NLE Paediatric Nursing — Paediatric Assessment, Hospitalization & PainSummary

The paediatric physical examination follows the principle of LEAST-TO-MOST DISTRESSING: perform observation and auscultation (heart, lungs, abdomen) BEFORE palpation and percussion, because crying and distress alter cardiopulmonary sounds. Save the ears, mouth, and throat examination for LAST, as these procedures are the most upsetting for young children. This sequencing builds the child's trust and cooperation while maximising the accuracy of findings. Infants and toddlers should be examined on the parent's lap or in a position of comfort whenever possible; the parent remains in the child's visual field to provide reassurance. Allow toddlers and preschoolers to handle equipment (stethoscope, penlight, tongue depressor) first, demonstrating use on the parent or a doll via 'medical play,' which reduces fear and increases cooperation.

Vital signs in children differ significantly from adults and change with age; the nurse must use age-specific techniques and interpret findings against correct reference ranges. APICAL PULSE (counted for a FULL MINUTE) is the standard in children under ~2 years because the radial pulse is unreliable and easily occluded by the examiner's hand. The apical point of maximal impulse (PMI) moves down and medially with age: in infants it is at the 4th intercostal space; by adolescence it reaches the adult position (5th intercostal space, mid-clavicular line). RESPIRATIONS are counted by observing ABDOMINAL MOVEMENT in infants (who are diaphragmatic/abdominal breathers, not chest breathers) for a FULL MINUTE, because infants breathe irregularly and pauses of 10–15 seconds are normal. BLOOD PRESSURE requires a cuff whose bladder encircles ~2/3 of the upper arm; a cuff that is too small falsely elevates the reading. BP is routinely measured from ~3 years of age onward. TEMPERATURE is best obtained via AXILLARY or TYMPANIC routes in young children; rectal thermometers are avoided when possible due to discomfort and perceived invasiveness, though some settings may use them for accuracy.

Critical memorisation point for NLE: As children grow, HEART RATE DECREASES, RESPIRATORY RATE DECREASES, and BLOOD PRESSURE INCREASES. Approximate awake, resting ranges are: 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 | Preschooler (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. Fever raises both HR and RR; a well child is compensating for illness/shock by increasing heart rate — hypotension is a LATE, ominous sign that suggests the child has exhausted compensatory mechanisms and is decompensating.

Effective communication with children requires matching language, explanations, and preparation to the child's cognitive and emotional development. INFANTS (birth–1 year) communicate through crying and body language; they respond to soft voices, holding, rocking, and the presence of the primary caregiver. Keep caregivers present and use consistent caregivers to build trust. TODDLERS (1–3 years) have limited vocabulary, think concretely, and have a very short sense of time; prepare them JUST BEFORE the procedure (not hours ahead), use simple words (e.g., 'your arm will feel a little pinch' rather than 'injection'), allow age-appropriate choices (e.g., 'Do you want the cuff on your right or left arm?'), tolerate comfort objects (blankets, favourite toys, pacifiers) and rituals, and expect regression and negativism — this is normal. PRESCHOOLERS (3–5 years) engage in magical thinking, fear bodily harm and mutilation, and may interpret illness/punishment as a consequence of their behaviour. Use concrete, non-threatening words: avoid 'take your blood pressure' (say 'the cuff will hug your arm'), never say 'we'll cut,' say 'open' instead; use 'shot' sparingly, prefer 'medicine through a small needle.' Reassure repeatedly that the illness is NOT a punishment. Allow medical play with dolls and equipment. Use bandages over injection sites — children fear their 'insides will leak out,' and the bandage provides security. SCHOOL-AGE CHILDREN (6–12 years) are concrete thinkers who want explanations and respect your knowledge of how equipment works. Give honest, factual information, allow questions, respect modesty and privacy (provide gowns, drape appropriately), and involve them in care decisions. ADOLESCENTS (13–18 years) demand respect, honesty, and privacy; interview them separately from parents regarding sensitive topics (sexual health, substance use, mental health); ensure confidentiality and legal privacy protections; allow control and participation in treatment decisions; recognise that peer acceptance is highly important.

