling ~1,000 mg. It is ANTIPYRETIC and ANALGESIC but NOT ANTI-INFLAMMATORY. NO GI irritation or bleeding risk — SAFEST first-line antipyretic for children.
• IBUPROFEN: DOSE = 5–10 mg/kg/dose PO every 6–8 hours. Indicated for children ≥6 MONTHS of age. Anti-inflammatory, antipyretic, analgesic. MUST BE GIVEN WITH FOOD. AVOID in dehydration, GI bleeding, or renal impairment.
• OPIOIDS (e.g., Morphine): For MODERATE TO SEVERE pain; dosed by weight; titrated to effect. Monitor for RESPIRATORY DEPRESSION (most dangerous), excessive sedation, constipation, and urinary retention.
• ASPIRIN is CONTRAINDICATED in children with VIRAL ILLNESSES (varicella/chickenpox, influenza) — risk of REYE'S SYNDROME (acute encephalopathy + hepatic dysfunction).
• ALL analgesic doses in children must be WEIGHT-BASED (in kilograms); verify current weight before every calculation; double-check high-alert medications with a second nurse.
• Pain management involves REASSESSMENT: document the pain score before and after every intervention.

Definitions

Section Title

Paediatric Pain Management

Common Mistakes

• Giving aspirin to a child with fever due to varicella or influenza — this is a dangerous, NLE-tested error that causes Reye's syndrome.
• Dosing paracetamol or ibuprofen by age instead of by WEIGHT — always use the current weight in kilograms.
• Giving ibuprofen to an infant younger than 6 months — it is not indicated below 6 months of age.
• Applying EMLA cream only 10–15 minutes before a procedure — it requires at least 60 minutes to be effective.
• Mixing oral medications into a full bottle of formula — the child may not finish the bottle and will not receive the full dose, AND it can create a negative association with feeding.

Exam Tips

• NLE PATTERN: 'Where should the nurse perform a painful procedure on a hospitalised child?' Answer: in the TREATMENT ROOM, not the bed or playroom.
• NLE PATTERN: 'What is the preferred IM injection site for a 3-month-old infant?' Answer: VASTUS LATERALIS.
• NLE PATTERN: 'What type of restraint is used to immobilise an infant for a throat examination?' Answer: MUMMY (PAPOOSE) restraint.
• Remember the restraint rules: ORDER required, check CIRCULATION regularly, NEVER tie to movable parts, use ONLY when necessary.

Key Points

• ATRAUMATIC CARE PRINCIPLE: Minimise physical and psychological distress through prevention of separation, promotion of control, and minimisation of pain.
• TREATMENT ROOM RULE: Perform painful or distressing procedures in a DESIGNATED TREATMENT ROOM — NEVER in the child's bed or the PLAYROOM. The bed and playroom must remain SAFE SPACES.
• Use POSITIONS OF COMFORT (therapeutic holding) whenever possible — the child is held upright by a parent who provides comfort. This is preferred over strapping the child in a supine position.
• Keep the PARENT AS A COMFORTER, not as the person who physically restrains the child during painful procedures.
• RESTRAINTS are a LAST RESORT — used only when necessary for safety or a specific procedure, require a physician's ORDER, must be monitored regularly for circulation (check colour, warmth, sensation of extremities), and must be REMOVED and REPOSITIONED at regular intervals.
• MUMMY RESTRAINT (Papoose): A technique to briefly immobilise an INFANT for specific procedures involving the SCALP, FACE, EYE, EAR, or THROAT (e.g., scalp vein IV insertion). The infant is wrapped snugly in a sheet with arms at the sides. Use is BRIEF and MONITORED.
• NEVER tie a restraint to a MOVABLE part of the bed (e.g., side rail) — it should be tied to the fixed bed frame.
• IM INJECTION SITE: VASTUS LATERALIS (anterolateral thigh) is the PREFERRED and SAFEST site for INFANTS and YOUNG CHILDREN — it is the largest available muscle with no major nerves or blood vessels at risk.
• VENTROGLUTEAL site: safe once the child is WALKING and has developed sufficient muscle mass.
• AVOID the DORSOGLUTEAL site in children under ~3 years or those who have not yet walked well — the muscle is underdeveloped and the SCIATIC NERVE is at risk.
• DELTOID: used mainly for small-volume injections and VACCINES in OLDER CHILDREN (school-age and adolescents).
• ORAL MEDICATIONS: Use a CALIBRATED ORAL SYRINGE or DROPPER; aim medication toward the SIDE/BACK OF THE CHEEK (not the tongue — avoids aspiration and gag reflex). Give slowly.
• DO NOT mix medication into a FULL BOTTLE of formula or a favourite food — incomplete ingestion = incomplete dose; can cause food aversion.

Definitions

Section Title

Atraumatic Care: Procedures, Restraints, and Medication Administration

Common Mistakes

• Performing a painful procedure (e.g., blood extraction) while the child is in their hospital bed — the bed must remain a safe space.
• Using the dorsogluteal IM site for an infant — this is dangerous due to the proximity of the sciatic nerve and underdeveloped muscle.
• Tying a restraint to the side rail — if the rail is lowered, it can injure the child.
• Mixing medication into the infant's main bottle of formula — the child may not finish it, and it creates a negative association with feeding.
• Keeping the restraint on for extended periods without monitoring — always check circulation (capillary refill, colour, sensation) regularly and remove/reposition as scheduled.