Children are not small adults. Their physical, mental and emotional needs differ from adults and vary based on their age and developmental stage. In my 20 years of experience in the pediatric emergency department of a Level 1 trauma center, I have led pediatric clinical rotations with students from four schools of nursing and have reviewed content for pediatric publications. Still, I often found that textbooks did not prepare me for these mighty little people. Pediatric patients range in age from 1 day through 18 years and are constantly changing. To help meet them where they are, I offer the following tips.
Approach to Assessment
Most of your assessment occurs before you ever touch a patient. This is commonly known as the general impression or Pediatric Assessment Triangle (PAT). PAT includes assessment of a child’s appearance, work of breathing and circulation to skin.
Airway assessment always comes first. Is your patient crying loudly or cooing? That airway is clear and patent. If your patient is gagging, grunting or tripoding, you have an airway issue. Any airway concern should be addressed immediately and communicated to the physician.
To help assess the child’s appearance, use the mnemonic TICLS (“Tickles”). TICLS stands for Tone, Interactiveness, Consolability, Look/gaze and Speech/cry.
- Tone – Does the child move spontaneously? Resist examination? Sit or stand as age appropriate?
- Interactiveness – Is the child alert and engaged with their parent or the clinician? Do they interact well with people or the environment? Do they reach for objects?
- Consolability – Does the child stop crying when the parent holds or comforts them? Do they have a different response to their guardian versus the examining clinician?
- Look/gaze – Does the child make eye contact with the clinician? Do they visually track?
- Speech/cry – Does the child use speech that is developmentally appropriate?
PAT: Work of Breathing
Due to immature muscle mass, children’s bellies go in and out when they breathe, making it easy to count respiratory rate. When infants and young toddlers must work to breathe, you may note retractions, nasal flaring and/or abnormal positioning (e.g., tripod). Note any of these assessment findings and quickly communicate them to the physician.
PAT: Circulation to Skin
Observe the child’s interaction with the caregiver for alertness and look at their skin color. Is it an appropriate color for the child’s ethnicity? Or do you note pallor, cyanosis, ashenness or mottling? If you see any changes of concern, assess further and notify the physician.
Infants and Young Toddlers (0-24 months)
For infants, stranger anxiety develops between 8 and 9 months and peaks at 12-18 months but may continue until they are 2 years of age. Until they are used to your presence, infants between 0 and 12 months are largely unapproachable, so working with the parent or guardian is important.
Children this age may be distracted with a toy. Younger infants might turn toward the sound (rattle), while older infants might engage with the toy. Approach gently, slowly and calmly, with a smile when possible. Organize your interventions from least invasive to most invasive (e.g., complete your PAT and discussion with the parent before taking the child’s blood pressure). When you touch a patient, make sure your hands are warm. Younger ones often startle easily, causing signs of physiological distress.
Toddlers, Inconsolable 2s and Terrible 3s (18 months to 3 years)
Give toddlers time to get used to you, as they still have stranger anxiety. Toddlers have short attention spans and respond to concrete language. Around 2 years of age, toddlers have a 400-word vocabulary and can speak in two- to three-word phrases. At 3 years of age, they should know their first and last names. Try to be physically on their level by sitting in a chair and having the child in the bed with the parent. Speak in a friendly and clear manner. Engage the parent, because toddlers often pattern their behavior based on their parent’s reaction. Friendly interactions will set you up for success with the child!
The older toddler may want to touch equipment you are going to use. If it is available, the support of a Child Life Specialist (CLS) is ideal for this age group. Give toddlers choices when you are able. When offering choices, avoid yes/no options because children almost always say “no.” Discuss procedures only when they are going to happen. Because toddlers have no concept of time, they may repeatedly ask when the procedure is going to take place. An older toddler may think their hospitalization is punishment for something they have done, so clear up any potential misconceptions. Involve parents to help direct or redirect the child’s attention.
Preschool Children (Ages 3-6)
Between ages 3 and 6, children move away from being egocentric and become aware of others and their needs. They start to develop a concept of time. While most preschool children can relate times of day to events such as lunchtime and bedtime, they generally do not measure minutes or hours. While communication varies by age, this age group tends to be more articulate about what bothers them. Avoid healthcare lingo because if the patient does not understand what you’re talking about, it may frighten them. Preschool children respond well to touching the equipment you are going to use for assessment. Consider making a game out of this process, and let them explore appropriate items such as a stethoscope, blood tubes or splinting materials.
Preschool children have concerns about body integrity. For example, if they have a wound that is bleeding even slightly, they often fear losing blood, so apply an adhesive bandage quickly. Patients this age will often be emotional and reactive about invasive procedures. It is best to tell them what is going to happen, but be sure to time your explanation carefully because they may think about it incessantly. Children tend to be anxious in healthcare settings and need concrete explanations about what is going to happen. If you say something will feel “like a bee sting,” for example, patients who were stung by a bee may react negatively; I once had a 3-year-old with an IV cry “take it out” for almost three hours. Speak concretely and be as honest as you can without frightening them.
School-Age Children (Ages 6-12)
Between the ages of 6 and 12, children develop morality, compromising, belonging, cooperative behaviors and true friendships. While a younger child tends to see things as right or wrong, by age 9, they begin to understand differing points of view, allowing a nurse to compromise with them. It is important to maintain their modesty as they begin to compare their bodies to others. Provide privacy during an examination, and explain all procedures at the child’s level of understanding. Because this age group can negotiate clearly, it is important to let them know what is and what is not negotiable. Education and information are crucial to gaining trust and cooperation. Approach school-age children honestly, and speak with both the child and the parent. These patients do not like to be left out or ignored. Let them be active participants in decision-making by telling them what needs to happen and how. While they may not be happy about it, they will be more likely to cooperate to get it done. Allow them to assist with their care whenever possible.
Oh-So-Confusing Adolescents (Ages 13-18)
Adolescents change daily. Between 13 and 18, they grow physically, emotionally and socially. Adolescents are abstract thinkers who challenge authority and choose their own values. They can also sexually reproduce, which creates its own set of challenges. Adolescents are generally concerned with confidentiality and autonomy. When approaching them, speak to them first and then the parent if present. Teenagers often ignore chronic illnesses, instead doing things that may exacerbate their health issues.
Adolescents do not want to be different from their peers. To improve the chances of receiving honest answers, interview these patients without their caregiver present. State laws vary, so it is important to know what you can disclose to a parent in your state. Partner with parents or caregivers, because an adolescent’s desire to be autonomous can be overwhelming. In my experience, the best approach is honesty and sincerity. Be sure to do a thorough assessment, considering all the risks that adolescents may take (e.g., alcohol, drugs, sexual activity, driving, access to guns). Assess their mental health as this can be a challenging time in their lives.
Upset Their Worlds Gently
Children can be challenging to care for. They are wary of strangers, and the hurried environments that we work in are not conducive to their way of thinking. Remember to access your resources when available. I am a huge fan of CLSs and, if you have them in your facility, they can help with every age of childhood.
When you approach pediatric patients with kindness and engage their families, you set everyone up for more success. As a pediatric emergency nurse, I have found that children thrive on trust and comfort, so we need to upset their worlds gently.
How do you foster a safe and trusting care environment with pediatric patients?
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