Separation anxiety is the MAJOR STRESSOR for hospitalised toddlers (1–3 years, though it begins around 6 months and peaks around 18–24 months). It progresses through THREE PREDICTABLE STAGES: (1) PROTEST (first stage, hours to days): the child cries, screams, clings to the parent, searches for the parent, rejects nurses and strangers, refuses to eat or sleep, and may thrash or fight. This is a HEALTHY response — it shows the child understands the separation and still maintains the parent-child bond. Do NOT interpret protest as 'rejection' of the parent; it is evidence of a secure attachment. (2) DESPAIR (middle stage, days to weeks): the child becomes withdrawn, sad, and quiet; stops crying; shows little interest in play, food, or the environment; appears 'settled' and 'well-adjusted,' which can mislead parents and staff into thinking the child is improving. However, despair signals depression and hopelessness — the child has given up expecting the parent to return. (3) DETACHMENT (late stage, after weeks): the child appears to have 'adjusted,' becomes friendly with staff, smiles, and shows little emotional response to the parent's visits — even when the parent returns. This is the MOST SERIOUS stage and represents resignation, not true coping; the child has emotionally withdrawn from the parent-child relationship. If prolonged separation continues, this detachment can become permanent, affecting future relationships and emotional development.

To minimise separation anxiety and the stress of hospitalisation, nurses implement family-centred care strategies: (1) ENCOURAGE ROOMING-IN: the parent stays in the hospital room or nearby, providing reassurance and participating in care. This is the single most effective intervention. (2) ALLOW LIBERAL VISITING and flexible visiting hours for extended family, siblings (where permitted), and close friends. (3) MAINTAIN COMFORT OBJECTS: ensure the child has access to favourite toys, blankets, stuffed animals, and pacifiers — these provide security and continuity with home. (4) PRESERVE HOME ROUTINES AND RITUALS: ask the family about bedtime routines, mealtimes, favourite foods, sleep patterns, and behavioural management; maintain these as much as possible. A child who sleeps with a particular blanket should have that blanket in hospital. (5) ASSIGN CONSISTENT CAREGIVERS: whenever possible, have the same nurse care for the child on consecutive shifts; consistency reduces the need to re-establish trust and allows the nurse to learn the child's cues and preferences. (6) USE TRANSITIONAL OBJECTS: if rooming-in is impossible, provide something that belonged to the parent (a pillowcase with the parent's scent, a photo) to remind the child of the parent's presence. (7) COMMUNICATE HONESTLY with the child about when the parent will return: 'Mummy will come after lunch' is concrete and understandable for a toddler. (8) ENCOURAGE PARENTAL PARTICIPATION IN CARE: parents can help with feeding, hygiene, comfort measures, and play. (9) AVOID USING THE PARENT AS A RESTRAINT: if the child must be held for a procedure, the nurse or a staff member (not the parent) should provide therapeutic holding; otherwise the child may begin to fear the parent's presence.

Hospitalised children commonly REGRESS to earlier developmental behaviours: bed-wetting, thumb-sucking, wanting a bottle instead of a cup, baby talk, loss of toilet training, increased dependence on parents, and clinging. Regression is a NORMAL COPING MECHANISM — the child is overwhelmed and seeks comfort in earlier, more secure periods. Parents often feel guilt or shame ('He was doing so well before') and may punish the child for regressive behaviour, worsening stress. LOSS OF CONTROL is a major stressor for all ages, particularly toddlers and adolescents: hospitalisation removes the child's autonomy (when to eat, sleep, toilet; what to wear; who touches their body). Children cope better when they have choices and some say in their care. However, choices must be REAL and AGE-APPROPRIATE (e.g., 'Do you want your medicine in the syringe or cup?' — but the medicine is not optional). Offering a fake choice ('Do you want your injection?') when the answer must be yes damages trust.

Pain is the FIFTH VITAL SIGN in paediatric nursing. Infants and young children CANNOT RELIABLY VERBALISE pain, so assessment depends on age-specific tools and observation of behavioural and physiologic indicators. INFANTS AND NON-VERBAL CHILDREN (birth–~7 years): use the FLACC SCALE (Face, Legs, Activity, Cry, Consolability), which scores each dimension on 0–2, for a total of 0–10. The FLACC assesses facial expression (grimace, clenched jaw), leg position (relaxed vs. tense/kicking), overall activity (playful vs. restless/rigid), cry quality (none vs. pain cry vs. inconsolable), and how easily the child is consoled. This tool is observer-rated and does NOT require the child to communicate pain verbally. NEONATAL PAIN: specialised scales like NIPS (Neonatal Infant Pain Scale) and CRIES (Crying, Requires oxygen, Increased vitals, Expression, Sleeplessness) evaluate behavioural and physiologic cues in non-verbal neonates, as the newborn brain responds to painful stimuli (a myth that newborns don't feel pain is dangerously false). Untreated neonatal pain has physiologic consequences: stress hormones are released, metabolic demands increase, and tissue healing is impaired. PRESCHOOLERS AND OLDER (~3 years and up): the WONG-BAKER FACES PAIN RATING SCALE is ideal; the child points to the face that best matches how they feel (very happy/no pain, slightly unhappy/a little pain, more unhappy/more pain, very unhappy/lots of pain). This tool requires minimal language and is highly reliable. SCHOOL-AGE AND ADOLESCENTS (~7–8 years and older): the NUMERIC RATING SCALE (0–10, where 0 = no pain and 10 = worst pain ever) is standard. Children this age can reliably self-report pain on a number line or verbal scale. PHYSIOLOGIC INDICATORS of pain include elevated heart rate, elevated blood pressure, rapid respirations, pupil dilation, and pallor. However, these are NON-SPECIFIC (they occur with anxiety, fear, fever) and should be used alongside behavioural assessment. BEHAVIOURAL INDICATORS include crying (but absence of crying does NOT mean absence of pain), guarding or protecting the painful area, grimacing, withdrawal, restlessness, and decreased play/interaction. The child's response to pain is also shaped by age, previous pain experiences, coping skills, and cultural background.

Effective pain management combines NON-PHARMACOLOGIC and PHARMACOLOGIC approaches, with non-pharmacologic measures as FIRST-LINE ADJUNCTS for all ages. NON-PHARMACOLOGIC MEASURES: (1) DISTRACTION (toys, music, animated videos, counting, blowing bubbles — particularly effective for procedural pain); (2) POSITIONING and HOLDING (comfort position, parent holding, swaddling for infants); (3) CUTANEOUS STIMULATION (massage, gentle stroking, cool compress); (4) RELAXATION and GUIDED IMAGERY (for older children); (5) NON-NUTRITIVE SUCKING and PACIFIERS (for infants); (6) ORAL SUCROSE (20–30% solution, 0.5–2 mL given 2–3 minutes before a procedure) — reduces pain and distress in neonates and young infants; evidence-supported for vaccination pain; (7) TOPICAL ANAESTHETIC EMLA (Eutectic Mixture of Local Anaesthetics: lidocaine 2.5% + prilocaine 2.5%) applied ~60 minutes (up to 120 minutes) before needle procedures (IV insertion, vaccination) under an occlusive dressing, reduces procedural pain; (8) COLD APPLICATION (ice packs) over the procedure site may reduce pain sensation; (9) MUSIC THERAPY, PLAY THERAPY, and presence of a comfort person (parent). PHARMACOLOGIC MANAGEMENT — WEIGHT-BASED DOSING (must be calculated in kg; verify with second nurse): (1) PARACETAMOL (acetaminophen): 10–15 mg/kg/dose PO or PR every 4–6 hours, NOT exceeding ~75 mg/kg/day and a single-dose adult ceiling of ~1,000 mg. Paracetamol is antipyretic and analgesic but NOT anti-inflammatory; it has NO GI bleeding risk and is the SAFEST first-line antipyretic. (2) IBUPROFEN: 5–10 mg/kg/dose PO every 6–8 hours (for children ≥6 months); anti-inflammatory and analgesic; GIVE WITH FOOD to prevent gastric upset; avoid in children with dehydration, GI bleeding, or renal impairment. (3) OPIOIDS (morphine, fentanyl) for moderate to severe pain: dosed by weight and titrated; monitor closely for RESPIRATORY DEPRESSION, SEDATION, and CONSTIPATION (a common side effect requiring stool softeners); respiratory depression is the most serious adverse effect — monitor respiratory rate, oxygen saturation, and level of consciousness. (4) TOPICAL ANAESTHETICS (lidocaine spray, cream) for mucous membranes. CRITICAL: AVOID ASPIRIN in children with viral illness (varicella, influenza) — risk of REYE'S SYNDROME (acute encephalitis + hepatic dysfunction, potentially fatal). Always REASSESS PAIN after every intervention and document response to guide further treatment.

ATRAUMATIC CARE is the systematic approach to minimising physical and psychological distress during hospitalisation and procedures. Core principles: (1) MINIMISE SEPARATION: encourage family presence, rooming-in, and parental involvement. (2) PROMOTE SENSE OF CONTROL: offer legitimate age-appropriate choices, maintain routines, and involve the child in care decisions. (3) MINIMISE PAIN AND DISCOMFORT: assess pain regularly, use non-pharmacologic and pharmacologic strategies, and avoid unnecessary painful procedures. PROCEDURAL STRATEGIES: (1) PERFORM PAINFUL PROCEDURES IN A DESIGNATED 'TREATMENT ROOM,' NOT IN THE CHILD'S BED OR THE PLAYROOM — the bed and playroom are 'safe spaces' where the child should feel secure; performing painful procedures in these spaces violates that safety and increases anxiety. (2) KEEP THE PARENT AS A COMFORTER, NOT A RESTRAINER: if the child needs to be held for a procedure, a nurse or aide (not the parent) provides therapeutic holding; this prevents the child from fearing the parent. (3) USE THERAPEUTIC HOLDING AND POSITIONS OF COMFORT rather than forced supine restraint when possible; hold the child upright, hugged against the parent's or nurse's body, facing away from the procedure site if appropriate. (4) RESTRAINT AS A LAST RESORT: physical restraints (e.g., soft wrist/ankle restraints, mummy restraint) are used ONLY when necessary for safety or the child's safety during a critical procedure, and ONLY with a physician order. Check circulation distal to the restraint regularly; reposition or remove restraints frequently to prevent skin breakdown. Never tie a restraint to a movable bed part — it may strangle the child if the bed moves. (5) MUMMY/PAPOOSE RESTRAINT: used briefly to immobilise an infant for scalp IV placement, throat/eye/ear examination, or other face/head procedures; the infant is wrapped snugly in a blanket or specialised wrapping to prevent arm and leg movement. Document the time of application, reason, and any skin changes. (6) COMMUNICATION: tell the truth always ('This will feel like a pinch'), give REAL choices ('Which arm?' not 'Do you want this?'), provide honest reassurance, and praise cooperation afterward. Use simple, concrete, non-threatening language; never use deceptive tactics ('This won't hurt' when it will) — this destroys trust.

Medication administration in children requires understanding age-appropriate routes, safe injection sites, and weight-based dosing. INTRAMUSCULAR INJECTION SITES: (1) VASTUS LATERALIS (anterolateral thigh) is the PREFERRED and SAFEST site for infants and young children up to ~3 years (and sometimes beyond for smaller children): it has the largest muscle mass relative to body size, no major nerves or blood vessels in the immediate area, and is easily accessible with the child in various positions. The site is located on the anterolateral thigh, one-third to one-half the distance between the greater trochanter and the knee. (2) VENTROGLUTEAL SITE (hip) becomes safer once the child is walking and the gluteal muscles are well-developed, typically around 2–3 years or when the child walks confidently. (3) AVOID THE DORSOGLUTEAL SITE (buttocks) in children under ~3 years or until the child walks well — the muscle is small and underdeveloped, and there is risk of sciatic nerve injury. (4) DELTOID (upper arm) is used mainly for older children and adolescents, and only for small-volume injections (vaccines, antibiotics); avoid in infants and young toddlers due to small muscle mass. ORAL MEDICATIONS: (1) use a CALIBRATED ORAL SYRINGE or dropper (never a household teaspoon, which is inaccurate); (2) direct the medication toward the SIDE or BACK of the cheek, not the middle of the mouth, to prevent choking and to allow the child to taste it (and cooperate) if it's not foul-tasting; (3) for infants, give slowly to prevent aspiration; (4) DO NOT MIX MEDICATION INTO A FULL BOTTLE OF FORMULA OR ESSENTIAL FOOD — if the child doesn't finish the bottle, they won't receive the full dose, and it may create aversion to that food. It is acceptable to mix with a small amount (5–10 mL) of food or juice immediately before administration, provided the child can consume it entirely. INTRAVENOUS: scalp veins (scalp vein IV, butterfly) are often used in infants; central lines and peripheral lines in limbs are used in older children. RECTAL: reserved for situations where oral/IV routes are not feasible (vomiting, unconsciousness, NPO status); use the smallest-diameter suppository or tube and lubricate with water-soluble jelly. CRITICAL FOR NLE: always VERIFY WEIGHT-BASED DOSES and use the child's most recent WEIGHT IN KILOGRAMS; ask the parent if uncertain. Double-check high-alert medication calculations with a second nurse. Document the site, route, time, and any unusual response.

A child's cognitive and emotional development determines the most effective communication approach. Toddlers' concrete thinking and short time sense require preparation JUST BEFORE procedures using simple words; school-age children's desire for explanations requires honest, factual information; adolescents' need for autonomy requires privacy and participation in decisions. Matching communication to developmental stage increases cooperation and reduces anxiety-related complications.

Age-appropriate pain assessment tools are necessary because children cannot reliably verbalise pain until ~7–8 years of age. Infants require observer-based assessment (FLACC); preschoolers benefit from facial scale tools (FACES); older children can use numeric or verbal scales. Selecting the WRONG tool for a child's age leads to underestimation of pain and inadequate treatment.

Least-to-most distressing sequencing is not arbitrary — it preserves the accuracy of cardiopulmonary examination. Performing ear/throat examination first causes crying, which elevates heart rate and respiratory rate, distorts lung sounds, and produces findings that may be misinterpreted as pathology when they are simply stress responses. Correct sequencing ensures valid assessment data and accurate diagnosis.

The three stages of separation anxiety represent a progression from healthy protest through emotional resignation (detachment). If separation persists unchecked and the child remains in the detachment stage, permanent emotional withdrawal and attachment difficulties may develop. Understanding this progression and intervening early (with rooming-in, consistent caregivers) prevents long-term psychological harm.

Interventions that support the parent-child relationship (rooming-in, liberal visiting, parental participation in care, consistent caregivers) directly reduce separation anxiety and its psychological consequences. These interventions are evidence-supported and reflect best practice in paediatric nursing, aligning with RA 9173's emphasis on family-centred care.

Accurate, age-appropriate pain assessment identifies which children need treatment. Non-pharmacologic measures are always implemented first; pharmacologic interventions (weight-based analgesics) are added as needed. Reassessment after each intervention determines effectiveness and guides titration of therapy. This systematic approach ensures adequate pain control and prevents complications of untreated pain (stress, impaired healing, negative psychological impact).

Using the correct technique (apical pulse in infants, abdominal breathing observation) and comparing findings to the appropriate age-specific normal range allows the nurse to distinguish normal from abnormal. For example, a heart rate of 120 bpm is normal for a 2-year-old but concerning for a 10-year-old. Misinterpreting normal findings as abnormal (or vice versa) leads to unnecessary interventions or delayed response to actual pathology.

Atraumatic care is a systematic philosophy that addresses the child's physical and psychological needs during hospitalisation. When implemented consistently — through family presence, offering choices, using least-distressing procedures, and managing pain — the child experiences less distress, copes more effectively, and recovers more quickly with fewer behavioural/emotional sequelae.

Hospitalisations inherently restrict a child's autonomy and control. When children have NO opportunities to make decisions or participate in their care, they feel powerless, regress to earlier coping mechanisms, and become anxious or non-cooperative. Restoring a sense of control through legitimate choices ('Do you want your bath now or after breakfast?') and involving the child in age-appropriate care decisions reduces these negative responses.